MEDICAL CODING

 Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.

Medical coding happens every time you see a healthcare provider. The healthcare provider reviews your complaint and medical history, makes an expert assessment of what’s wrong and how to treat you, and documents your visit. That documentation is not only the patient’s ongoing record, it’s how the healthcare provider gets paid.

Medical codes translate that documentation into standardized codes that tell payers the following:

• Patient's diagnosis
• Medical necessity for treatments, services, or supplies the patient received
• Treatments, services, and supplies provided to the patient
• Any unusual circumstances or medical condition that affected those treatments and services

Like a musician who interprets the written music and uses their instrument to produce what's intended, Medical Coding requires the ability to understand anatomy, physiology, and details of the services, and the rules and regulations of the payers to succeed.

The healthcare revenue stream is based on the documentation of what was learned, decided, and performed.

A patient's diagnosis, test results, and treatment must be documented, not only for reimbursement but to guarantee high quality care in future visits. A patient's personal health information follows them through subsequent complaints and treatments, and they must be easily understood. This is especially important considering the hundreds of millions of visits, procedures, and hospitalizations annually in the United States.

The challenge, however, is that there are thousands of conditions, diseases, injuries, and causes of death. There are also thousands of services performed by providers and an equal number of injectable drugs and supplies to be tracked. Medical coding classifies these for easier reporting and tracking. And in healthcare, there are multiple descriptions, acronyms, names, and eponyms for each disease, procedure, and tool. Medical coding standardizes the language and presentation of all these elements so they can be more easily understood, tracked, and modified.

This common language, mandated by the Health information Portability and Accountability Act (HIPAA), allows hospitals, providers, and payers to communicate easily and consistently. Nearly all private health information is kept digitally and rests on the codes being assigned.

Medical Coding is best performed by trained and certified Medical Coders. The following example outlines what a typical day in the life of a Medical Coder may look like...

After settling into the office and grabbing a cup of coffee, a Medical Coder usually begins the workday by reviewing the previous day's batch of patient notes for evaluation and coding. The type of records and notes depends on the clinical setting (outpatient or facility) and may require a certain degree of  specialization (Healthcare systems may have individuals who focus on medical specialties while coders who work in smaller, or more general offices, may have a broad range of patients and medical conditions.).

Selecting the top patient note or billing sheet on the stack, the coder begins reviewing the documentation to understand the patient's diagnoses assigned and procedures performed during their visit. Coders also abstract other key information from the documentation, including physician names, dates of procedures, and other information.

Coders rely on ICD-10 and CPT code books to begin translating the physician's notes into useful medical codes. An example of basic procedure documentation and subsequently assigned codes can be seen below.

Many cases are simple to code. Individual Medical Coders develop a detailed understanding of the procedures and commonality of their specific clinic or facility. Coders occasionally encounter a difficult note requiring in-depth research, taking more time to code correctly. Even among the more commonly used codes are significant gray areas open for examination among coders. With very complex or unusual cases, coding guidelines may be confusing to interpret. Experienced coders will rely on their network of peers and professionals to discuss nuances in online forum, networking with specialists they have met at national conferences, or consulting with co-workers to help understand the issue and determine the proper codes. 

Finally, the coder completes the chart and begins the next patient record. This cycle of reading, note taking, assigning codes, and computer entry repeats with each chart. Most coders will spend the majority of their day sitting at the computer reading notes and using their computer to enter data into a billing system or search for information to clarify the documentation in the notes. 

This is a 40-year-old male with rectal pain, rectal bleeding, and some left-sided lower abdominal pain. The colonoscopy procedure and the risks, not limited to bleeding, perforation, infection, side effects from medication, need for surgery, etc., and were fully explained to the patient. An informed consent was taken.

Instrument Used: CF-Q160.
Sedation: Versed 5 mg IV in incremental doses and Demerol 100 mg IV in incremental doses performed by the anesthesia team.
Extent of Exam: Up to cecum as identified by ileocecal valve and appendiceal orifice.
Length of Scope Insertion: 110 cm.

Postop Diagnoses/Impression:
1. Moderate-sized, internal hemorrhoids.
2. Mild diverticulosis.

Description of Procedure: With the patient being in the left lateral position, first digital examination of the rectum was done, which was unremarkable. Then, the CF-Q160 was passed through the rectum under direct visualization and advanced all the way to cecum. The cecum was identified by ileocecal valve and appendiceal orifice. There were a couple of tics/diverticula seen on the left side of the colon. A careful look was taken while withdrawing the scope. Retroflex view in the rectum showed moderate-sized internal hemorrhoids.

Plan:
1. Anusol-HC suppositories for hemorrhoids.
2. High-fiber diet.
3. If there is no family history, a follow-up colonoscopy in 10 years.

CPT® Code: 45378
ICD-10-CM Codes: K64.8, K57.30