Medical coding involves assigning numeric or alphanumeric codes to diagnoses and procedures. The purpose of medical coding is to translate medical documents into a standardized language that can be used for billing, reimbursement, and record-keeping between healthcare providers and institutions.
The two main code sets used in the United States are the American Medical Association’s Current Procedural Terminology (CPT) and the International Classification of Diseases, Tenth Revision (ICD-10) by the World Health Organization. The ICD-10 has two subsets, the Procedural Coding System (ICD-10-PCS) used primarily in inpatient and hospital settings and the Clinically Modified (ICD-10-CM) code set for clinical and outpatient settings. These diagnostic and procedure codes are used across public and private healthcare systems and updated annually.
When a hospital or medical practice receives a new patient, they need to learn the patient’s medical history to provide the best treatment. But thousands of diagnoses, procedures, tools, and services exist, and clinicians need to get up to speed on medical records in a short amount of time.
Medical codes allow healthcare professionals to efficiently share patient information between organizations. Instead of reading a myriad of documents, practitioners use the shorthand medical codes as a common language to communicate complicated details in just a few letters and numbers.
Coding also helps finance teams understand why patients received the treatments and services for which providers are seeking reimbursement. Healthcare organizations bill patients and insurance companies by quantifying their work in medical codes. Accurate, up-to-date coding is the key to optimizing revenue and ensuring practitioners get paid for every service they provide.
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