Understanding Medical Coding and its Need

Understanding Medical Coding and its Need

Medical coding has been the procedure that converts a medical narrative into standard alphanumeric codes. This accurate and detailed coding of all descriptive medical information associated with healthcare process has been a major stage in providing high quality healthcare. Medical records coding also caters valuable information for healthcare planning and medical research. In most jurisdictions, medical coding has also been known as healthcare coding, clinical coding and diagnostic coding. It has been electronic data capture of medical records.

Medical clinical coders

Medical or clinical coders have been health care professionals. They would be responsible for the coding process. They would interpret clinical statements, medical records and then map the results of their analysis to a series of standard medical codes. These coding professionals would operate in a wide range of healthcare environments. However, they would be present in a wide range of non-provider settings. Across the world, several national associations have been known to exist for monitoring, regulating and maintaining the professional standards of medical coders.

Process of medical coding

The coding process informational output has been a valuable resource for a number of health information management systems. They have been used by various healthcare organizations, medical administrations, governments, insurance companies, educational establishments, research institutions and international agencies. Worldwide, the coding process would also be known as medical classification. It has been a standardized process, which generally divides into three broad stages, namely, abstraction, assignment and review.

Abstraction

In the process of abstraction, the foremost concern of a medical coder would be the analysis of an individual health. It would be associated with a specific patient or group of patients. The coder would examine various symptoms present forth, diagnoses, administered treatments, achieved results and outcomes. In this stage of coding process, the coder would analyze along with interpret data from a range of sources namely surgical notes, clinical notes and laboratory results.

Assignment

In the process of assignment, the coder would be concerned with mapping the data, which is produced by abstraction process. It would help him to set standard codes. The assignment phase has been divided into two stages, namely, identifying the appropriate codes and entering the results into relevant information management system. Usually, information would be stored on a computer-based relational database system.

Reviewing

Reviewing has been the final and major step in the medical coding solution. The coder should establish precision of outputs pertaining to initial case inputs. It would be important to establish that the applied code has been set accurately and fairly. It would represent the patient’s health and unnecessary medical codes should not be applied.

 

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