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What Is Medical Coding?

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Medical coding is essential to ensuring that medical procedures and diagnoses are properly classified. Medical coders, who have specialized training and a firm grasp of medical terminology, are responsible for entering the correct codes onto insurance claim forms, Medicare and Medicaid claim forms and diagnostics forms. Many in the healthcare industry, from providers to insurance carriers, depend upon medical codes to tell them with what a patient has been diagnosed and what treatment was carried out.

Definition

Medical coding, also called medical classification, is a process during which standardized numeric and alphanumeric codes are assigned to medical diagnoses and procedures. The medical coder uses transcribed doctor's notes, a patient's medical records or lab results to determine which diagnoses or procedures need to be coded. The purpose of diagnostic codes is to keep track of contagious diseases, such as the flu, and common diseases, including heart disease and diabetes, while procedure codes keep track of the course of treatment provided. Medical codes serve numerous purposes. In addition to being used on diagnostic request forms, insurance claim forms and Medicare and Medicaid reimbursement forms, medical codes are also used for research and statistical purposes.

Types

The codes that medical coders frequently use in their jobs are CPT codes and ICD codes. CPT, or Current Procedural Terminology Codes, are used to code everything from an office visit to brain surgery. ICD codes, or International Disease Codes, on the other hand, identify the problem for which the patient was seen and the patient's diagnosis. Medical coders will use a combination of CPT and ICD codes on insurance, Medicare and Medicaid claim forms, for example, to inform them of the problem the patient had and how the patient was treated.

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Considerations

Medical coders, along with the rest of the healthcare community, are bound by the rules of the Health Insurance Portability and Accountability Act, or HIPAA. Instituted by Congress in 1996, HIPAA includes a privacy act designed to protect patient information. Patient information is referred to as Protected Health Information (PHI), which includes a patient's contact information, medical records, birthday and research records. PHI is required to be secure regardless of whether that information is spoken, electronic or written. As a medical coder, you are responsible for keeping all patient information to which you have access confidential.

Benefits

Medical coding is a fertile career option, offering medical coders the opportunity to work in a variety of settings including hospitals, doctors' offices, dental practices, health insurance companies, workers' compensation providers and the federal government. Many medical coders find work-from-home positions while others start their own businesses. Training for a career in medical coding can be completed, in some instances, in less than a year. A bachelor's degree, which typically takes four years, is the best option for those medical coders who want to secure a management position upon graduation.

Training and Certification

Becoming a medical coder requires specialized training. In addition to having a firm grasp of medical terminology and medical codes, medical coders must possess computer skills and strong communication skills. Aspiring medical coders have numerous educational options, including earning a certificate, a diploma, an associate's degree or a bachelor's degree. Upon completing your education, consider becoming certified in medical coding. Certification is generally not a requirement of employment, but it will illustrate that you know what you're doing. Two professional organizations that offer both medical coding training and certification are the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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