Clinical coder
Encyclopedia
A clinical coder – also known as diagnostic coder, medical coder or medical records technician – is a health care 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
or the Common Coding System for Healthcare Procedures, 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
, gastrointerology, nephrology
, neurology
or orthopedic care.
A clinical coder therefore requires a good knowledge of medical terminology
, clinical documentation, legal 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.
. Most clinical coders are employed in coding inpatient episodes of care. However, mortality
events, outpatient episodes, general practitioner
visits and population health
studies can all be coded.
Clinical coding has three key phases: a) Abstraction; b) Assignment; and c) Review.
, such as clinical notes, laboratory and radiology results, and operation notes.
mechanism, the clinical coder will also review the diagnosis-related group
to ensure that it does fairly represent the health encounter.
Nosologists are usually expert in more than one classification, including morbidity, mortality and casemix. In some countries the term "nosologist" is used as a catch-all term for all levels.
In some countries, clinical coders may seek voluntary accreditation through assessments conducted by professional associations or health authorities.
(AHIMA) and the American Academy of Professional Coders.
Other national associations include the Health Information Management Association of Australia (HIMAA) and the Canadian Health Information
Management Association (CHIMA).
Health care provider
A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....
whose main duties are to analyse clinical statements
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
and assign standard codes using a classification system
Medical classification
Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers...
. The data produced are an integral part of health information management
Health Information Management
Health information management is the practice of maintenance and care of health records by traditional and electronic means in hospitals, physician's office clinics, health departments, health insurance companies, and other facilities that provide health care or maintenance of health records...
, 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
Epidemiology
Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...
, health resource allocation, case mix
Case mix
The term Casemix refers to the type or mix of patients treated by a hospital or unit. The term is often used to describe the billing system of the hospital or unit, since the "cost per item" of healthcare is based on the casemix.-Background:...
management, public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population 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-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
or the Common Coding System for Healthcare Procedures, for reporting to the health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
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
Procedure codes
Procedure codes are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals.-International:...
, pharmaceuticals
Pharmaceutical codes
Pharmaceutical codes are used in medical classification to uniquely identify medication. Examples of coding systems include:* Anatomical Therapeutic Chemical Classification System -- administered by World Health Organization...
or topography
Topographical codes
In medicine, "topographical codes" are codes that indicate a specific location in the body.-Examples:Only the first of these is a system dedicated only to topography. The others are more generalized systems that contain topographic axes.* Nomina Anatomica * ICD-O* SNOMED* MeSH...
. The medical notes may also be divided into specialities for example cardiology
Cardiology
Cardiology is a medical specialty dealing with disorders of the heart . The field includes diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology...
, gastrointerology, nephrology
Nephrology
Nephrology is a branch of internal medicine and pediatrics dealing with the study of the function and diseases of the kidney.-Scope of the specialty:...
, neurology
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
or orthopedic care.
A clinical coder therefore requires a good knowledge of medical terminology
Medical terminology
Medical terminology is a vocabulary for accurately describing the human body and associated components, conditions, processes and process in a science-based manner. Some examples are: R.I.C.E., trapezius, and latissimus dorsi. It is to be used in the medical and nursing fields...
, clinical documentation, legal 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.
Clinical coders in practice
The basic task of a clinical coder is to classify medical and health care concepts using a standardised classificationMedical classification
Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers...
. Most clinical coders are employed in coding inpatient episodes of care. However, mortality
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....
events, outpatient episodes, general practitioner
General practitioner
A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...
visits and population health
Population health
Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It is an approach to health that aims to improve the health of an entire population. One major step in achieving this aim is to reduce health...
studies can all be coded.
Clinical coding has three key phases: a) Abstraction; b) Assignment; and c) Review.
Abstraction
The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical recordMedical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
, such as clinical notes, laboratory and radiology results, and operation notes.
