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Medical Coding Process

Author: Harshal

Outline:

• Introduction
• What is Medical Coding?
• Origin of Medical Coding

1. Medieval Era
2. Early Modern Era
3. Modern Contemporary Era

• What do Medical Coders do?
• Significance of Medical Coding in present times
• How can one become a Medical Coder?

1. Education/Qualifications required
2. Certifications
3. Practicing/Internships
4. Mistakes to avoid

“In the world full of variables, sometimes it’s better to be constant”

It feels fascinating how diverse humans are and are able to prosper under the influence of different cultures and languages. It is great, but it comes with one problem, Miscommunication. In order to describe anyone’s grave medical condition and evaluate what combination of therapy will work for them, it becomes necessary to bring uniformity in describing the patient’s information regarding their health. For this conundrum, Medical Coding enters the picture.

What is Medical Coding?

Medical Coding is an art of communicating hospital data/records in such a way that computers are able to read and store it for later use. Medical Coders are the professionals who deal in this art. They are the backbone of keeping records of hundreds and thousands of patients and providing them with uniform diagnosis data and cost of treatment that they will have to incur.

According to the American Association of Professional Coders(AAPC), Medical Coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.

Origin of Medical Coding

Though recordkeeping goes back to 5000 years in Sumerian Cuneiform Clay tablets, Medical Coding as a practice dates to 1340’s. The parishes of the small village of France named Givry kept written records of baptism(birth), marriage and death from the age of Black Death.

(Bibliothèque de l’École des chartes (1334-1357)

Robert S. Gottfried, The Black Death: Natural and Human Disaster in Medieval Europe (1983))

Later in the early modern age, the renowned figure Florence Nightingale aka Mother of Modern Nursing emphasized the importance of consistent recordkeeping as she implemented a system for collecting and organizing patient data at the military hospitals in Crimea. She believed that collecting and analyzing data on patient care could help improve the quality of care and identify areas for improvement.

History of the statistical classification of diseases and causes of death (2011) (cdc.gov)

This practice was not popularized until the 1900s, when the first International List of Cause of Death (ICCD) was published which was based on Bertillon’s System of Classification(1893). Later ICCD was changed to International Classification of Death (ICD) in 1946 under the interim commision of WHO. Till date there have been 11 revisions in the index of ICD namely ICD-11, which came into effect on 1st January 2022, but it’s implementation will be little slow as its predecessor ICD-10 will be in effect until 2025.

(International Classification of Diseases (wolfbane.com))

(https://www.cms.gov/medicare/icd-10/2023-icd-10-cm)

What do Medical Coders do?

The role of medical coders is important because it helps to ensure that medical records are accurate and complete. This is important for a number of reasons. For example, accurate medical coding can help to reduce errors in billing, which can save money for both healthcare providers and patients. In addition, accurate medical coding can help to improve the quality of medical research and data analysis, as it allows researchers to accurately track and compare health outcomes across different populations.

Medical coders work closely with other healthcare professionals, such as doctors, nurses, and medical billing specialists, to ensure that medical records are coded correctly. They must be familiar with a variety of coding systems, such as the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT), and must be able to use these systems accurately and efficiently.

Overall, the role of medical coders is crucial in helping to ensure that medical records are accurate and complete, which can have a positive impact on the quality of healthcare and the efficiency of the healthcare system.

Significance of Medical Coding in present times and it’s demand

How to become a Medical Coder?

Becoming a medical coder involves several steps, including completing education and training, obtaining certification, and gaining practical experience. Here is a more detailed description of the process:

Step I: Educational Qualifications

Medical coders typically need to have a high school diploma or equivalent, although some employers may prefer candidates who have completed some college coursework or have a degree. Many medical coding programs are available at community colleges, vocational schools, and online schools, and these programs typically take anywhere from several months to a couple of years to complete. These programs usually include coursework in anatomy, physiology, medical terminology, and coding systems such as the International Classification of Diseases (ICD).

Step II: Certification

Medical coders can obtain certification through various organizations, such as the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).

