A clinical coder commonly known as a coding officer or a diagnostic coder refers to the position of a health information professional who does the work of analysis of the clinical statements made by registered physicians and helps assign standardised codes to each statement by the use of a classification system.
The health data comes from a variety of sources and forms an integral part of the health information management on which the working of the local and national governments including private healthcare organisations and international agencies depends. This information is important for a variety of purposes that includes medical and health services research, research on the spread of epidemics, health resource allocation depending on the requirement of resource and case mix management.
Thus, the job of a medical coder requires an in-depth knowledge of the different medical terminologies and a brief idea regarding anatomy and physiology including a basic systematic knowledge of the clinical procedures and the related diseases, injuries and other rare conditions associated with patients. The medical illustrations and clinical documentation employ a set of charts and legal and ethical aspects of health information, health data standards and classification conventions.
Types Of Medical Alphanumeric Codes
International Classification of Diseases (ICD):This code is specifically created by the World Health Organization (WHO) with the intention of using it on an international level. This classification system is mainly applied with the intention of health recording and data collection. The advantage of using a system of codes is that it can be easily used to classify symptoms, diseases, illnesses, and even the causes of death.
Current Procedural Terminology (CPT):CPT is a system of coding medical issues that is used primarily in the US with the aim of identifying medical, surgical, and diagnostic procedures and services that are available within the country. The American Medical Association are the founders of this system which has been divided into three categories for better understanding. These include procedures and contemporary medical practices, systems of clinical labs, and emerging new technologies.
Healthcare Common Procedure Coding (HCPCS): This system was founded by the Centers for Medicare and Medicaid Services and was intended to assist with the processing of insurance claims for Medicare and other providers. It is used by coders for recording medical procedures, products, supplies, and services.
Responsibilities Of A Medical Coder
The core responsibility of any medical coding Services is the accurate maintenance of medical records. The foundation of this duty relies on the proficiency in a variety of medical codes and experience in following the medical coding code of ethics. Some regular responsibilities include-
Preparation of the patient information into a set of appropriate medical codes for easier reference.
Cross-checking of medical documents and records to look out for missing information
Preparing chart audits
Collecting, researching, and recording the medical history of patients.
Ensuring the correctness of all documents.
In addition to the above-mentioned tasks, a medical coder is also responsible for staying updated with the latest coding guidelines and regulations to ensure compliance with legal and industry standards. They collaborate with healthcare professionals to clarify any ambiguous documentation, resolve discrepancies, and obtain necessary information for accurate coding.
Frequently Asked Questions
Q.1 What is medical coding?
Medical coding is the analysis of the clinical statements made by any patient and the translation of them into a set of standard codes for easier understanding.
Q.2 What are the required skills for the job?
The important skills include In-depth knowledge and understanding of medical terminologies and a brief idea of the physiology, and anatomy of medical science.
Q.3 How can you become a medical coder?
To become a medical coder it is important to have complete medical coding training done with an associate degree program in medical coding or by obtaining a certificate in medical coding.