Medical coding is the process of converting a medical narrative into a series of standard alpha-numeric codes. The detailed and accurate coding of all the descriptive medical information associated with a healthcare procedure is a key stage in the efficient delivery of high quality healthcare. The coding of medical records also provides valuable information for medical research and healthcare planning. In certain jurisdictions, medical coding is also known as clinical coding, diagnostic coding and healthcare coding.
Medical or clinical coders are the health care professionals responsible for the coding process. They interpret medical records and clinical statements, and then map the results of their analysis to a series of standard medical codes. Coding professionals operate in a wide variety of healthcare environments, but are also present in a wide range of non-provider settings. Worldwide, many national associations exist to monitor, maintain and regulate the professional standards of medical coders.
The Medical Coding Process
The informational output of the coding process is a valuable resource for the various health information management systems that are used by medical administrations, healthcare organizations, insurance companies, governments, research institutions, educational establishments and international agencies. Internationally, the coding process is also know as medical classification and is a standardized process that is generally divided up into three broad stages: abstraction, assignment and review.
During the abstraction process the primary concern of a medical coder is the analysis of an individual health encounter associated with a particular patient or patient group. The coder will examine symptoms presented, diagnoses made, treatments administered, results achieved and final outcomes. During this stage of the coding process, the coder will typically analyze and interpret data from a wide variety of sources such as, clinical notes, surgical notes and laboratory results.
During the assignment stage of the process a coder is concerned with mapping the data produced by the abstraction process to a set of standard codes. The assignment phase is divided into two stages: identifying the correct codes and entering the subsequent results into the relevant information management system. Typically, information will be stored on a computer-based relational database system.
Reviewing is the final and key step in the medical coding process. The coder must establish the appropriateness of outputs with regard to the initial case inputs. It is important establish that the applied code set accurately and fairly represents the patient’s health encounter, and that no superfluous or unnecessary medical codes have been applied to the case history.
International Medical Coding Standards
Medical coding standards are maintained on an international basis and are regulated by the World Health Organization. These internationally endorsed classifications are needed to facilitate valid and consistent health-related data comparisons on both an inter and intra-national basis. World Health Organization standards include three broad reference categories: ICD, which covers the statistical classification of diseases and their related health Problems; ICF, which relates to the coding of disability and related health matters; and the ICHI coding standards, which deal with the international classification of health interventions.
Although these international coding standards have obtained almost complete worldwide recognition and acceptance, many national governments and national health bodies have developed national coding standards that have been derived from these internationally recognized classification systems. Because of this, the vast majority of medical coding training programs and qualification have only national recognition.