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Certification !er!iew "edica# Coding Certification "edica# $i##ing Certification "edica# %uditing Certification "edica# Co&'#iance Certification (ractice "anager Certification Locate E)a& (re'are for E)a& E)a& Ti's Credentia# *erification +%,

-o&e . "edica# Coding . /0at is "edica# Coding1

What is Medical Coding?

"edica# coding 'rofessiona#s 'ro!ide a ke2 ste' in t0e &edica# bi##ing 'rocess3 E!er2 ti&e a 'atient recei!es 'rofessiona# 0ea#t0 care in a '02sician4s office5 0os'ita# out'atient faci#it2 or a&bu#ator2 surgica# center 6%SC75 t0e 'ro!ider &ust docu&ent t0e ser!ices 'ro!ided3 T0e &edica# coder wi## abstract t0e infor&ation fro& t0e docu&entation5 assign t0e a''ro'riate codes5 and create a c#ai& to be 'aid5 w0et0er b2 a co&&ercia# 'a2er5 t0e 'atient5 or C"S3

(re'are for certification and a career in &edica# coding

*a#idate 2our know#edge5 ski##s5 and e)'ertise wit0 &edica# coding certification

Is Medical Coding the same as Medical Billing?

No3 /0i#e t0e &edica# coder and &edica# bi##er &a2 be t0e sa&e 'erson or &a2 work c#ose#2 toget0er to &ake sure a## in!oices are 'aid 'ro'er#25 t0e &edica# coder is 'ri&ari#2 res'onsib#e for abstracting and assigning t0e a''ro'riate coding on t0e c#ai&s3 In order to acco&'#is0 t0is5 t0e coder c0ecks a !ariet2 of sources wit0in t0e 'atient4s &edica# record5 6i3e3 t0e transcri'tion of t0e doctor4s notes5 ordered #aborator2 tests5 re8uested i&aging studies and ot0er sources7 to !erif2 t0e work t0at was done3 T0en t0e coder &ust assign C(T9 codes5 ICD-: codes and -C(CS codes to bot0 re'ort t0e 'rocedures t0at were 'erfor&ed and to 'ro!ide t0e &edica# bi##er wit0 t0e infor&ation necessar2 to 'rocess a c#ai& for rei&burse&ent b2 t0e a''ro'riate insurance agenc23 T0ere is a great dea# of di!ersit2 a&ong t0e nu&erous c#ai&s a &edica# coder 'rocesses on a dai#2 basis3 /0i#e codes !ar2 a great dea# in breadt0 and s'ecificit25 t0e fo##owing artic#e re'resents w0at a sa&'#e &edica# coding transaction &a2 #ook #ike3 Article: /0at Does a "edica# Coder Do1 It takes a good dea# of education and training to beco&e a ski##ed &edica# coder3 To begin5 coders &ust 0a!e a t0oroug0 know#edge of anato&2 and &edica# ter&ino#og23 It is a#so i&'ortant to beco&e fa&i#iar wit0 different t2'es of insurance '#ans5 regu#ations5 co&'#iance5 and t0e coding co&&unit24s t0ree critica# resource books; C(T95 -C(CS Le!e# II and ICD-:-C" a#ong wit0

t0eir corres'onding codes and guide#ines3 <sing code books t0e &edica# coder assigns correct codes to record t0e ser!ice #e!e#s for t0e 'rocedures 'erfor&ed and to account for su''#ies used to treat t0e 'atient during an encounter wit0 t0e '02sician3 (ro'er assign&ent of ICD-:-C" codes corres'onds wit0 t0e '02sician4s diagnoses and co&'#etes t0e =stor2> of t0e 'atient4s i##ness or in?ur23 n ctober 15 @01A t0e <nited States wi## ado't t0e #atest !ersion of &edica# codes b2 u'dating to ICD-103 Last u'dated in 1:BB t0e new ICD-10 wi## increase t0e nu&ber of codes fro& a''ro)i&ate#2 1C5D00 to &ore t0an 1AA50003 Read "ore; -ow t0e Transition fro& ICD-: to ICD-10 wi## %ffect Coding and t0e "edica# Co&&unit23 In addition to assigning ICD-:5 C(T95 and -C(Cs codes5 toda24s &edica# coder &a2 be in!o#!ed in a wide !ariet2 of coding-re#ated acti!ities3 T0e coder &a2 audit and re-fi#e a''ea#s of denied c#ai&s3 T0e coder &a2 a#so educate 'ro!iders and reco&&end t0e a''ro'riate a''#ication of federa# &andates and co&'#iance t0at re8uire 'ro!iders to use s'ecific coding and bi##ing standards t0roug0 c0art audits3 -e/S0e &a2 a#so act as an ad!ocate for t0e 'ro!ider and 'atient in issues of co!erage and &edica# necessit23 Starting a career in &edica# coding o'ens a nu&ber of coding-re#ated ?obs #ike Certified (rofessiona# "edica# %uditor 6C("%975 Certified (rofessiona# Co&'#iance fficer 6C(C E75 and Certified (02sician (ractice "anager 6C(("973

