The terms Medical Coding is defined as the “Transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes”.
The codes were formed from the medical records such as transcription of physician’s notes, laboratory and radiologic results, etc. During a Patient’s diagnosis and procedures that were taken to a medical coding professional to check and to ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from the documents, Assigning appropriate codes, and creating a claim to be processed by insurance companies.
Why Medical coding is needed?The healthcare industry is based on documentation of what was learned, decided and performed. A patient’s diagnosis, test results, and treatment must be taken into record not only for reimbursement but to guarantee high-quality care in future visits. A patient’s personal health information follows them through subsequent complaints and treatments and they must be easily understood. This is extremely important considering the hundreds of millions of visits, procedures, and hospitalizations annually in united states. The main challenge is that there are over thousands of conditions, diseases, injuries, causes of death. there are also thousands of services performed by the providers and also there is an equal number of injectable drugs and supplies to be tracked. Medical coding classifies these for easier reporting and tracking. The medical coding also standardizes the languages and presentation of each element in a way that can be more understood, tracked and modified. For example, there are multiple descriptions, acronyms, eponyms for each disease but medical coding standardizes them to be more understood and tracked. This common language, regulated and mandated by Health information and probability and accountability act (HIPAA) allows hospitals, providers, and payers to communicate easily and consistently. Nearly all private health information kept digitally and rest on the codes to being assigned.
How is medical coding done?Medical Coding is best performed by trained professional coders. The following are an example of how medical coding is done by professionals. The medical coder usually begins the workday by reviewing the previous day’s batch of patient notes for evaluation and coding. The type of records and notes depend on clinical settings (outpatient or facility). The medical coders are subdivided into two The individuals who focus on medical specialities which require a certain degree of specialization and coders who work in smaller, and more general offices that have a broad range of patients and medical conditions. The coder begins reviewing the documentation to understand the patient’s diagnosis assigned and procedure performed during their visit. Coders also abstract key information from the documentation such as patient names, date of procedures and other information. Coders rely on ICD-10 and CPT code books to begin translating the physician’s notes into useful medical codes an example of the basic procedure documentation process and the subsequently assigned codes can be given below. Many cases are simple to code. Individual medical coders develop a detailed understanding of the procedure and commonality of their specific clinic or facility. Coders occasionally encounter a difficult note requiring in-depth research, taking more time to code correctly. even among the more commonly used codes are significant areas open for examination among coders. with very complex unusual cases, coding guidelines may be confusing to interpret. Experienced coders will rely on their network of peers or professionals to discuss nuances in online forums, networking with specialists that they have met at national conferences, or consulting with co-workers to help understand the issue and determine the proper codes. ongoing training and the current coding related periodicals such as Healthcare business monthly also provide important opportunities to advance understanding and professionalism. Finally, the coder completes the chart and begins the next patient record. This cycle of reading, note-taking, assigning codes, and computer entry repeat with each chart. Most coders will spend the majority of their day sitting at their computer reading notes and using their computer to enter data into a billing system or search for information to clarify the documents in the notes.
Who is a medical coder?Medical coders are individuals responsible for translating physician’s report into useful medical codes. These professionals work behind the scenes in a variety of settings, ensuring all important information is coded appropriately to ensure consistency and accuracy. After the medical provider examines or treats a patient, the insurance company needs to understand what was done to process the bill. Common languages may be inappropriate to the insurance companies the accurate details it needs, so a set of specific codes has been established to define medical procedures. It’s the role of a medical coder to pass along the information in a way that is useful and efficient.
Where do they work?
After you read the roles and responsibilities of medical coders you might have thought that the coders have to work on hospitals but there are several other settings a medical coder might work professionals are employed anywhere that provides medical services. This includes hospitals, clinics, urgent care facilities, nursing homes, IT companies, etc.Some insurance agencies also employ medical coders to handle patient claims from the other side of the table, verifying the accuracy of incoming claims. Speaking of accuracy, some law firms even employ medical coders to help identify billing fraud.