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Medical coding and history


Medical coders review the documents in the patient’s medical record and abstract (collect clinical data) or retrieve information from specific documents. They then assign numeric or alphanumeric codes to each piece of data they retrieve. Medical coders must use their skills in research, reasoning, and interpretation of medical coding guidelines to ensure that physicians and hospitals are reimbursed accurately and completely for the services that they provide. This part of your program will introduce you to this exciting field. You’ll learn all about ICD-10 medical coding and the steps involved in assigning diagnosis and procedure codes using this code set. The material that follows will lead you step-by-step through a wide range of ICD-10 coding examples, offering invaluable tips and suggestions that you can use along the way. The same tips and suggestions that you use in Basic Medical Coding Using ICD-10 will also serve as a foundation for your next two courses, Intermediate Medical Coding and Advanced Medical Coding Scenarios. You’ll also find Quick Checks and Exercises in your textbook. Be sure to complete all of these additional practice tools to help you fine-tune coding skills, master the fine points of ICD-10 coding, and learn about a wide range of medical terms. Doing so will further sharpen your skills, strengthen your ability to accurately interpret these terms, and, in turn, translate these terms into accurate code. By choosing to learn medical coding, you’re embarking on a journey that essentially means learning a new language. Although this new language may seem a bit complicated and overwhelming at first, it becomes easier once you learn the basics of ICD-10 coding (and with lots and lots of practice). Your confidence will increase as you learn the basics and then apply what you learn to basic coding scenarios.

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Recent changes in healthcare have created a great demand for medical coders. An older population; advances in techno - logy; an increased demand for healthcare services; and an increase in the number of medical tests, treatments, and procedures means that the number of people seeking healthcare services has increased. 




Additionally, the increased use of outpatient facilities means that the government is exerting greater control and becoming more involved with services provided to Medicare and Medicaid patients. These changes in healthcare have resulted in an increased demand for certified medical coders. Prominent healthcare organizations in the field of medical coding include the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Both of these organizations offer credentials in medical coding. Certifications offered by both organizations are nationally recognized and accepted by healthcare employers worldwide. Most coders choose to sit for one of four certifications: the CPC-A, CPC, CCS, or CCS-P. The CPC-A and the CPC are both offered by the AAPC. CPC (Certified Professional Coder) indicates that you’ve completed the necessary educational requirements and now have experience in the field. In CPC-A, the A stands for apprentice. The CPC-A demonstrates that you’ve completed the necessary educational requirements for a career in coding, but haven’t yet obtained the required experience in reviewing, abstracting, interpreting, and correctly assigning codes. After you earn the required two years of full-time coding experience, the A is dropped from the credential and you become a CPC. CCS and CCS-P are certifications offered by AHIMA. CCS (Certified Coding Specialist) demonstrates that you’ve gained proficiency in assigning codes to inpatient as well as outpatient medical records. CCS-P indicates that a coder is adept at coding medical records in the outpatient setting, such as in the physician’s office, emergency room, or clinic. Although many coders do, it isn’t necessary to earn more than one credential to demonstrate proficiency in a certain area of coding. At least one credential is needed to gain entry into the field of medical coding. Basic Medical Coding Using ICD-10, Intermediate Medical Coding, and Advanced Medical Coding Scenarios combine in one comprehensive package to prepare you to sit for the CPC-A exam, pass the exam, and become a working medical coder! Success in medical coding means being able to convert medical terms into standardized numeric and alphanumeric codes for physician and hospital reimbursement. The rule of thumb for medical coding is: If it wasn’t documented, it wasn’t done. While coders are primarily concerned with correct interpretation of coding guidelines, accurate code assignment, and optimized reimbursement for physicians and hospitals, medical coding also involves ethical concerns. Medical coders must ensure that the codes they select accurately reflect what’s in the patient’s medical record. All diagnosis and procedure codes should be assigned based strictly on the content of the medical record. Coders use standardized code sets to assign codes for diagnoses, procedures, drugs, medical devices, supplies, and equipment. (You’ll learn more about the code set used for drugs, medical devices, supplies, and equipment in Intermediate Medical Coding). Accurate and complete coding helps minimize turnaround in terms of medical claims processing, and as a result, it helps expedite reimbursement for physicians and hospitals. In addition to increasing the likelihood of faster claims turnaround, accurate and complete coding also minimizes the likelihood of fraud. Medical coders are required by law to assign codes based only on the documentation in the medical record. Assigning codes that aren’t supported by the medical record to increase reimbursement constitutes fraud and can result in civil and criminal penalties for healthcare facilities. Proficiency in medical coding means learning both how to determine the specific piece of data that requires a code assignment and the rules for assigning your codes.

