MEDICAL CODING AND BILLING
Medical coding is the process of collecting health care information from a patient's physician's notes, such as medical procedures, diagnoses, essential medical equipment, and medical services. This information is converted into universal medical alphanumeric codes by a medical coder.
Medical coders are essential members of the healthcare team because they accurately translate medical services and diagnoses into standardized codes for billing, insurance claims, and medical record-keeping. Their roles and responsibilities may include the following:
Medical coders analyze patient medical records, including physician notes, test findings, and other paperwork, to identify the medical services given and diagnoses made during the patient's visit.
Coders use code sets such as ICD-10 (diagnoses) and CPT (procedures) to assign appropriate codes to reflect the services and diagnoses. They must guarantee accuracy and adherence to coding standards.
Ensuring Data Accuracy: Coders are responsible for ensuring that medical records are accurate and comprehensive. They may need to consult with healthcare specialists to clarify any unclear or missing information.
Coding Guidelines: Coders must adhere to specified coding guidelines, rules, and regulations in order to ensure coding integrity and compliance. They must stay current on coding changes and updates.
Maintaining Patient Privacy: To protect sensitive patient information, coders must follow patient privacy and confidentiality standards such as HIPAA.
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