The Best Way to Code Medical Files

Medical coding is the process of translating the descriptive text for medical diagnoses and procedures into the matching numeric or alphanumeric codes. Coding is an important process in health care reimbursement and billing, and also in the storage and retrieval of patient data. The process is performed by specially-trained health care professionals called medical coders. To appropriately assign codes to medical records, the coder must follow a specific strategy.

Adhering to Guidelines

• Coders are required to follow ethical standards and professional guidelines for assigning codes to medical records. Code assignments in medical records must be complete and accurate to promote high-quality health care data. Coding guidelines are provided by the American Health Information Management Association, American Hospital Association, American Medical Association, Centers for Medicare and Medicaid Services and National Center for Health Statistics. These organizations provide the professional coding rules and guidelines, such as which codes can be reported for specific health care settings.

Reviewing Documentation

• The coding process requires a complete review of a patient’s medical record. Major reports such as the discharge summary, history and physical, operative or procedure reports and physician progress notes give the most information on the patient’s diagnoses and procedures. The coder can then review other supportive documentation such as laboratory results, nursing notes and pharmacy reports in order to clarify information or provide the complete information needed for coding. For example, a physician progress note may document a patient infection. The coder can refer to the laboratory report to determine if there was a bacterial cause so that the most specific medical code is assigned.

Assigning Codes

• Guidelines are provided on how codes should be sequenced, or listed in the coding system and then transferred onto the medical claim for billing to the insurance payer. The reason the patient presented for treatment should be listed as the first diagnosis, with additional current illnesses and conditions listed as secondary. In addition, if a surgery was used to treat the condition listed first, it should also be listed first in the procedure section. Coding professionals can also assist in educating clinicians on how to document appropriately to support the coding function.

Discussing with Clinicians

• Many times a coder may find ambiguous, conflicting or illegible information in a patient’s record that may affect the way a code is assigned. Discussing the information with physicians or other clinicians is an appropriate route if there is questionable information. Helping to verify the information will ensure that the most accurate code is assigned so that reimbursement, billing and data integrity is maintained.