Coders use two types of tools to assign codes: textbooks and/or encoders. Encoders are coding software programs that you can use to locate and assign diagnoses and procedure codes. However, when you test for a medical coding certification such as the CPC-A, you’ll be required to use your coding textbooks to assign codes. The textbooks that you’ll use in this course are

  The International Classification of Diseases, 10th Revision, Clinical Modification (commonly referred to as ICD-10-CM) The International Classification of Diseases, 10th Revision, Procedure Coding System (commonly referred to as ICD-10-PCS) To be successful in medical coding, you must be

Detail oriented. In medical coding, the old adage “little things mean a lot” is especially true. The descriptions for two codes may be identical except for one word. That one word may be the difference in choosing code A vs. code B. If you’re good at picking up on the little things, then you’ll enjoy coding.

A detective. If you like being a sleuth and researching coding guidelines to understand how, when, and where you should assign a specific code, then you’ll like medical coding.

A good storyteller. Much of coding involves reading the medical record and then painting a mental picture in your mind of what took place, as if you were right there in the doctor’s office or emergency room. If you can visualize what occurred based on what you read in the medical record, you’ll love medical coding.

Analytical. If you’re good at analyzing pieces of information from different documents in the same record and finding contradictory information, then medical coding is a great career choice for you. Maybe you’re working on a medical chart for a patient who was admitted to the hospital. Dr. Brown’s report indicates that the patient has diabetes, which is well controlled on insulin, but Dr. Smith’s report indicates that the patient has diabetes, but it isn’t well controlled on insulin. These are two different doctors saying two different things about the same patient’s diabetes, and hence, these two statements would translate into two different diabetes codes for the same admission. You would need to determine which statement is correct so that you can assign the right code. In the previous example, you’d need to send a query to the hospital to determine whether the patient’s diabetes is controlled or out of control. You’d then assign your diabetes code based on the answer that you receive from the hospital, and the answer would be placed in the patient’s medical record so that the record is kept up to date. You develop each of these skills as you proceed through Basic Medical Coding Using ICD-10, as well as the courses that follow. In addition to being able to accurately review and abstract clinical data from the medical record, good computer skills are essential to your success as a medical coder for several reasons.

1. If you work from home, you’ll need to set up a connection to your employer’s office or the hospital client that you’re assigned to in order to access medical charts. Your company’s IT department or the hospital’s technical support department will help you do this. You may need to access and navigate specific websites and download certain programs in order to sign in to the system and begin to code your charts. The setup process should be relatively simple, but you’ll need to be able to follow the directions provided by the IT person to set up the website links on your computer and begin coding.

On a daily basis, you’ll log in to the website provided by your company, retrieve charts, open reports within each chart, and review the documents in order to locate your codes. 3. You’ll also need to go online to research medical or surgical terms that pertain to a specific diagnosis or procedure. This is why it’s important to complete courses in medical terminology, anatomy, and physiology in addition to your coursework in medical coding. Once you start working as a coder, you’ll find that the opportunities in coding are plentiful, from coding for doctors’ offices and hospitals to educating new coders. You’ll likely have more than one kind of coding position during your career. You might initially start working as a medical coder and later become a medical coding auditor, for example. A medical coding auditor reviews the charts coded by the medical coders, pinpoints errors, and provides feedback on making corrections. The auditor also provides references to supplemental coding documents to help coders improve their accuracy. You might become a medical coding supervisor, overseeing a team of medical coders and assigning accounts. Or, you may choose to specialize in one particular area of medical coding, such as cancer registry, where you review medical records and capture diagnoses for cancer patients, and obtain a medical coding certification in cancer registry. 

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