How to Read Medical Codes

Otherwise known as medical documentation, in simpler terms, medical coding is the translation of the diagnoses and medical procedures concerning the patient. The information is translated through a standard coding process which is classified into a series of code numbers illustrating the diagnoses or procedures performed. The utilization of the medical language varies from each geographical locality. This coded information is used to manage the care of the patient, research, financial reimbursements as well as the assessment of services rendered. Each service delivered to the patient needs to be summarized for statistical and billing purposes. The determinants of which coding system is to be utilized are the type of procedure, who performed the procedure and its location.

Things You'll Need

• Patient's chart
• Computer or simple encoder

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Instructions

• 1

  Check the patient's chart to have knowledge of his condition such as the chief complaints, physician's impression and diagnosis.

• 2

  Note the code assigned to the condition, as there is a designated code for every diagnosis and procedure performed.

• 3

  Enter the designated code or number into the simple encoder or the computer.

• 4

  Wait until a list of entries appear.

• 5

  Verify the designated number in the tabular list such as the numerical part of the International Classification of Diseases or ICD-9-CM utilized for Diagnostic Coding.
  For example, the diagnostic terms listed under 034.0 do not only include streptococcal pharyngitis but streptococcal laryngitis and tonsillitis as well. Thus, the designated coding indicates that the patient had a streptococcal infection located at some portion of the throat but not limited to or specific to the pharynx.

• 6

  Select the correct entry from the tabular list.

• 7

  Answer the simple encoder's follow-up questions that will help confirm the diagnosis or procedure before a code has been selected.