RELATED ARTICLES: /0at "edica# Coding Training is Re8uired to $eco&e a Coder1 /0at Does a "edica# Coder Do1

What Education and Medical Coding Training is Required to Become a Medical Coder?
/0i#e &an2 coding 'rofessiona#s 0a!e strengt0ened t0eir career b2 earning t0eir bac0e#or4s degrees and &aster4s degrees5 neit0er is re8uired for a career in &edica# coding3 /0at is re8uired is a so#id understanding of anato&25 '02sio#og2 and &edica# ter&ino#og23 It is a#so 0ig0#2 reco&&ended for serious coders to co&'#ete a &edica# coding course of stud25 'ass t0e C(C e)a& and earn t0eir certification as a Certified (rofessiona# Coder5 or C(C93 Certified

(rofessiona# Coders5 or C(Cs95 are in 0ig0 de&and because e&'#o2ers know t0at t0ese indi!idua#s can 'erfor& t0e ?ob of &edica# coder wit0 t0e ut&ost 'roficienc23 Toda2 &ore t0an 1@D5000 &edica# 'rofessiona#s are &e&bers of %%(C3 T0is 'rofessiona# association 'ro!ides a !ariet2 of o''ortunities to e#e!ate t0e standards of &edica# coding b2 de!e#o'ing training5 'rofessiona# certification5 o''ortunities to network wit0 ot0er re#ated &edica# 'rofessiona#s and a !ariet2 of ?ob searc0 database and career bui#ding o''ortunities3 Learn &ore about %%(C and take ad!antage of t0e works0o's5 on-de&and webinars5 regiona# and nationa# conferences5 and t0e &ont0#2 &agaFine5 Coding Edge to de!e#o' 2our ski##s and stand out in 2our fie#d3 %s a &e&ber of %%(C 2ou wi## a#so be ab#e to &eet ot0er coding 'rofessiona#s b2 'artici'ating in t0e coding discussion foru&s5 +acebook grou'5 or one of &ore t0an GG0 #oca# c0a'ters t0roug0out t0e <nited States and out#2ing areas3 %%(C &e&bers a#so en?o2 0uge sa!ings on &edica# coding books as we## as a !ariet2 of ot0er &e&bers-on#2 e)c#usi!e discounts3 Since its ince'tion &ore t0an @0 2ears ago %%(C 0as de!e#o'ed a wide !ariet2 of 'rofessiona# credentia#s a##owing its &e&bers to stand out a&ongst t0eir 'eers and !a#idate t0eir e)'ertise in a !ariet2 of fie#ds3 Coders &a2 c0oose to broaden t0eir ski##s b2 e)tending into &edica# auditing5 co&'#iance5 out-'atient 'ractice5 or 'ractice &anage&ent3 t0ers &a2 c0oose to co&'#ete a &edica# coding training course or s'ecia#iFe b2 earning one of %%(C4s s'ecia#t2 credentia#s3 T0e %%(C credentia# is recogniFed nationa##2 b2 e&'#o2ers5 &edica# societies and go!ern&ent organiFations3 T0e2 are a great wa2 to start a career in &edica# coding and t0e recent &edica# coding sa#ar2 sur!e2 suggests t0at %%(C certified coders earn significant#2 &ore t0an noncredentia#ed coders3

Where Do I Begin?
If 2ou are interested about w0at 2ou 0a!e read so far about %%(C and o''ortunities 'ursuing &edica# coding5 &edica# auditing5 'ractice &anage&ent5 co&'#iance5 or one of t0e ot0er s'ecia#iFed credentia#s 2ou can start 2our new career b2 ?oining %%(C or b2 registering for one of t0e &edica# coding training courses toda23

