A deep dive into medical coding

A deep dive into medical coding

Quality healthcare for all is the biggest priority for the medical industry – no wonder, consistent efforts are being made to improve the accuracy of services. Medical coding is one such profession that ensures consistency – through this process, long and cumbersome medical reports are translated into short codes. In a nutshell, any healthcare diagnoses, procedures, as well as information about any equipment are converted into universal medical alphanumeric codes.

As we go along, let us understand who a medical coder is, what their role entails, and the tools that assist them in their profession. 

Who Is A Medical Coder?

We have already described the process of medical coding, but who exactly is a medical coder? It is an individual who carries out this particular job, ensuring all the critical information is properly coded and nothing is lost. 

After a patient is treated by a physician, the insurance company that is in touch with them needs accurate information to process the bill. In most cases, the common language isn’t enough to explain the details, which is where the medical coder steps in. There are several medical procedures that can be defined using a set of specific codes. 

There are largely three sets of medical codes – Current Procedure Terminology (CPT), International Classification of Diseases (ICD), and Health Care Procedural Coding System (HCPCS). 

The medical coder translates the medical reports of a patient into the desired language. Insurance companies then review and validate the treatment given for a particular condition. Once this step is carried out, the processing of claims begins. Thereafter, healthcare facilities are compensated for their services, depending on the patient’s insurance coverage and other factors.

What Does A Medical Coder Do?

Contrary to popular perception, medical coders do not just work in hospitals, but also in dental clinics, rehabilitation facilities, and therapy centers. Here are some of the tasks they carry out on a typical day: 

  • Evaluate a patient’s report and present meaningful information
  • Sequence all codes that are rendered to a patient 
  • Re-evaluate and review the coding to ensure accuracy has been maintained
  • Train physicians and other people who are a part of their team in medical coding 
  • Ensure compliance with state and central governments, with regard to medical coding protocol
  • Analyze documents for any missing information 
  • Ensure accurate information has been filled in, so that no claims are rejected

There are several tools that a medical billing and coding specialist uses, as part of their job. A digital coding tool that includes ICD, HCPCs, and CPT codes can be particularly helpful. These also come with features like main term search, spell checks, annotation, and notes, as well as a multi-screen view. The coding software must ensure accuracy in the process, so that claims are not rejected by the insurance company. 

How Can You Become A Medical Coder?

There are certain qualities that are essential, if you want to become a medical coder. Strong attention to detail, effective communication and organizational skills, computer literacy, and understanding of basic medical terminology are critical, if this is a profession one wants to pursue. 

Here are the next steps to follow to become a medical coding professional

  • Go for a Bachelor’s degree in Biology, Life Science, Biotechnology, Botany, or Zoology. Any other related field is also a good starting point. 
  • Join a coding-specific training program that will help gain a better understanding of various medical concepts. 
  • Gain professional experience by working as a medical coder. This will ensure hands-on training to understand the nuances of the trade. 
  • Although certifications are not a mandate, getting a few will provide medical coders with an edge in the professional world.
  • Next, a postgraduate diploma in medical coding will help in strengthening the skillset.

Medical Coding With ScribeEMR

ScribeEMR employs comprehensive, rigorous processes in delivering accurate medical coding, ensuring that clinicians and healthcare providers are adequately reimbursed for the services they provide. We have recruited highly-skilled, certified medical coders that help healthcare facilities streamline their medical coding and billing, optimizing their cash flow and revenue cycle. 

The team of medical coders is CPC-certified and highly skilled in expertly analyzing clinical documentation, from the type of visit to the diagnosis to the treatment offered. This information is then accurately translated in the form of ICD and CPT codes using highly advanced tools and software.

Our medical coders are well-versed with the latest and revised Evaluation and Management (E/M), ICD-10, HCPCS, and CPT codes, ensuring optimized coding and accurate billing. We make consistent efforts to eliminate any instances of over-coding and under-coding, so that no penalties crop up for our customer base. 

ScribeEMR is in complete compliance with all HIPAA rules. Our medical coders undergo the required training through our Learning Management System, so that they are up-to-date in all aspects!

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