MEDICAL CODING
Medical Coding is the process of using standardized coding systems to assign codes to diagnoses and procedures in order to accurately track and report healthcare services.
Code Assignment: Assign ICD-10-CM or ICD-11 diagnostic codes to describe a patient's medical condition or reason for the visit. Assign CPT or HCPCS codes to the services, treatments, and procedures done during the patient's visit.
Examine Patient Medical Records: To ensure proper coding, review patient medical records, including physician notes, laboratory findings, and other pertinent evidence.
Comply with all coding guidelines, rules, and regulations, including those established by government agencies (e.g., CMS) and medical coding organizations (e.g., AAPC or AHIMA).
Maintain Patient Privacy: In compliance with Health Insurance Portability and Accountability Act (HIPAA) rules, handle patient health information (PHI) in a secure and confidential manner.
Stay Current: Stay up to current on changes in coding standards and rules, as these can change on a regular basis. To keep informed, it is critical to pursue ongoing education.
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