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WHAT REALLY IS MEDICAL CODING

Converting a medical narrative into a series of codes which are standard and alpha numeric is the process called medical coding. All the medical information that is related with healthcare processes are converted into code in an accurate and detailed manner, this helps in delivering high quality healthcare to the patients. Coding also aids researchers as the information is arranged and can then be helpful in deriving new things and utilized in planning. Medical Coding is also known as clinical coding, healthcare coding and diagnostic coding in some jurisdictions.


Medical Coders
Healthcare professionals responsible for the coding process are the ones who are medical or clinical coders. They are responsible for the interpretation of all Electronic Medical Records and statements, they also do mapping of the results they find and apply analysis to the medical codes. These professionals of coding are present mostly in a large amount of environments related to healthcare but often are also operating in non-provider settings. All over the world medical coders are maintained, regulated and monitored by national associations which uphold their professional standards.

The Medical Coding Process
Health information management systems are widely used by medical administrations, organizations, insurance companies, governments, research institutions, international agencies and educational establishments. The output of these systems is the information that is the result of the coding process and it is a vital resource to all these organizations. The coding process is divided into three stages abstraction, assignment and review. It is internationally called as medical classification which is standardized process.

Abstraction is the process in which the medical coder focuses on analyzing a single health encounter of a specific patient or group of patients. Then the coder examines symptoms that the patient shows, how they are diagnosed, what treatments are given and the results of these treatments along with the final outcome of the whole process. In this stage the coder uses a wide variety of sources like clinical notes, surgical notes and laboratory test results to help him analyze and interpret the data.

The next stage is the assignment stage. In this stage the coder now focuses on mapping the data he gathered in the abstraction process to a number of standard codes. This phase is divided into two sub stages. Firstly to identify the appropriate codes and secondly entering the results into the management system. The information is stored mainly on a computer based relational database system.

The last step in this process is the most important step. In this step the coder has to create outputs that are appropriate and in coordination with the initial case inputs. It is vital to establish the outputs are representing the health encounter accurately and that the code was applied appropriately. There should be no redundancy and unnecessary medical codes applied to the case history.