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As viewed by many HIM professionals Computer-assisted coding is a valuable tool for enhancing the effectiveness of coding and billing. CAC software scans medical documentation in the electronic health record (EHRs) using a natural language processing (NLP) engine, identifying key terminology and proposing codes for that specific treatment or service. Human coder then revised these codes. CAC can also investigate the background of key words to conclude whether they need coding.

In the daily changes of healthcare, health information technology is evolving rapidly. The generation of coding is making significant developments along the years as well. The 3M-encoder system provides number of essential options to coders in just one click. It provides sophisticated, easy-to-learn solution for accurate, complete, and compliant coding and grouping. Coders need to be acquainted with these references because they provide back up through the articles in each one of them. 3M Coding and Reimbursement System, 3M Coding Reference, and 3M Coding Reference plus have articles for coders to read and get answers to use the appropriate codes. (Prophet). Due

Studies have found that coded data collected with a sole focus on reimbursement can poorly affect the use of the data for other purposes. Coded data goes farther and does more than ever before, making it imperative that professionals stay up to date of many rapid changes. One of the biggest changes is the expansion of coding from its traditional role of translating narrative clinical text into diagnosis and procedure codes. Coded data are now used for purposes such as severity adjustment, quality of care assessment, patient safety evaluation, public health surveillance, and decision support process development. Coding must meet an emerging need to capture healthcare data in a standard format that has universal meaning and can be applied both at the individual and aggregate levels. With this expansion come additional new responsibilities, such as entry of health information into a database and the need to understand how the quality and accuracy of the data are

First, I like how it explains the use of outpatient coding by describing the patient’s condition such as symptoms, problems, and reasons for visiting the hospital facility. Second, I like how it distinguishes inpatient and outpatient coding by listing different sets of clinical documentations. For instance, inpatient coding includes face sheet, progress notes, history and physical and discharge summary; meanwhile, outpatient coding includes an authenticated physician order for services, clinician visit notes, a diagnosis, therapies, and the medication

Medical coding is a very detailed process in which health care professionals use to code an insurance claim, to submit for reimbursement of services. In the following scenario, my task would be to explain the process and steps I took, to code patients cases using ICD-9. When coding it’s very important to code correctly to avoid delays in reimbursement and proper reimbursement. The following will explain the steps I took to perform proper medical coding.

Coding is the medical field is regarded as being an important role in providing proper billing for healthcare services. Therefore, the level of responsibility for ethical coding practices is essential in maintaining the integrity of the healthcare organization that they work in. Coders are faced with challenges every day to maybe upcode, down code or assigned inappropriate classification system codes (Flite, 2013). According to the Dictionationary.com, a coder is, “a person who assigns numeric codes to represent diagnosis and procedures, describe patient treatment and delineates fees for health services based on an official classification system (www.dictionary.com).” The coder must adhere to the policies and procedures as outline in the

Proper medical coding is important, from ensuring accurate payment for physicians to creating a valid record of patient care history. In addition to aiding the medical billing process for procedures administered and helping expedite the payment of services for physicians, medical codes also serve the purpose of comparing projects for research and planning for under-served health care areas, aiding in administrative functions, as well as identifying symptoms that have medical necessity and referenced by other physicians or specialists. As an example, for a general urinalysis, the coder must input the code of 81000 for male or female patients. The mistake that could be made is if the coder input 81025 for a specific urinalysis for a pregnancy test. This event could happen if the diagnosis was reversed and a female expecting a pregnancy urinalysis gets a general urinalysis ordered. It may seem minor, but this type of error can still be

A CAC system uses Natural Language Processing (NLP) in the review of the clinical documentation to assist in coding. For example, using NLP, the clinical documentation in the patient’s health record is scanned and the documentation is read by the CAC. The CAC would interpret the documentation and prompt a code for the diagnosis and procedure. The three factors that influencing the implementation and adoption of the CAC system is that coders will be able to provide uniform assignment of codes. The CAC will also be a resource for consistency. Coding guidelines are very specific. A CAC will facilitate the guidelines to provide consistent code selection. A CAC system should improve the productivity of the coding department. This is due to the fact that there will be fewer manual tasks required of

Coding systems are standardized systems used in over 100 different countries to decrypt all services, conditions and items to be billed to a patient or their insurance provider. There are two main coding classifications systems: International Classification of Diseases (ICD) and Current Procedural Terminology (CPT). Currently, ICD is in its 10th edition making the current complete system name ICD-10. ICD-10 uses up to seven

Clinical vocabularies are defined as terminologies or coding systems that are structured list of terms which together with their definitions are designed to describe unambiguously the care and treatment of patients. The clinical vocabularies are used to create classification systems that are used around the world to provide a method of distributing coded concepts in a stored meaningful manner. (Thomson 2013)

They are the most frequently used codes and are used by all medical specialties, so they are placed first in the manual for convenience.

Medical Coding- Medical coding, at its most basic, is a little like translation. It’s the coder’s job to take something that’s written one way (a doctor’s diagnosis, for example, or a prescription for a certain medication) and translate it as accurately as possible into a numeric or alphanumeric code. For every injury, diagnosis, and medical procedure, there is a corresponding code. There are thousands and thousands of codes for medical procedures, outpatient procedures, and diagnoses. Let’s start with a quick example of medical coding in action. A patient walks into a doctor’s office with a hacking cough, high production of mucus or sputum, and a fever. A nurse asks the patient their symptoms and performs some initial tests, and then the doctor examines the patient and diagnoses bronchitis. The doctor then prescribes medication to the patient.

In regards to the misconception that “the new ICD-10 codes are simply increased and renumbered code sets,” Medicaid.gov gives an overview of how the ICD-9 and ICD-10 codes differ and the far-reaching effects of the new codes. (Medicaid, n.d.) This overview discusses the expansion of the code set and the increase in the number of codes, but it goes on to relate other characteristics of the codes. The codes were in desperate need of change due to the dramatic changes in healthcare since ICD-9 was implemented over 25 years ago. The new code set provides for the consistency and modernization of medical terminology in the codes to reflect these dramatic changes. Although they seem more complex, the specificity of ICD-10 codes allows for more information to be conveyed using less codes when documenting a condition. Each code is not only a representation of a diagnosis, it also represents the associated symptoms, exact locations, and certain detailed information that is beneficial for future patient care and crucial for reimbursement and revenue processes. This is a definite improvement over the ICD-9 codes. (Medicaid, n.d.)

A universally accepted set of codes for diagnoses and procedures/interventions is important because there are so many branches of medicine and medical study, and each has its own jargon. There has to be a way to communicate across the board. Coding provides a common “language” for all providers to use – specifically when using third-party payers – so that they can provide an adequate picture of the care they are providing and the services that require reimbursement. Different branches of medicine may use similar looking or sounding treatments or services for widely different purposes. The universal coding of these items makes it clear what and why things are being done.

1. Differentiate between the official coding guidelines for using V codes in an inpatient and outpatient setting.