Medical coding is the transformation of narrative descriptions of diseases, injuries, and healthcare procedures into numeric or alphanumeric designations (that is, code numbers). The code numbers are detailed in order to accurately describe the diagnoses (that is, what is wrong with the patient) and the procedures performed to test or correct these diagnoses. Because medicine is not always an exact science, codes were developed to identify all reasons for seeking healthcare.
Coding health-related data permits access to health records according to diagnoses and procedures for use in clinical care, research, and education. Common uses of medical codes in healthcare include:
- Identifying symptoms that must be evaluated and to alert other healthcare professionals to life-threatening allergies
- Reporting services performed for reimbursement
- Helping with administrative functions such as staffing, scheduling, and adding or decreasing healthcare services
- Comparing facilities and planning for new services in underserved areas
Medical Coding Profession
Delivering quality healthcare depends on capturing accurate and timely medical data. Medical coding professionals fulfill this need as key players in the healthcare workplace.
The medical coding professional (or coder) is responsible for translating healthcare providers’ diagnostic and procedural phrases into coded form. Coding professionals do this by reviewing and analyzing health records to identify relevant diagnoses and procedures for distinct patient encounters. This translation process requires interaction with the healthcare provider to ensure terms are translated correctly.
Coding professionals must possess a thorough understanding of the health record’s content in order to find information to support or provide specificity for coding. Certified medical coders are trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. The job entails much more than simply locating diagnostic and procedural phrases in the coding manuals or with encoder software. It requires knowledge of disease processes and procedural techniques to consistently apply the correct codes. A medical coding professional works as part of a team to achieve the best quality patient care.
