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Medical Coding & Documentation

Medical coding and documentation is a field of study an individual can enter without clinical training. Certainly medical professionals with clinical training, such as nurses and physicians, have medical coding knowledge, but others in the administration side of medical practices take courses to learn about medical coding and documentation. These skills are highly valued in the workplace as they allow medical facilities to run more smoothly.

  1. Uses

    • Medical coding and documentation are used to make communication flow more easily between doctors and medical facilities. Medical codes are a string of numbers attached to a certain diagnosis or medical procedure. When someone uses this code, anyone who is trained in medical coding will know what the person meant without confusion.

    Benefits

    • Medical coding and documentation allow patients to move between doctors without problems. Specialists all seeing one patient can pass information on without hassle. Using universal forms of medical documentation make patient care less error-prone.

    Insurance

    • Another reason for universal medical coding and medical documentation is that doctors and hospitals need to bill insurance companies easily and effectively. The Health Care Financing Administration (HCFA) is the governing body for Medicaid and Medicare, and officials from this group release documentation standards for billing Medicaid and Medicare. These standards tend to become the norm for private insurance as well.

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