Essay On Medical Coding

Improved Essays
Research 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. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.
Education and training is key to becoming a skilled and successful medical coder. The first step coders must take is to have a thorough knowledge of anatomy and medical terminology. It's also important to become familiar with the codebook resources CPT, HCPCS Level II, and ICD-10-CM and their coding systems. It's also vital to know the coding systems' corresponding guidelines and what codes are accepted by which insurance plans, which government and payer regulations to follow, and how
…show more content…
After settling into the office, a medical coder usually begins the workday by reviewing the previous day's batch of patient notes for evaluation and coding. The type of records and notes depends on the clinical setting (outpatient or facility), and may require a certain degree of specialization (Larger facilities may have individuals who focus on medical specialties while coders who work in smaller, or more general offices, may have a broad range of patients and medical conditions.).
Selecting the top patient note or billing sheet on the stack, the coder begins reviewing the documentation to understand the patient's diagnoses assigned and procedures performed during their visit. Coders also abstract other key information from the documentation, including physician names, dates of procedures, and other

Related Documents

  • Improved Essays

    The writings must be written in a certain way in order to have a consistency in the medical field. Patient notes must be written in SOAP format, drug orders must have the correct information from both PA’s and physicians, and journals must be reliable and up to date on current medical issues. Key words: Physician assistants, patient notes, examine, prescribes, journals, flexibility, medicine, drug orders. Introduction…

    • 1031 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    This committee include the physician representative and hospital administration. The process is done according to the credential verification policy manual. 10. Hospital medical staff bylaws are very important for smooth operation of any health care organization. This help the governing board of a hospital to confer on the medical staff the power to set up a form of organization by which that staff can give assurance of quality hospital medical care (Taylor, nd).…

    • 896 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    However, the control of treatment selection cannot be well-established because it relies on the clinical experience of the medical doctors. Therefore, physician should have continuous study on medical diagnosis and therapeutics. A continuous monitoring will also be given to the patients in order to confirm the efficacy of the drugs, health condition of the patients and early detection of side effects raised. Any abnormal condition found shall be reported to the corresponding medical doctor and he or she can adjust the treatment plan immediately. Monitoring can be well managed by good recording and documentation practice.…

    • 1179 Words
    • 5 Pages
    Improved Essays
  • Improved Essays

    The form is then returned to the front desk after the physicians’ examination. A copy of the patients’ charge sheet is copied and attached to the patients file. If a patient is a returning patient the personnel at the front desk will ask if there has been any change in phone number, address, and insurance provider. The patient encounter form is also filled out for returning patients as well as new patients. The information being updated in a preexisting patients file is another important step to the patient intake process.…

    • 781 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    This is also known as the credentialing process. There are regulations and interpretive guidelines outlined for the medical staff, retrieved from §§https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf , ” Interpretive Guidelines § 482.22(2) (a) There must be a mechanism established to examine credentials of individuals perspective members (new appointments or reappointments) by medical staff. The individual’s credentials to be examined must include at…

    • 951 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    I work on a general surgery unit. If I get an admission during my shift, I have to get an understanding of the patient’s diagnosis. It is important for me to ask questions and get a clear picture of the patient’s symptoms and communicate this information with other health care team members involved. I need to ask questions to get a background of why the patient is being admitted. It is also important for me to get the patient’s medical history.…

    • 1463 Words
    • 6 Pages
    Improved Essays
  • Great Essays

    HIS Patient Registration and Order Entry The workflow begins when the patient is visiting their doctor or admitted to the hospital. The patient will fill out paperwork that explains the patient 's current issues as well as updated medical history…

    • 1811 Words
    • 8 Pages
    Great Essays
  • Great Essays

    Nursing documentation is defined as “the supplying of documentary evidence, and the collecting, abstracting, and coding of printed or written information for future reference”. This simple definition fits all the varied roles that documentation, or the process of documenting and demonstrating delivery of patient care, assumes in health care. (Webster’s New World Dictionary) Nursing documentation represents the quality of care that we provided. Through complete documentation, the nurse can claim credit for meeting responsibilities inherent in the profession. Documentation is also a vital adjunct to provide patient care as record of patient’s condition from admission till discharge including discharge care plan.…

    • 1009 Words
    • 5 Pages
    Great Essays
  • Great Essays

    Instead, she had her work routine and prioritized her work based on needs. She described her routine as 1. Find out which cardiologist she will be working with that day and print out a patient list for whom she will be taking care for; 2. Go through the list, review relevant information, including lab results, vital signs, nursing notes, and etc. 3.…

    • 1949 Words
    • 8 Pages
    Great Essays
  • Improved Essays

    Medical Records at South Carolina Heart Center are split between two distinctive groups: Analysts and Health Information Management Specialists. The Analyst’s purpose is to analyze medical records for completeness in order to provide an accurate and complete medical record for patient encounters. The Health Information Management Specialists is to ensure patient records are obtainable by filing loose or batched information on patients. The functions are different for each group as well. Health Information Management Specialists essential functions are: • Assist in answering the telephones in a polite and efficient manner • Receive, sort, and distribute mail appropriately • File nuclear charts in filing area • Operate designated equipment in…

    • 752 Words
    • 4 Pages
    Improved Essays