AAPC provides more than a dozen different medical coding certifications for use in various hospitals and specialties. Additionally, they provide certifications in practice management, medical billing, auditing, documentation, compliance, and compliance.

The most popular AAPC certification is for Certified Professional Coder (CPC). 70% or higher is required to score in order to pass the certification.

AHIMA on the other hand, provides certification in half a dozen certifications, but it is more focused on coding and health information management. The most popular AHIMA credential is Certified Coding Specialist (CCS). One needs to score more than 300 out of 400 in the CCS test.

They use the same medical coding systems, namely CPT and HCPCS codes for medical procedures and services and ICD codes for medical diagnoses, so there isn’t a lot of difference between the certifications.

You can even get  Medical coding certification under Ayushmann Bharat, wherein the NHA-IRDAI document has proposed to use ICD 10 for coding of diagnosis and ICD 10 PCS for coding of procedures. It said, “Accurate medical coding is key to good auto adjudication and fraud waste and abuse management.” In the future, the Indian Government can introduce a coding protocol for effective e-claim reimbursement.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.cdr (abdm.gov.in)

To become certified, candidates must pass a written exam that tests their knowledge of medical terminology, coding systems, and other relevant topics. Certification is not always required, but it can improve job prospects and may be preferred by some employers.

Step IV: Practical experience

Many medical coding programs include an internship or practicum component, which allows students to gain hands-on experience working with actual medical records and coding them using appropriate systems. This can be an important way for aspiring medical coders to develop the skills and knowledge needed to succeed in the field.

Step V: Continuing education

Medical coding is a rapidly evolving field, and coders are expected to stay up-to-date with new coding systems and techniques. As a result, many medical coders choose to pursue continuing education opportunities to stay current in their field. This can involve taking additional courses or workshops, attending conferences, or earning additional certifications. It is always better to be on your toes and be on par on the latest updates

AAPC’s official website sums it up like this:

1. Take these courses: Anatomy, medical terminology, and pathophysiology.
2. Take an online exam preparation course for the specific credential you want.
3. Read the study guide for the credential you want.
4. Take an online practice exam.
5. Take and pass the actual certification exam.

What does Medical Coding involve?

The first step in the medical coding process is to review the medical documentation. This typically involves reviewing patient medical records, including progress notes, lab results, and diagnostic test results, to determine the appropriate codes to assign. The medical coder must carefully review the documentation to ensure that all relevant information is captured and that the codes accurately reflect the patient’s diagnosis, procedures, and treatments.

To determine the appropriate codes to assign, the medical coder must have a thorough understanding of medical terminology, anatomy, and the coding systems being used. This requires ongoing education and training to keep up with changes in medical terminology and coding guidelines. Medical coders may also use reference materials, such as code books and online resources, to help them accurately assign codes.

Once the appropriate codes have been determined, the medical coder must input the codes into a coding software or database. This may involve creating a new patient record or updating an existing one with the appropriate codes. The medical coder must ensure that the codes are entered accurately and that all relevant information is included in the record.

After the codes have been entered, the medical coder must review the coded documentation to ensure that it is complete and accurate. This may involve comparing the coded documentation to the original medical documentation or reviewing the codes with a supervisor or peer. Any discrepancies or errors must be corrected before the coded documentation is submitted for billing purposes.

Once the coded documentation has been reviewed and any errors corrected, it is submitted to the appropriate parties, such as insurance companies or healthcare facilities. The coded documentation is used to bill insurance companies for medical services and to track healthcare data for research and quality improvement purposes.

In addition to coding diagnoses and procedures, medical coders may also be responsible for assigning codes for medical supplies and equipment. This may involve reviewing invoices or other documentation to determine the appropriate codes to assign.

Conclusion

Medical Coding is a great career, it develops a person’s skills to understand the medical world and how insurance claims are reimbursed. It also develops soft skills to converse with fellow co-workers, it brings an order in the organizations. Everything in the workplace becomes systemic, organized and streamlined because of the effort and work done by coding specialists. The work of a medical coder may not be visible to the patient, but it impacts almost every sphere of the Healthcare Industry.