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Medical Coding Process

Medical Coding Process 

Author: Prathamesh Jagdale 

We all familiar with Coding in IT sector but does you have any idea how it is used in medical field…? Medical Coding is all about maintaining a records of healthcare information of patient such as medical procedures, diagnosis & medical service information.

What is medical coding?

Medical coding began in 17th century England, but has seen rapid development over the past few decades. According to the American Academy of Professional Coders (AAPC), the medical coding is defined as “Medical coding is the conversion of healthcare diagnoses, procedures, medical services, and equipment into a universal medical alphanumeric codes.”  Refers to the process of translating important medical information into simple codes for the purpose of documenting medical records and informing accurate medical billing. Medical coding allows for the efficient transfer of huge amounts of information and for uniform documentation between medical facilities.

Each code set has its own rules and guidelines.  As some codes indicate a pre-existing condition. The coding process ends when the medical coder enters the correct code based on the information he has obtained in a form or software program.  Once the report is coded, it is sent to the medical biller. It is necessary to keep that code in a very specific position.  Each code will be coded accurately and within specific guidelines.

What are the different types of codes?

     Coading is done by using different codes but what are the different types of codes? There are three main codes used by medical coder they are as follows:

1. International Disease Code (ICD): In 1949 WHO approved a “Mannual Of International Statistical Classification Of Disease Injuries and Cause Of Death” and the referred as ICD. So then ICD is used for maintaining data and record for planning and evolution of healthcare services. This ICD is implemented over 60 plus year the number followed by ICD is represent number of revision of code currently. ICD 10 CM is used in United States. The technical name of this code is International Classification of Disease 10th Revision Clinical Modification. Clinical modification increase the scope by increasing number of course for diagnosis. Clinical modifications are the revision put forward by National centre of health service (NCSH). It is a division of centre for medical studies (CMS). ICD code records doctors diagnosis and patient condition. In January 2022 WHO formally adopted ICD 11 as International standard.  International Classification of Diseases (ICD) introduced the latest version of ICD known as ICD-11.  It aims to replace ICD-10 as the new global standard for diagnosis codes.  ICD-11 came into use in January 2022.  It is used to closely classify various diseases and their symptoms.  It also reclassifies some diseases, expands the definition of sexual health. The new modification is that it includes new entries for immune system and sleep-wake disorders.
2. Current Procedure Terminology (CPT): This code is used for documentation of the medical procedures. This code is published and maintained by American Medicinal Association (AMA). This are five digit numaric codes and basically divided into three categories. First category is mostly used which divided into six ranges. Which deals with evaluation and management, anesthesia, surgery, radiology, pathology and laboratory and medicine. Second category codes are useful for provides more accurate information while third category is used in emerging medical technology.
3. Healthcare Common Procedure Coding System (HCPCS): This is set of code based on CPT codes. This code deals with services, procedures and equipment not covered by CPT codes. This code is published by CMS and maintained by American Medical Association. This code is divided into two levels. Level I codes are identical to CPT. Level II code is set of alphanumeric code and is divided into 17 sections.

Diagnosis coding:-

Every disease has some specific symptoms.So it’s easily diagnosed. But some symptoms are common in many diseases so far correct diagnosis doctor ask eight categories of questions called as history of present illness (HPI). It  consist chronological description of your symptoms.

Computer assisted coding (CAC):-

Computer software generate set of medical code. It is a type of autocoding. There are two types of technology available for computer. They are as follow:

1) natural language processing (NCP): It use many methods. It analyse the report context and convert it into code and at least coder finalize the coding selection. This technology provide flexibility to coding. This course run on some guidelines and these is disadvantage for it. Because this guidelines are not modified, then it result in faculty code assignment.

2) Structural output: Another type of technology available for CAC is in this technology data is  captured in structural manner. In this clinical documentation linked to applicable manner.