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"edica# Coding Career Sur!e2 H Discount Coding $ooks H "edica# Coding Training and Education H "edica# Coding Certifications H Certified (rofessiona# Coder 6C(C97 H Coding S'ecia#ties H n#ine +oru& H "edica# Ter&ino#og2 and Coding I#ossar2 H +ind Coding Jobs in Jour %rea

Medical classi&ication
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Medical classi&ication5 or medical coding5 is t0e 'rocess of transfor&ing descri'tions of &edica# diagnoses and 'rocedures into uni!ersa# &edica# code nu&bers3 T0e diagnoses and 'rocedures are usua##2 taken fro& a !ariet2 of sources wit0in t0e 0ea#t0 care record5 suc0 as t0e transcri'tion of t0e '02sicianKs notes5 #aborator2 resu#ts5 radio#ogic resu#ts5 and ot0er sources3 Diagnosis codes are used to track diseases and ot0er 0ea#t0 conditions5 w0et0er t0e2 are c0ronic diseases suc0 as diabetes &e##itus and 0eart disease5 to contagious diseases suc0 as noro!irus5 t0e

f#u5 and at0#eteKs foot3 T0ese diagnosis and 'rocedure codes are used b2 go!ern&ent 0ea#t0 'rogra&s5 'ri!ate 0ea#t0 insurance co&'anies5 workersK co&'ensation carriers and ot0ers3 "edica# c#assification s2ste&s are used for a !ariet2 of a''#ications in &edicine5 'ub#ic 0ea#t0 and &edica# infor&atics5 inc#uding;

statistical analysis of diseases and therapeutic actions reimbursement; e.g., based on diagnosis-related groups knowledge-based and decision support systems direct surveillance of epidemic or pandemic outbreaks

Contents
!lassification types " W#$ Family of %nternational !lassifications o ". &eference classifications o "." 'erived classifications o ".( &elated classifications ( $ther medical classifications o (. 'iagnosis o (." )rocedure o (.( $ther (.(. *ibrary classification that have medical components + %!', ,-$./' and /lectronic #ealth &ecord 0/#&1 o +. What is ,-$./'2 o +." What is %!'2 o +.( ,-$./' !3 vs %!' o +.+ 'ata .apping of ,-$./' and %!' 4 !linical !oding in 5ustralia o 4. What is clinical coding2 o 4." What does clinical coder do2 o 4.( What is coded data used for2 6 ,ee also 7 &eferences 8 /9ternal links

Classi&ication t'(es
"an2 different &edica# c#assifications e)ist5 t0oug0 t0e2 occur into two &ain grou'ings; Statistical classifications and Nomenclatures3 % statistical classi&ication brings toget0er si&i#ar c#inica# conce'ts and grou's t0e& into categories3 T0e nu&ber of categories is #i&ited so t0at t0e c#assification does not beco&e too big3 %n e)a&'#e of t0is is t0e Internationa# Statistica# C#assification of Diseases and Re#ated -ea#t0 (rob#e&s 6known as ICD73 It grou's diseases of t0e circu#ator2 s2ste& into one Lc0a'terL 6known as C0a'ter IM5 co!ering codes I00HI::73 /it0in t0is c0a'ter5 t0ere is for instance5 code IAB313 T0e code tit#e 6rubric7 is Su'ra!entricu#ar tac02cardia3 -owe!er5 t0ere are se!era# ot0er c#inica# conce'ts t0at are a#so c#assified 0ere3 %&ong t0e& are 'aro)2s&a# atria# tac02cardia5 'aro)2s&a# ?unctiona# tac02cardia5 auricu#ar tac02cardia and noda# tac02cardia3

%not0er feature of statistica# c#assifications is t0e 'ro!ision of residua# categories for Lot0erL and Luns'ecifiedL conditions t0at do not 0a!e a s'ecific categor2 in t0e 'articu#ar c#assification3 In a nomenclature t0ere is a se'arate #isting and code for e!er2 c#inica# conce't3 So5 in t0e 're!ious e)a&'#e5 eac0 of t0e tac02cardia #isted wou#d 0a!e its own code3 T0is &akes no&enc#atures unwie#d2 for co&'i#ing 0ea#t0 statistics3 T2'es of coding s2ste&s s'ecific to 0ea#t0 care inc#ude;
'iagnostic codes

- %re used to deter&ine diseases5disorders5 and S2&'to&s -Can be used to &easure &orbidit2 and &orta#it2 E)a&'#es; ICD-:-C"5 ICD-10
)rocedural codes

