Overview of Medical Coding

Abstract

Medical coding involves converting medical procedures, diagnoses, services, and equipment into alphanumeric codes. ICD codes are used to represent a patient's illness or injury, while CPT codes pertain to the services performed by healthcare providers for the patient. HCPCS level II codes are utilized for healthcare equipment and supplies. Each code comes with its own specific rules and guidelines, and they must be applied in a specific sequence. When billing for services, medical billers rely on the reported codes. Even a minor error can result in significant time spent identifying the source of mistakes and cause substantial delays in receiving payments. Medical coders from clinical data management team process these terms and perform medical coding. Medical coding is performed to categorize the medical terms reported appropriately so that they canbe analyzed/reviewed. This article describes process which is used for medical coding in clinical data management and two most commonly used medical dictionaries MedDRA and WHO-DDE in brief. It is expected to help medical coders to understand the process of medical coding in clinical data management. Few common issues which the medical coder faces while performing medical coding, are also highlighted.