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Although certified medical coders are required to complete an accredited two- to four-year degree program, you can learn the basics of medical coding on your own. In order to teach yourself medical coding, you’ll need to have a basic understanding of a few key fundamentals.
Starting Point: Explanation of Medical Coding
The American Health Information Management Association (AHIMA) defines coding as the conversion of verbal descriptions of diseases, injuries and procedures into numeric or alphanumeric terms, which enable access to medical records by diagnoses and procedures, and are required for reimbursement, clinical care, research and instruction (www.ahima.org). Medical coders review data such as records, doctors’ notes, various test results and more to assign the correct code. Because these documents contain words and jargon you may not know, the first step in teaching yourself medical coding is to become familiar with medical terminology, human anatomy and physiology.
Learning the Basics: Medical Terminology & Human Anatomy and Physiology
Health-care professionals use the language of medical terminology to describe the body, the body’s systems, diagnoses and conditions, treatments, procedure and developments. The origin of medical terminology comes from Greek and Latin and adheres to a methodical structure that divides the terms into definite elements. Recognizing these elements or parts of the term is critical and includes the word root, prefix, suffix and combining form. To start, learn where each of these word parts is located within a term, as well as the particular purpose that it has. Note how the word root is regularly in the center of the term, the prefix is before the word root, the suffix is at the end, and the combining form (usually an “o”) is after the prefix. Recognizing the elements that are used the most will help you identify the terms more easily. Practice by writing medical terms on index cards and changing their elements, to see the impact that it will have on the overall meaning of the term. Look over medical documents to see the way the terms appear or how they’re used and visit websites that have an inclusive list of medical terminology and demonstrate the methods that are used to construct the terminology.
Learning the Basics: Human Anatomy and Physiology
Next, you’ll want to have an understanding of the key basics concerning anatomy and physiology. This is important because when it comes time to assign the codes, you’ll be using a code manual which is split up into the different parts and systems of the body. Remember, the word "anatomy" pertains to the configuration of body parts and the relationship they have toward one another. The word "physiology" pertains to the way our body's structures operate. Instead of starting with the body as a whole, get to know the different groups of systems that the body is broken down into: body structure/functions, cells/tissues/membranes, skeletal system, muscular system, nervous system, endocrine system, cardiovascular system, lymphatic system, respiratory system, digestive system, urinary system and reproductive system. InnerBody.com is great reference site that allows you to explore the anatomy of the human body in depth by examining each system individually.
Learning the Basics: Coding Systems
Medical coding and classification systems have a range of functions within the field; for example, the classification codes used can fall under the category of: diagnostic codes, procedural codes, pharmaceutical codes or topographical codes. There are also an assortment of coding systems that can be used (they will vary according to the particular field or practice). That being said, the foremost coding systems you’ll want to become acquainted with are the CPT (Current Procedural Terminology), HCPS (Healthcare Common Procedure Coding System) and ICD (International Statistical Classification of Diseases and Related Health Problems). As mentioned on its site, The American Medical Association (AMA) developed CPT in 1966 and it is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. Within the Current Procedural Terminology, there are Category I CPT Codes, Category II CPT Codes: Performance Measurement and Category III CPT Codes: Emerging Technology. The World Health Organization (WHO) endorsed ICD codes, which contain a widespread alphanumeric system that’s used internationally and follows its classification of diseases. ICD codes are revised periodically; we are currently using ICD-10; the 10th revision version. HCPCS procedure codes are used to classify specific procedures, services, equipment and supplies that occur within health care transactions (www.cms.hhs.gov). These codes are then submitted to Medicare, Medicaid and other health insurance programs for reimbursement purposes.
Additional Tips & Considerations
Even if you are not enrolled in a medical coding class, you can still gain access to a number of the materials and guides that such classes use, for free. Create your own study guide and use flashcards to go over the information you learn, and obtain various medical documents to practice with. It’s worth taking the time to understand medical terminology and anatomy and physiology, as it will provide you with a solid foundation when it comes to looking up and identifying the correct numeric code within the primary sections of coding manuals. Additionally, use guides, tutorials, quizzes and assessments that are available online.
Serena Spinello holds two master’s degrees and is pursuing her Ph.D. in medical science. She has been a professional writer and researcher for over 10 years and is an active member of the American Medical Writers Association, Academy of Medical Educators, and the National Association of Social Workers.