-T0e2 are nu&bers or a#'0anu&eric codes used to identif2 s'ecific 0ea#t0 inter!entions taken b2 &edica# 'rofessiona#s3 E)a&'#es; IC("5 IC-I
)harmaceutical codes

-%re used to identif2 &edications E)a&'#es; %T5 NDC

3opographical codes

-%re codes t0at indicate a s'ecific #ocation in t0e bod2 E)a&'#es ;ICD- 5 SN "ED

W)" !amil' o& International Classi&ications

T0e /or#d -ea#t0 rganiFation 6/- 7 &aintains se!era# internationa##2 endorsed c#assifications designed to faci#itate t0e co&'arison of 0ea#t0 re#ated data wit0in and across 'o'u#ations and o!er ti&e as we## as t0e co&'i#ation of nationa##2 consistent data3N1O T0is L+a&i#2 of Internationa# C#assificationsL 6+IC7 inc#ude t0ree &ain 6or reference7 c#assifications on basic 'ara&eters of 0ea#t0 're'ared b2 t0e organiFation and a''ro!ed b2 t0e /or#d -ea#t0 %sse&b#2 for internationa# use5 as we## as a nu&ber of deri!ed and re#ated c#assifications 'ro!iding additiona# detai#s3 So&e of t0ese internationa# standards 0a!e been re!ised and ada'ted b2 countries for nationa# use3

Re&erence classi&ications
International Statistical Classification of Diseases and Related Health Problems 0%!'1:"; o %!'-< 0<th revision, published in <771 %!'-<-!. 0!linical .odification, used in the =,1 o %!'- > 0 >th revision, in use by W#$ since <<+1 %!'- >-!. 0!linical .odification, used in the =,1 %!'- >-)!, 0)rocedure !oding ,ystem, used in the =,1 %!'- >-!5 0used for morbidity classification in !anada1. :(; %!'- >-5. 0used in 5ustralia and -ew ?ealand1 :+; /=&$!53 - an e9tension of the %!'- > @ chapter for congenital disorders International Classification of Functioning, Disability and Health 0%!F1 International Classification of Health Interventions 0%!#%1 0previously known as %nternational

!lassification of )rocedures in .edicine1 :4;

Deri*ed classi&ications

Deri!ed c#assifications are based on t0e /- reference c#assifications 6i3e3 ICD and IC+73N1O T0e2 inc#ude;
International Classification of Diseases for Oncology, 3hird /dition 0%!'-$-(1 ICD-10 for Mental and Behavioural Disorders :6; Application of the International Classification of Diseases to Dentistry and Stomatology, (rd

/dition 0%!'-'51:7; Application of the International Classification of Diseases to eurology 0%!'- >--51:8;

Related classi&ications
Re#ated c#assifications in t0e /- -+IC are t0ose t0at 'artia##2 refer to t0e reference c#assifications5 e3g3 on#2 at s'ecific #e!e#s3N1O T0e2 inc#ude;
%nternational !lassification of )rimary !are 0%!)!1:<; o %!)!-" )*=, %nternational !lassification of /9ternal !auses of %nAury 0%!/!%1: >; 5natomical 3herapeutic !hemical !lassification ,ystem with 'efined 'aily 'oses 053!B'''1 !echnical aids for persons "ith disa#ilities$ Classification and terminology 0%,$<<<<1: ; International Classification for ursing %ractice 0%!-)1: ";

"ther medical classi&ications

Diagnosis
T0e categories in a diagnosis c#assification c#assif2 N and &edica# signs3 In addition to t0e ICD and its nationa# !ariants5 t0e2 inc#ude;
Diagnostic and Statistical Manual of Mental Disorders 0',.1 o ',.-%C !odes International Classification of &eadache Disorders "nd /dition 0%!#'-%%1: %nternational !lassification of ,leep 'isorders 0%!,'1 $nline .endelian %nheritance in .an , database of genetic codes &ead codes ,ystematiDed -omenclature of .edicine - !linical 3erms 0,-o.ed-!31

(;

+rocedure
T0e categories in a 'rocedure c#assification c#assif2 s'ecific 0ea#t0 inter!entions undertaken b2 0ea#t0 'rofessiona#s3 In addition to t0e IC-I and IC(C5 t0e2 inc#ude;

