What is Medical Coding?
Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc.
Facility coding reflects the volume and intensity of resources utilized by the facility to provide patient care, whereas professional codes are determined based on the complexity and intensity of provider performed work and include the cognitive effort expended by the provider.
A clinical coder – also known as clinical coding officer, diagnostic coder, medical coder, certified professional coder, nosologist or medical records technician – is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system.
Medical coding audits should include a select sample of patient encounters as coded and billed. To design an audit, identify strategic initiatives, such as performance measures, validation of coded claims, prevalence of diseases, and treatments and adherence to policies and procedures to ensure compliance.
The denial management team establishes a trend between individual payer codes and common denial reason codes. This trend tracking helps to reveal billing, registration and medical coding process weaknesses that are then corrected to reduce future denials, thus ensuring first submission acceptance of claims.