Why Is Medical Record Documentation So Critical in Relationship to Diagnostic Coding?

Diagnostic coding is a process by which descriptions in medical records are transformed into a numeric code for record keeping and billing purposes. Accurate documentation is critical to diagnostic coding -- a necessary part of any medical practice.

History

• Diagnostic coding came from the need to standardize and classify the terminology used by doctors when diagnosing diseases and symptoms, according to the Colorado Department of Public Health and Environment. In 1900, the first International Classification of Diseases was developed in Europe. Further classification was introduced in 1966 when the American Medical Association released the Current Procedural Terminology, which classifies tests and treatments.

Accuracy

• Documentation is the basis for coding. Incomplete documentation may result in an insurance company's refusal to reimburse for a test or service rendered. Medical coders may work with physicians to facilitate medical billing and record keeping. The patient's record must have explicit documentation for a medical coder to assign specific diagnostic codes.

Training

• The requirements of medical record documentation as related to diagnostic coding can be complicated. Initial training and refresher courses will help physicians and coders maintain accurate records and code properly.