5ustralian !lassification of #ealth %nterventions 05!#%1 !anadian !lassification of #ealth %nterventions 0!!%1 : +; !hinese !lassification of #eath %nterventions 0!!#%1 !urrent )rocedural 3erminology 0!)31 #ealth !are )rocedure !oding ,ystem 0#!)!,1 %!'- > )rocedure !oding ,ystem 0%!'- >-)!,1 $ffice of )opulation, !ensuses and ,urveys !lassification of ,urgical $perations and )rocedures 0$)!,-+1

"ther
!lassification of )harmaco-3herapeutic &eferrals 0!)&1 *ogical $bservation %dentifiers -ames and !odes 0*$%-!1, standard for identifying medical

laboratory observations

.edical 'ictionary for &egulatory 5ctivities 0.ed'&51

 .edical ,ubAect #eadings 0.e,#1 o *ist of .e,# codes -ursing %nterventions !lassification 0-%!1 -ursing $utcomes !lassification 0-$!1 3%./-%3/., ontology of topics in medical education 3-. !lassification of .alignant 3umors =nified .edical *anguage ,ystem 0=.*,1 Cictoria 5mbulatory !oding ,ystem 0C5!,1 B @ueensland 5mbulatory !oding ,ystem 0@5!,1,

5ustralia:citation needed; Library classification that have medical components 'ewey 'ecimal ,ystem and =niversal 'ecimal !lassification 0section 6 >E6">1 -ational *ibrary of .edicine classification

ICD, S#"MED and Electronic )ealth Record -E)R.

What is S#"MED?
T0e S2ste&atiFed No&enc#ature of "edicine 6SN "ED7 is t0e &ost wide#2 recognised no&enc#ature in 0ea#t0care3N1GO Its current !ersion5 SN "ED C#inica# Ter&s 6SN "ED CT75 is intended to 'ro!ide a set of conce'ts and re#ations0i's t0at offers a co&&on reference 'oint for co&'arison and aggregation of data about t0e 0ea#t0 care 'rocess3N1DO SN "ED CT is often described as a reference ter&ino#og23N1BO SN "ED CT contains &ore t0an C115000 acti!e conce'ts wit0 uni8ue &eanings and for&a# #ogic-based definitions organised into 0ierarc0ies3N1DO SN "ED CT can be used b2 an2one wit0 an %ffi#iate License5 A0 #ow inco&e countries defined b2 t0e /or#d $ank or 8ua#if2ing researc05 0u&anitarian and c0aritab#e 'ro?ects3N1DO SN "ED-CT is designed to be &anaged b2 co&'uter5 and it is a co&'#e) re#ations0i' conce'ts3N1GO

What is ICD?
T0e Internationa# C#assification of Disease 6ICD7 is t0e &ost wide#2 recogniFed &edica# c#assification &aintained b2 t0e /or#d -ea#t0 rganiFation 6/- 73N1PO Its 'ri&ar2 'ur'ose is to categorise diseases for &orbidit2 and &orta#it2 re'orting3 T0e <nited States 0as used a c#inica# &odification of ICD 6ICD-:-C"7 for t0e additiona# 'ur'oses of rei&burse&ent3 ICD-10 was endorsed b2 /- in 1::05 and /- "e&ber states began using t0e c#assification s2ste& in 1::A for bot0 &orbidit2 and &orta#it2 re'orting3 In t0e <S5 0owe!er5 it 0as on#2 been used for re'orting &orta#it2 since 1:::3 $ecause of t0e <S de#a2 in ado'ting its !ersion of ICD-105 it is current#2 unab#e to co&'are &orbidit2 data wit0 t0e rest of t0e wor#d3 ICD 0as a 0ierarc0ica# structure5 and coding in t0is conte)t5 is t0e ter& a''#ied w0en re'resentations are assigned to t0e words t0e2 re'resent3N1PO Coding diagnoses and 'rocedures is t0e assign&ent of codes fro& a code set t0at fo##ows t0e ru#es of t0e under#2ing c#assification or ot0er coding guide#ines3

S#"MED CT *s ICD
SN "ED CT and ICD are designed for different 'ur'oses and eac0 s0ou#d eac0 be used for t0e 'ur'oses for w0ic0 it was designed3N1:O %s a core ter&ino#og2 for t0e E-R5 SN "ED CT 'ro!ides a co&&on #anguage t0at enab#es a consistent #anguage t0at enab#es a consistent wa2 of ca'turing5 s0aring5 and aggregating 0ea#t0 data across s'ecia#ties and sites of care3N@0O It is 0ig0#2 detai#ed ter&ino#og2 designed for in'ut not re'orting3 C#assification s2ste&s suc0 as ICD-:-C"5 ICD-10-C"5 and ICD-10-(CS grou' toget0er si&i#ar diseases and 'rocedures and organise re#ated entities for eas2 retrie!a#3N@0O T0e2 are t2'ica##2 used for e)terna# re'orting re8uire&ents

