Medical Records Coding

Every time a patient is seen by a doctor or receives some form of medical treatment or intervention, a medical record is created. These medical records contain copies of the patient's medical history, current health problems and symptoms, notes pertaining to treatments and medications, results of various diagnostic tests and lab reports. Here is where medical records coding comes into play.

The information contained is used not only by doctors, nurses and various therapists but also by medical coders who are also known by the titles of medical coding specialist or health information technician. Medical coders use software programs, coding manuals or a combination of both to find the right code for each diagnosis and treatment. Codes for the same services vary depending on if the services were received in a doctor's office, hospital or long-term care facility. Medical coding in records are either numeric or alphanumeric designations which are uniformly used across the health care and insurance industry and by the federal government.

Medical Records Coding for Better Patient Care

This coding information is then used to bill the patient's insurance company for services. If the medical records coding is incorrect then payment may be denied or delayed. Use of the wrong code can also result in lower payment for services.

Coding data is also used to help improve patient care services. Various diagnoses and treatments can be studied through the sharing of information relative to various codes. Coding in medical records also allow for the sharing of health information without violating the confidentiality of specific patients. Coding is used in health research, in response to surveys and for clinical studies as well as can be used for legal purposes. Most states have a cancer register and track the types and incidence of cancer within age groups or by geographic areas. Such information can help researchers to identify trends such as an increased rate of a certain type of cancer or the success rate of various treatments.

Although medical records coding is not done by the people in the front lines of health care, medical coders are as key as any other member of the health care team in ensuring quality services and improvements in care for patients.

Medical Coding Nexus, conceptualized in Feb, 2005, is an online portal which provides up-to-date, pertinent information about medical coding and billing. Copyright @2005 Honlyn Limited All Rights Reserved

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