He was a standout Heisman Trophy finalist in 1998 while playing for the University of Kentucky, and was the number one selection in the 1999 NFL Draft by the Cleveland Browns.

As a prep quarterback at Leslie County High School, Couch set a number of national high school records — most pass completions, passing yardage, touchdown passes (133), and passing percentage for a season (75.1). Recruiting analyst Tom Lemming called Couch the best quarterback prospect since Brett Favre. ESPN ranked Couch as the #6 of the best high school athletes ever.

Couch also starred on the Leslie County High School basketball varsity team. He scored 36 points per game as a junior, which was the highest average in the state. Couch scored 3,023 points in his career, which as of April 2010 is good for the 26th highest total in Kentucky state history.

The highly recruited Couch decided to play at the University of Kentucky. During his freshman year (1996) under head coach Bill Curry, Couch split time as the starting quarterback with Billy Jack Haskins. Curry's firing was announced after a 1-6 start that season. Incoming head coach Hal Mumme announced early that Couch would be the starter in his new pass-oriented "Air Raid" offense. In 1997, Couch set several school records as the previously anemic Kentucky offense topped national offensive rankings and finished 5-6 on the season, including a win over #20 Alabama. During the 1998 Wildcats season, Couch led Kentucky to seven wins (including a win on the road at #21 LSU) and a spot in the Outback Bowl (in which Couch completed 30 of 48 passes for 336 yards and 2 touchdowns, though Kentucky lost to Penn State 26-14).

Following his junior season in 1998, Couch announced he would leave Kentucky to enter the NFL draft early.

Couch's career totals at Kentucky included completing 795 of 1,184 passes (.671 completion rate) for 8,435 yards (including 4,275 passing yards during the 1998 season alone) and 74 touchdowns (including a 97-yard touchdown pass to Craig Yeast against Florida on September 26, 1998). Couch still holds the NCAA record for completion percentage in one game (minimum of 40 completions) at 83.0% vs. Vanderbilt (44 of 53) in 1998 and for completions per game (36.4, 400 in 11 games) that same season. He also left Kentucky holding NCAA records for most completions in a season (400 in 1998), most completions in a two-year period (763 in 1997-1998), most completions per game in a two-year period (34.7, 1997-1998) and career completion percentage (67.1%). His 1998 records of 4,151 offensive yards in a season, 377.4 offensive yards per game and 4,275 passing yards, stood as Southeastern Conference records for years after his departure.

Couch's college success culminated in his selection as the number one overall selection in the NFL draft by the revived-Cleveland Browns in 1999. Couch took over for Ty Detmer as the team's starting quarterback in the second game of his rookie season. The Browns front office had high expectations for Couch. Spokesperson John Schober was quoted in 2003 as saying the former Kentucky All-American would win at least six playoff games. But Couch was joining a team that had been hastily assembled in the wake of the former Browns squad moving to Baltimore three years earlier. He spent five seasons as a starting quarterback for Cleveland, eventually facing competition from journeyman backup Kelly Holcomb during his final two seasons.

Couch's tenure in Cleveland ranged from leading the team to a playoff appearance, to boos and inconsistent play, which was partially a result of being constantly plagued by injuries. These injuries were due, in turn, to his exposure to pressure due to the expansion Browns' inexperienced offensive line. He missed the final nine games of the 2000 season with a shoulder injury. The high point of Couch's career came in 2002, when he threw for almost 3,000 yards and 18 touchdowns in leading the upstart Browns to a 9-7 record and a playoff appearance. However, he suffered a broken leg in the final game of the regular season and was forced to watch as Holcomb threw for over 400 yards in a loss to the Pittsburgh Steelers in the Wild Card round of the playoffs. This was the beginning of a quarterback controversy in Cleveland that would not be resolved until a year later when head coach Butch Davis tapped Holcomb as his starter. By the end of the 2003 season, after exhausting both quarterbacks with the rotation, it became clear that Davis, struggling with a 5-11 football team, would never give Couch the opportunity to start again.  Couch is now considered by many to be one of the NFL's biggest draft busts in its history after being taken no. 1 with high expectations only to falter through most of his career. Some attribute his pass-oriented college career to be a factor in his failure in the pros.

Hail Maries Couch had several notable moments for the Browns, including two "Hail Mary" passes. In 1999 against the New Orleans Saints, his last-second TD pass to Kevin Johnson gave the expansion Browns their first win. Three seasons later, in Jacksonville he tossed a game-winning pass on the last play of the game to Quincy Morgan.

Magical 2002 Season The Browns' 2002 campaign was a special one. Coming off a mediocre 7-9 finish the previous season, the Browns had little to no expectations heading into 2002. However, the reincarnated "Kardiac Kids", led by Couch, won 9 games, including five in the final two minutes and seven by 10 points or less. Those thrillers included a 31-28 overtime win over Tennessee in which Couch threw for 326 yards and 3 TDs, a last minute TD and two point conversion passes from Couch to Dennis Northcutt against the Jets, and a final-minute TD drive against Baltimore where Couch threw a 1-yard strike to tight end Mark Campbell after being pinned inside his own 5-yard line with 0 timeouts and 1:30 left in regulation.