What is the Medical Coding Process?

The foremost role of a medical coder is to standardise digital procedures, medical services, and equipment in an alphanumeric code. Medical coding companies have played a major role in accelerating the revenue cycle of healthcare organisations. Since more and more hospitals are resorting to medical coding services to document their medical bills and reports, their requirement has witnessed a surge in the healthcare industry.

There are three main coding manuals containing the majority of codes that can also be included for reimbursements are stated below.

Processing a medical code is highly essential for maintaining a coherent insurance system. The primary reason for it being the backbone of the revenue cycle is because the insurance companies make payments based on all the codes they receive from their provider.

  • ICD – 9 or ninth revision international classification of diseases implies diagnostic codes. It is primarily used to notify the insurance companies of the reason for utilising healthcare services.
  • CPT, also known as Current procedural terminology, stands for the procedures and operation services implemented on the patients. It gives a clear and concise report on the process to render transparency to the insurance company.
  • HCPCS acronym for Healthcare Common Procedural coding system, that focuses on the miscellaneous supplies.

It is needless to point out how the integration of an efficient coding system mitigates any form of discrepancies in documenting medical reports and bills. So let’s get an insight into the six-step procedure that goes behind medical coding.

Summarising the documents

The first and most important step of carrying out the medical coding process is to ask all the needful questions of – How, When, Where, Why and so on. This generates an abstract document with all the important information about the patient. It acts like an overview of all the procedures, tests and diagnoses the subject undergoes. Note that it is important to be well-acquainted with the medical terminologies as most of the documents are made by referring to the physiologist or doctor’s notes. It is mandatory to be accurate with all the information pertinent to the subject as it is the groundwork of carrying forward the medical processing. If a piece of information is not documented by the hospital or physician, a medical coder is not authorised to inculcate it in the program.

Generating accuracy through query

To mitigate any possibilities of errors, it is crucial to query the curated report. Seeking additional information, clarification at areas of doubt and digging deep into the subject history is necessary. This makes the documentation even more accurate. Since the physicians are not completely aware of the information that medical coders require, there is a possibility of information gaps. Bridging this gap is only possible through interrogation, as a medical coder cannot document something if it isn’t mentioned in the report. Whatever is imprinted on the document reflects on the code, and running incomplete codes often leads to discrepancies that must be avoided at all costs.

Coding the entire procedure

Converting all the documents to codes is the most crucial step in medical processing. Since documentation is the basis of the entire coding procedure, ensuring all the correct information is in hand is advisable. Every organisation uses a different version of the software. It is necessary to acquire medical coding services from an organisation with an in-depth knowledge of the syntax. The documents are then coded and interpreted to give an output.

Confirmation before processing

The succeeding step is to align the diagnosis code with the procedure codes. This confirms all the medical necessities before computing the output. The medical coders require familiarity with the medical terminologies pertinent to the subject report they are working on. It is advisable to keep encyclopedias and online dictionaries handy to mitigate any possibility of error.


A very effective coding habit is double-checking the code before running the program. There is always a leeway of human error while documenting, but double-checking eliminates it. Practices such as re-checking the code, matching the code information to the document and looking for mistakes is a great way of avoiding inconsistency in the processing.

Parting Words

The emergence of the importance of the healthcare facilities and organisation is clearer than ever, and integrating the functioning with the technological advancements have further boosted the profit margin.

A healthcare organisation that has an intricate knowledge of the medical coding procedure can aid benefits by ensuring the smooth functioning of the billing procedure.

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