or ot0er uses w0ere data aggregation is ad!antageous5 suc0 as &easuring t0e 8ua#it2 of care &onitoring resource uti#isation5 or 'rocessing c#ai&s for rei&burse&ent3 SN "ED is c#inica##2based5 docu&ent w0ate!er is needed for 'atient care and 0as better c#inica# co!erage t0an ICD3 ICD4s focus is statistica# wit0 #ess co&&on diseases get #u&'ed toget0er in =catc0-a##> categories5 w0ic0 resu#t in #oss of infor&ation3 SN "ED CT is used direct#2 b2 0ea#t0care 'ro!iders during t0e 'rocess of care5 w0ereas ICD is used b2 coding 'rofessiona#s after t0e e'isode of care3 SN "ED CT 0ad &u#ti'#e 0ierarc025 w0ereas sing#e 0ierarc02 for ICD3 SN "ED CT conce'ts are defined #ogica##2 b2 t0eir attributes5 w0ereas on#2 te)tua# ru#es and definitions in ICD3N@0O

Data Ma((ing o& S#"MED and ICD

SN "ED and ICD can be coordinated3 T0e Nationa# Librar2 of "edicine 6NL"7 &a's ICD-:C"5 ICD-10-C"5 ICD-10-(CS5 and ot0er c#assification s2ste&s to SN "ED3N@1O Data "a''ing is t0e 'rocess of identif2ing re#ations0i's between two distinct data &ode#s3 T0e fu## !a#ue of t0e 0ea#t0 infor&ation contained in an E-R s2ste& wi## on#2 be rea#ised if bot0 s2ste&s in!o#!ed in t0e &a' are u' to date and accurate#2 ref#ect t0e current 'ractice of &edicine3N1PO

Clinical Coding in Australia

"edica# coding and c#assification s2ste&s are e)'ected to beco&e increasing#2 i&'ortant in t0e 0ea#t0 care sector3 Toget0er wit0 and as an integrated 'art of t0e e#ectronic 0ea#t0 infor&ation s2ste&s5 t0e coding and c#assification s2ste&s wi## be used to i&'ro!e t0e 8ua#it2 and effecti!eness of t0e &edica# ser!ices3N@@O

What is clinical coding?

C#inica# coding is t0e trans#ation of written5 scanned and/or e#ectronic c#inica# docu&entation about 'atient care into code for&at3 +or e)a&'#e5 02'ertension is re'resented b2 t0e code KI10KQ genera# anaet0esia is re'resented b2 t0e codeK:@G1A-MMN1:10OK3 % standardised c#assification s2ste&5 T0e Internationa# Statistica# C#assification of Diseases and Re#ated -ea#t0 (rob#e&s5 10t0 Re!ision5 %ustra#ian "odification 6ICD-10-%"75 is a''#ied in a## %ustra#ian acute 0ea#t0 faci#ities3 It is based on t0e /or#d -ea#t0 rganisation 6/- 7 ICD-10 s2ste&5 u'dated wit0 t0e %ustra#ian C#assification of -ea#t0 Inter!entions 6%C-I75 %ustra#ian Coding Standards 6%CS73 C#inica# coding is a s'ecia#ised ski## re8uiring e)ce##ent know#edge of &edica# ter&ino#og2 and disease 'rocesses5 attention to detai#5 and ana#2tica# ski##s3N@CO

What does clinical coder do?

% c#inica# coder is res'onsib#e for abstracting re#e!ant infor&ation fro& t0e &edica# record and deciding w0ic0 diagnoses and 'rocedures &eet criteria for coding as 'er %ustra#ian and State Coding Standards3 T0e coder t0en assigns codes for t0ese diagnoses and 'rocedures based on ICD-10-%" con!entions and standards3N@CO

What is coded data used &or?

T0e assigned codes and ot0er 'atient data are 'rocessed b2 grou'er software to deter&ine a Diagnosis Re#ated Irou' 6DRI7 for t0e e'isode of care5 w0ic0 is used for funding and rei&burse&ent3 T0is 'rocess a##ows 0os'ita# e'isodes to be grou'ed into &eaningfu# categories5 0e#'ing us to better &atc0 'atient needs to 0ea#t0 care resources3N@AO