Assignment
The assignment phase has two parts: finding the appropriate code(s) from the classification for the abstraction; and entering the code into the system being used to collect the coded data.Review
Reviewing the code set produced from the assignment phase is very important. Clinical coder must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility." By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mixCase mix
The term Casemix refers to the type or mix of patients treated by a hospital or unit. The term is often used to describe the billing system of the hospital or unit, since the "cost per item" of healthcare is based on the casemix.-Background:...
mechanism, the clinical coder will also review the diagnosis-related group
Diagnosis-related group
Diagnosis-related group is a system to classify hospital cases into one of originally 467 groups. The 467th was "Ungroupable." The system of classification was developed as a collaborative project by Robert B Fetter, PhD of the Yale School of Management, and John D Thompson, MPH of the Yale...
to ensure that it does fairly represent the health encounter.
Competency levels
Clinical codes may have different competency levels depending on the specific tasks and employment setting:- Entry-level coder: someone who has completed (or nearly completed) an introductory training course in clinical classification, and whose work is typically checked by an experienced coder before being used.
- Intermediate level coder: has acquired the skills necessary to code many cases independently. Coders at this level are also able to code cases with incomplete information. They have a good understanding of anatomyAnatomyAnatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...
and physiologyPhysiologyPhysiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...
along with disease processes. Intermediate level coders have their work audited periodically by an Advanced coder. - Advanced level coder: authorized to code all cases including the most complex. Advanced coders will usually be credentialled and will have several years experience. An advanced coder is also able to train entry-level coders.
- Nosologist: understands how the classification is underpinned. Nosologists consult nationally and internationally to resolve issues in the classification and are viewed as experts who can not only code, but design and deliver education, assist in the development of the classification and the rules for using it.
Nosologists are usually expert in more than one classification, including morbidity, mortality and casemix. In some countries the term "nosologist" is used as a catch-all term for all levels.
In some countries, clinical coders may seek voluntary accreditation through assessments conducted by professional associations or health authorities.
Classification types
Clinical coders may use many different classifications, which fall into two main groupings: statistical classifications and nomenclatures.- A statistical classification brings together similar clinical concepts and groups them into one category. This allows the number of categories to be limited so that the classification does not become too big. An example of this is in ICD-10ICD-10The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
at code I47.1. The code title (rubricRubricA rubric is a word or section of text which is traditionally written or printed in red ink to highlight it. The word derives from the , meaning red ochre or red chalk, and originates in Medieval illuminated manuscripts from the 13th century or earlier...
) is Supraventricular tachycardiaSupraventricular tachycardiaSupraventricular tachycardia is a general term that refers to any rapid heart rhythm originating above the ventricular tissue. Supraventricular tachycardias can be contrasted to the potentially more dangerous ventricular tachycardias - rapid rhythms that originate within the ventricular...
. However, there are several other clinical concepts that are also classified here. Amongst them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia.
- In a nomenclature there is a separate listing and code for every clinical concept. So, in the example in the previous paragraph, each of the tachycardia listed would have its own code. This makes nomenclatures unwieldy for compiling health statistics.
Professional associations
There are several associations that medical coders in the United States may join, including the American Health Information Management AssociationAmerican Health Information Management Association
-References:* -External links:* * * * * *...
(AHIMA) and the American Academy of Professional Coders.
Other national associations include the Health Information Management Association of Australia (HIMAA) and the Canadian Health Information
Management Association (CHIMA).
See also
- Clinical medicineClinical MedicineClinical Medicine is a peer-reviewed medical journal published bimonthly by the Royal College of Physicians. It was established in 1966 as the Journal of the Royal College of Physicians of London. It was doubly named between 1998 and 2000, and since 2001 it has appeared as Clinical Medicine. Its...
- Health informaticsHealth informatics.Health informatics is a discipline at the intersection of information science, computer science, and health care...
- Health information managementHealth Information ManagementHealth information management is the practice of maintenance and care of health records by traditional and electronic means in hospitals, physician's office clinics, health departments, health insurance companies, and other facilities that provide health care or maintenance of health records...
- Medical classificationMedical classificationMedical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers...
- Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental DisordersThe Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DMS) / DSM-IV CodesDSM-IV CodesDiagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders... - Health Care Procedure Coding System (HCPCS)
- International Classification of Diseases (ICD) / ICD-10ICD-10The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
/ ICD-9-CM - WHO Family of International Classifications
- Diagnostic and Statistical Manual of Mental Disorders
- Medical diagnosisMedical diagnosisMedical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
- Nosology