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