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Medical Coding Process

Author: Shubhmohan Raj

To understand the medical coding process let’s first try to understand,

What is medical coding?

Medical coding is a process in which a patient’s health information is taken such as Medical procedures, diagnoses, medical equipment, medical services etc from the physician’s note and recorded in form of codes.

These codes are in form of alphanumeric which is standardized and universally accepted.

In a simple way, we can say that medical coding is a type of translation or transformation in which a medical report of the patient such as a doctor’s diagnosis, prescription, procedure etc is transcribed into a set of universally accepted standard medical codes.

The question now arises is – why medical coding?

In early days it was started to track disease but now a days its utility is seen in various aspects such as medical billing, insurance carriers pay, track patient’s medical records, for uniform documentation between medical facilities, to look at the prevalence and the effectiveness of treatment at the various units.

Other needs of medical coding are for to guarantee high-quality care to patients in future visits, to standardize the language and presentation, and to keep the information in digital form.

It will be interesting to have a look on the beginning of medical coding so let’s see the history of medical coding-

The medical coding system was first started in the 17^th century in England. At that time London bills of mortality uses numerical codes to organize the data to track diseases. These codes represent mortality causes with the no. of deaths.

Now lets focus on our main aspects which is medical coding process so here is how medical coding is done-

It is best performed by trained and certified medical coders.

The various steps to perform a good medical coding is as follows-

Step-1: Abstract the documentation of the patient

It is required to read the entire document such as procedure notes, and operative reports, in order to get the entire details.

Step-2: Ask for any additional information and to clarifies any doubts.

Step-3: Code the diagnosis and procedures

Step-4: Confirm medical necessities

Aligning the diagnosis codes with the procedure codes. It is necessary to perform to ensure that service is in accordance with the standards of care.

Step-5: double check your codes

It includes – looking up the code, re-read the description and comparing this to what the documentation states. It is necessary before finalizing the coding process to avoid any errors.

Coders also abstract other key information from the documents such as physician’s name, date of procedure etc.

The persons who perform medical coding are called medical coders. Let’s have a look at medical coders’.

Medical coders are professionals who translate the notes from the doctor and other medical professionals into a uniform set of codes that is given to a data analyst. They are trends and certified medical coders.

The main task of a medical coder is to review clinical statements and assign standard codes using CPT, ICD and HCPCS classification systems. Medical coding professionals help to ensure the codes are applied correctly during the medical billing process.

There are various types of codes which are used during medical coding. So here is a time to review the three types of medical code which are standardised and is done all over the world. Most of the country uses the following three international sets of medical codes.

1. ICD-11 (international classification of diseases – 11^th revision)

• It was created by WHO (world health organisation) in the late 1940s and is modified by each member country to serve its needs.
• It is mainly used for the purpose of health recording and data collection.
• It can classify symptoms, injuries, diseases, illnesses and causes of death.

2. CPT (current procedural terminology)

• It is developed by AMA (American medical association) and is updated annually.
• These are five-digit numeric codes.
• It also has addendums that increase the specificity and accuracy of the code.
• It codes for medical, surgical and diagnostic procedures and services within the US.

3. HCPCS (healthcare common procedure coding)

• It is developed by centres for medicare and medicaid services (CMS) intended to help with the processing of insurance claims processed through medicare or other provider.
• HCPCS code set is divided into two levels
  • The first of these levels is five digit numeric code identical to the CPT codes.
  • Level-II is a set of alphanumeric codes.
• HCPCS is the official code set for outpatient hospital care, chemotherapy drugs, medicaid and medicare.

These are a few notes about medical coding. I hope that it will let you understand about medical coding and its various aspects.