Medical Records & Coding

Medical coders work in hospitals, doctor's offices and other facilities. They use patient's medical records to determine which procedures to bill to the insurance company. Physicians and other medical staff are required to provide complete and accurate medical records for medical coders to translate the information and perform medical coding. Using the medical records to determine which codes to bill ensures that the proper codes that match the procedures are billed.

Records

• Medical records consist of the information concerning a patient and his medical treatment and are considered legal documents. The medical records for a patient must contain a form of patient identification, such as a name or patient number, the diagnosis that denotes medical necessity for treatment, the level of care offered and procedures performed along with any other information the physician or staff finds appropriate.

Determining Coding

• A medical coder reviews a patient's medical records and other documentation, such as test results, available. She uses the information to determine what procedures were performed and which diagnosis justify the procedures.

Current Procedural Terminology

• The standard used for coding procedures is the Current Procedural Terminology, or CPT manual set forth by the American Medical Association. Medical coders determine which CPT code to use to represent procedures done in a medical office, hospital or other medical facility by a patient's medical records. The codes consist of five numerical digits. Each code is related to a medical service, like office visits, X-rays and therapy.

International Classification for Diseases (ICD)

• The International Classification for Diseases, or ICD, sets for the coding standards for diagnosis codes. These codes consist of three digits and may contain up to two decimal places if required. Upon reviewing medical records, the coder determines which ICD code is equivalent to the diagnosis listed. Each code represents a condition or symptom that is used in conjunction with a CPT code to denote medical necessity.

Correcting Coding Errors

• In the event a claim is rejected by the insurance company due to incorrect coding, the medical coder corrects the codes and re-bills the claim as a "corrected claim." In certain instances, the medical coder may be required to send medical records along with the corrected claim to show the correct procedure and diagnosis code is billed. This requires the medical records to be completed in an accurate manner.