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What is Medical Coding?

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Medical coding specialists works in all kind of healthcare facilities, from medical offices and hospitals to rehabilitation centers, skilled nursing facilities and more. Then, what is Medical Coding?

Medical coding is the translation of diagnosis, treatments, supplies, medical services and equipment into alphanumeric codes, classified in ICD-10- CM, ICD-10-PCS, HCPCS, Revenues Codes and CPT. The diagnoses and procedure codes are taken from medical record documentation. A medical coder is responsible for assigning the correct code to describe the type of service a patient received.

What do a medical coder do?

The day-to-day work of a medical  coding specialist includes:

  • Assign codes to diagnoses, procedures, medical services, supplies or equipment using ICD (International Classification of Diseases), CPT (Current Procedural Terminology) codes, HCPCS and  Revenues codes.
  • Ensure codes are accurate and sequenced correctly in accordance with guidelines and insurance regulations
  • Follow up with the provider on any documentation that is insufficient or unclear
  • Communicate with other clinical staff regarding documentation
  • Search for information in cases where the coding is complex or unusual
  • Receive and review patient charts and documents for accuracy
  • Ensure that all codes are current and active
CPT® codes are copyrighted by the American Medical Association

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