Clinical Coder
A Clinical Coder is a health information professional which duties are to analyze medical records and assign clinical standard codes using a clinical classification system.
- AKA: Medical Coding Professional, Medical Coder.
- Example(s):
- a skilled worker who converts information in patient discharge notes into clinical code.
- …
- Counter-Example(s):
- See: Clinical Terminology Standard, Clinical Coding Task, Medical Coding Dictionary, Health Information Management System, Healthcare, Current Procedural Terminology (CPT), Clinical Trial, Healthcare Common Procedural Coding System (HCPCS).
References
2022a
- (Wikipedia, 2022) ⇒ https://en.wikipedia.org/wiki/Clinical_coder Retrieved:2022-3-4.
- A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.
For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases (ICD), the Healthcare Common procedural Coding System (HCPCS), and Current Procedural Terminology (CPT) for reporting to the health insurance provider of the recipient of the care. The use of standard codes allows insurance providers to map equivalencies across different service providers who may use different terminologies or abbreviations in their written claims forms, and be used to justify reimbursement of fees and expenses. The codes may cover topics related to diagnoses, procedures, pharmaceuticals or topography. The medical notes may also be divided into specialities for example cardiology, gastroenterology, nephrology, neurology , pulmonology or orthopedic care. There are also specialist manuals for oncology known as ICD-O (International Classification of Diseases for Oncology) known as "O Codes" which are also used by tumor registrars (who work with cancer registries) as well as dental codes for dentistry procedures known as "D codes" for further specifications. A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information, health data standards, classification conventions, and computer- or paper-based data management, usually as obtained through formal education and/or on-the-job training. [1] [2]
- A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.
- ↑ World Health Organization. Classifying health workers: Medical records and health information technicians. Geneva, 2010.
- ↑ Department of Human Services, Victoria, Australia. Clinical Coders Creed. Health Data Standards and Systems Bulletin, Issue 13, 19 July 2000.
2022b
- (AAPC, 2022) ⇒ https://www.aapc.com/medical-coding/medical-coding.aspx Retrieved:2022-3-6.
- QUOTE: Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.
2021
- (Erstad, 2021) ⇒ Will Erstad (2021). "What is Medical Coder? An Easy Explanation". In: Rasmussen University - Health Sciences Blog.
- QUOTE: Before we talk about what medical coders do, it’s important to have a solid understanding of what medical coding is at its core. Medical coding and record keeping in a crude form can be tracked as far back as 17th-century England, but it has rapidly evolved during the past few decades(...)
There are two different types of medical codes primarily used in healthcare settings today: International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT)®(...).
Medical coders are the individuals responsible for translating physicians' reports into useful uniform medical codes. These professionals work behind the scenes in a variety of settings, ensuring all pertinent information is coded appropriately to ensure consistency and accuracy.
After a medical provider examines or treats a patient, the insurance company or government provider needs to understand what was done in order to process the bill. Common language is too inexact to give the insurance company the accurate details it needs, so a set of specific codes has been established to define medical procedures. It’s the role of the medical coder to pass along this information in a way that is useful and efficient.
- QUOTE: Before we talk about what medical coders do, it’s important to have a solid understanding of what medical coding is at its core. Medical coding and record keeping in a crude form can be tracked as far back as 17th-century England, but it has rapidly evolved during the past few decades(...)
2015
- (Nouraei, 2015) ⇒ Seyed Ahmad Reza Nouraei, Jagdeep Singh Virk, Anita Hudovsky, Christopher Wathen, Ara Darzi, Darren Parsons (2015)."Accuracy of clinician-clinical coder information handover following acute medical admissions: implication for using administrative datasets in clinical outcomes management". In: Journal of Public Health, 38(2).
- QUOTE: Clinical coding is the process of translating the pertinent events that occur over the course of a patient's encounter with a healthcare provider to an internationally recognized coded language (Fig. 1)[1]. The coded data are locally generated within clinical coding departments and are eventually aggregated into a single national dataset known as the Hospital Episode Statistics (HES) (hscic.gov.uk/casemix, accessed 28 November 2014). This dataset is the most comprehensive source of information about acute care provided within the United Kingdom National Health Service (hscic.gov.uk/casemix, accessed 28 November 2014). The clinical information it contains is increasingly used for audit and benchmarking of health services and outcomes at local, regional and national levels (drfosterintelligence.co.uk, accessed 28 November 2014).
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- ↑ Payment by Results Team. A Simple Guide to Payment by Results (Gateway Reference 18135). Leeds: Department of Health, 2012.
2010
- (Babre. 2010) ⇒ Deven Babre (2010). "Medical Coding in Clinical Trials". In: Perspectives in clinical research, 1(1), 29.
- QUOTE: Data generated in all clinical trial are recorded on the data collection instrument Case report Form/Electronic Case Report Form by investigators located at various sites in various countries. In multicentric clinical trials since different investigator or medically qualified experts are from different sites/centers recording the medical term(s) uniformly is a big challenge. Medical coders from clinical data management team process these terms and perform medical coding. Medical coding is performed to categorize the medical terms reported appropriately so that they can be analyzed/reviewed.