Medical coding is essential to ensure that medical procedures and diagnoses are properly classified. Medical coders with specialist training and a solid grasp of medical terminology are responsible for entering the correct codes on insurance claim forms, Medicare and Medicaid claim forms, and diagnostic forms. In the healthcare industry, from providers to insurance companies, it relies on medical guidelines to tell a patient what was diagnosed and what treatment was performed.
Medical coding, also called medical classification, is a process in which standardized numerical and alphanumeric codes are assigned to medical diagnoses and procedures. The medical coder uses copied physician notes, patient medical records, or laboratory results to determine which diagnoses or procedures should be coded. The purpose of diagnostic codes is to track infectious diseases such as influenza and common diseases including heart disease and diabetes, while procedure codes follow the given treatment process. Medical codes serve many purposes. In addition to being used in diagnostic claim forms, insurance claim forms, and Medicare and Medicaid reimbursement forms, medical codes are also used for research and statistical purposes.
The codes that medical coders frequently use in their work are CPT codes and ICD codes. CPT or Current Procedural Terminology Codes are used to code everything from an office visit to brain surgery. On the other hand, ICD codes or International Disease Codes describe the problem the patient is seen and the patient’s diagnosis. Medical coders will, for example, use a combination of CPT and ICD codes on insurance, Medicare and Medicaid claim forms to report the problem the patient is experiencing and how the patient has been treated.
Medical coders, together with the rest of the healthcare community, are subject to the Health Insurance Portability and Accountability Act or HIPAA rules. Founded by Congress in 1996, HIPAA includes a privacy law designed to protect patient information. Patient information is called Protected Health Information (PHI), which includes the patient’s contact information, medical records, birthday, and research records. Regardless of whether the information is spoken, electronic or written, PHI needs to be secure. As a medical coder, you are responsible for keeping all patient information to which you have access confidential.
Medical coding is a productive career option and offers medical coders the opportunity to work in a variety of settings such as hospitals, doctor’s practices, dental practices, health insurance companies, workers compensation providers, and the federal government. While many medical coders find work from home, others start their own businesses. Training for a career in medical coding can be completed in less than a year in some cases. A bachelor’s degree, which usually lasts four years, is the best option for those seeking a postgraduate management position.
Training and Certification
Becoming a medical coder requires special training. In addition to a solid understanding of medical terminology and medical codes, medical coders must have computer skills and strong communication skills. Aspiring medical coders have numerous educational options, including earning a certificate, diploma, associate or bachelor’s degrees. Consider becoming certified in medical coding after completing your studies. The certificate is not usually an employment requirement, but it shows that you know what you are doing. The two professional organizations that offer both medical coding training and certification are the American Academy of Professional Coders (AAPC) and the American Association for Health Information Management (AHIMA).