A Brief Introduction to the Basics of Medical Coding
You may or may not be aware that medical coding is a vital part of the healthcare system. Every single illness, disease, treatment, procedure, test, and administrative task relating to patient care is coded in a universal language that helps with accurate treatment, reimbursement of expenses, and improvement of overall healthcare.
What Coding is Used?
There are a number of different coding structures used by the healthcare industry, and these are actually shared throughout the world. The good folk at Find-A-Code.com (https://www.findacode.com/) explain that different medical coding is used for different categories, such as diagnosis and treatment of diseases. To that end, below is a brief explanation of some of the codes that are most commonly used.
CPT, or current procedural terminology, codes are owned and maintained by the AMA (American Medical Association) and are alphanumeric codes with five characters. There are more than 8,000 codes in this set, and they are used to describe diagnostic, surgical, and medical procedures and services. Medical coders and billers use CPT codes to document and bill insurance companies and government agencies for any services that have been provided by the healthcare facility in question.
ICD, or international classification of diseases, codes are used to document various diseases, illnesses, and health conditions. Created by the World Health Organization (WHO), these codes are used globally to capture and identify health statistics and trends. The 11th edition of the system is currently being implemented in countries across the world.
HCPCS, or healthcare common procedure coding, is used to document equipment, supplies, chemotherapy drugs, ambulance services, and more.
CDT, or current dental terminology, codes are maintained and owned by the ADA (American Dental Association). These codes have five characters and all start with the letter D to denote dental treatments and procedures.
Coding in Practice
With hundreds of thousands of different codes used within the medical industry today, you might be forgiven for thinking that the practice of coding is one that requires years and years of training. However, medical coding is made simpler with online databases, which enable coders to search for the relevant code based on the information in a patient record.
That being said, medical coders do need to have education and training, which can take up to two years. Most employers require their medical coders be trained and certified, although some will offer on-the-job training.
It should also be noted that coders need to have a knowledge and understanding of basic medical terminology. They need to know which codes to use and when to use them. Some patient files are straightforward and easy to code; others are more complicated and may require the coder to do some detective work to ensure the right codes are used. It is important that all patient files are kept confidential to comply with the HIPAA (Health Insurance Portability and Accountability Act). Full training is usually provided on the employer’s procedures and policies around HIPAA compliance.
Medical coding involves translating patient records into readable codes that are used for statistic gathering but also by payers such as insurance companies and government agencies. There are different codes used depending on the information in the file. CPT codes are used to describe treatments and procedures, while ICD codes describe the illness, disease, or injury.
Those who work as medical coders usually need to be trained and certified, but can rely on online databases to help them find the relevant codes. This means there is no need to learn the thousands of codes to do the job.