Use of medical coading in clinical trials:

Data generated in clinical trials is used for analysis. Data from clinical trials generated on Data Collection Instruments (DCIs) known as Case Record form (CRFs) or Electronic Case Records Form (eCRF). By this data coding is done by medical coder. For this purpose two dictionaries are commonly used which are: MedDRA (Medical Dictionary for regular activities) and WHO-DDE (world health organization Adverse Reaction Terminology). MedDRA developed by Maintainance and Support Services Organization (MSSO). It’s two versions are releases every year first is in March and second in September. Other commonly used dictionary is WHODRUG (World Health Organization Drug Dictionary). This dictionary contains information of medical products from more than 90 countries.  This dictionary is updated by Uppsala Monitoring Centre (UMC). It’s is used by drug regulatory authorities and by contract research organizations.

What does meaning of medical coder?

Any person who perform medical coading is known as medical coder. Medical coder collect all medicinal information of patient such as physician note, lab reports, procedures and diagnosis reports and translate all this information in medical code. This medical codes of patient used for billing and record keeping. The coder review the clinical statement and assign standard codes using different classification system. Medical coading classification. Medical coding Classifies services and supply of drugs for easy tracking. Insurance agencies also employ medical coders to handle patient claims.

Reasons for learning medical coading are follow: 

1. Comprehensive Training: The duration of the training course is short.  Its courses are available both online and offline.  Hands-on classroom training and internships can help one learn the workflow quickly.  Many courses offer certification, tuition and job placement support.
2. High demand: According to the Bureau of Labor Statistics in the US, the demand for medical coding professionals has increased by 15% in the last few years.  Certified coders are widely used in medical claims receiving organizations and insurance companies. As digital health records become more widely used, the demand for medical coding professionals is increasing.  Medical coders with experience and certification may work as health information managers or coding supervisors.
3. Scale Career: Medical Coding Experts have the opportunity to work along the administrative side of the Healthcare industry. These experts can grow to lead large teams and lead coding sections, support in Healthcare space.

Career in medical coading: 

Medical coder is great career choice in upcoming years. It is the fastest growing jobs in the healthcare sector. The covid-19 situation changes the healthcare services. Hence competent revenue cycle management has become an important requirement. The staffing requirements increased manifold, which had led to increased focus on back end services as well. Medical coading become another important part of the system requiring more expertise across the healthcare continuum.

A number of factors such as being an aging population, an increasing focus on health data and informatics, and the digitization of health records are responsible for growing of medical coding field. There are a lot of organizations and companies offer training in medical coding.

Career as medical coder start with general certification from professional coading organization. It covers 24 different aspects of the coding profession.

Problems faced by coder during coading:

Faulty coding is not always the coder’s fault.  Often the provider does not give the coder enough information about the process they perform.  Providers may leave important details of the procedure out of the report or they may provide invalid medical reports.  Therefore, the coding process may be incorrect.

Every coder should be in constant contact with the provider they are coding with.  Providers are not always available to consult on a matter.  In that case coders have to make the best of what they have.

The organizations that maintain the three major medical coding code sets (WHO for ICD, AMA for CPT, and CMS for HCPCS) continue to change coding rules every year.  It is up to the coder to learn the newly introduced codes and use them correctly.  This is why professional organizations like AAPC and AHIMA require every member to have a certain amount of educational training every two years.

How to overcome medical coading problems?

Every year, coders have to update the coding manuals as per their new version.  Sometimes a new manual is provided by your employer as part of the cost of employment.  This manual includes new code and new, revised guidelines that all coders need to know.

It is not always possible for the coder to speak with the provider frequently.  Coders should develop good relationships in the provider’s office.  One should try to communicate with them regularly.

Coder can avoid a lot of medical coding errors just by double-checking his work.

Reference:

1. Understanding Medical Coding: A comprehensive guide Fourth Edition by Sandra L. Johnson and Robin linker.
2. A book of Medical billing and medical coding certification.
3. https://www.rasmussen.edu/degrees/health-sciences/blog/what-is-medical-coder/