What is Medical Coding?

Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.

Are Medical Coding and Medical Billing The Same?

The main task of a medical coder is to review clinical statements and assign standard codes using CPT®, ICD-10-CM, and HCPCS Level II classification systems. Medical billers, on the other hand, process and follow up on claims sent to health insurance companies for reimbursement of services rendered by a healthcare provider.

Medical Coders work in a variety of settings and their individual workday may differ depending on the size of the facility, type of physician, type of specialty etc.

After settling into the office and grabbing a cup of coffee, a medical coder usually begins the workday by reviewing the previous days’ batch of patient notes for evaluation and coding.  The type of records and notes depends on the clinical setting (outpatient or facility), and may require a certain degree of specialization.

Selecting the top note on the billing sheet on the stack, the coder begins reviewing the documentation to understand the patient’s diagnoses assigned and procedure performed during their visit.  Coders also abstract other key information from the documentation, including physician names, dates of procedures and other information.  Coders rely on regulatory coding guidelines and good documentation to assign the correct code.