Quiz 1: Introduction to the Languages of Coding
Health care is the maintenance of the health of the population by the diagnosis, treatment and prevention of disease, injury or other medical impairments. Medical coding is the conversion of the description of medical diagnosis, treatment, procedures and equipment into a universal alphanumeric code. Medical coding is the field of science that deals with the conversion of the physician's documents including diagnosis, treatment, procedures and equipment into a universal alphanumeric code. The purpose of medical coding is to create clear and crisp communication between all the parties involved in providing health care to a population. Primarily, there are three parties involved namely, health care provider, patient and the insurance company. Medical coding helps to establish clear communication between the three. Additionally, medical coding data is used to study the disease pattern in the community by various research agencies. Hence, health care coding serves as a communication bridge between the parties involved in the health care system, and it also helps to concise the disease data in the community for research purposes.
The Ninth revision of International Classification of Diseases Clinical Modification was created in February by the National Center for Health Statistics . It a directory of code set that precisely explains the diagnosis, signs, and symptoms identified by a health care provider with regard to a patient encounter. The statement, " will be implemented in the United States on January , is not true. Reasons for the incorrect statements: Option a. is given as, " will replace as the code set to report diagnoses." was replaced by in in the United States. The given statement is true. Option c. is given as, "The coding process is the same for both and ." The codes are different in , but the coding process is the same in both and . Therefore, the statement is true. Option d. is given as, " codes will require more specific information." provides coding specialists with additional codes to report diagnoses, signs, and symptoms with more specificity. The given statement is true. Hence, options a. , c. , and d. are incorrect. Reason for the correct statement: The United States healthcare industry implemented the use of the Revision of International Classification of Diseases Clinical Modification on October . Hence, is correct.
The healthcare diagnoses, procedures, medical services, and equipment are transformed into alphanumeric codes in medical coding. The information is abstracted from the physician's notes, lab reports, superbills, and other related documents. Appropriate codes are assigned to the information for insurance claims. Accurate coding is a seven-step process that is followed to code a health care encounter in an appropriate manner. The appropriate steps of coding can be explained as follows: • First, the superbill and the physician's notes are read completely. • The physician's notes are read again, and the keywords regarding diagnoses and procedures are highlighted. The key words are then evaluated, and the diagnostic and procedural statements are distinguished. • A list of questions regarding the missing or unclear information is made. The queries are cleared with the help of a health care provider. Information available in the actual documentation is only used for coding purposes. • Each diagnosis and appropriate signs or symptoms are coded. The most accurate codes are based on the documentation. • Each procedure that is stated in the notes is coded. The codes can be reviewed in the book, titled "The Complete Procedure Coding Book". • Every medical procedure is linked to coding. At least one diagnosis code is used to verify the medical condition of a patient. • The codes are again checked from the books and notes, and then the code descriptions are assigned. The appropriate coding requires seven steps. Coding involves gathering information by reviewing the physician's notes, lab reports, superbill form, and other necessary documents for the encounter. Diagnoses, symptoms, and procedures are accurately coded based on the documentation. The codes are re-checked before submission.