Rules of Medical Coding

Medical records coders read physical medical records that contain notes by physicians and nurses, as well as patient test results. Coders convert that information into proper diagnosis and, sometimes, procedure codes. Overall, medical coding has two main purposes: billing and statistics. The rules for medical coding make sure that processes are properly followed to ensure that information is accurate.

Reading the Medical Record

• The biggest rule in medical coding is to read the medical record and code only what the medical record says. Though that statement seems to make sense, quite often what the medical record says and what was actually done don't quite match. Physicians and nurses often forget to write everything they do into the record, and by law, if it's not in the record, it wasn't done. Medical coders can't code based on what they know physicians and nurses did, and this can affect reimbursement in a negative way.

Altering the Medical Record

• Medical coders are not allowed to alter medical records for any reason. What the coder can do is contact the physician and ask for a review of the record to make any changes that are necessary for record-keeping purposes, not for reimbursement purposes. For instance, if a certain procedure required the physician to indicate whether it was a single or bilateral procedure, the medical coder would have to ask the physician to clarify that in the medical record if it was missing.

Coding Order

• Medical coders have to know how to interpret the medical record so they can list diagnosis and procedure codes in the proper order. They also need to know how to code when the reason a patient might have visited a physician may be related to a preexisting condition. For instance, coding for a bloody nose is fairly simple. But if the person is on blood thinners for a heart condition, that has to be taken into account. It's even more critical if that person is a hemophiliac. The rules state that coders always have to make the first code the specific reason the patient is there, and then add contributing codes in order of their relationship if they're available.

Billing

• Although medical coders aren't supposed to be concerned with billing, the truth is that how they code impacts how claims are paid. Inpatient claims are paid by diagnosis groups which are calculated by the order of diagnosis claims for a patient. Outpatient claims are paid by the relationship between the diagnosis and procedure codes.

Statistics

• Insurance companies compile these statistics to calculate how much they're going to pay for services on a yearly basis. They also look for trends on the health of the population they serve. Both state and federal governments use this same information to help set health care policy in general, but more specifically for Medicare and Medicaid patients.