Medical coding is the conversion of the description of medical 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.
Many times the patients visiting the physician may be diagnosed with multiple diseases or conditions. Whenever multiple medical issues are presented and require multiple diagnosis and treatment, a particular sequence is to be followed while coding. In the case of multiple diagnoses, the most severe conditions are coded first and then followed in the decreasing order of seriousness. For example, a patient may come with leg pain, but upon, checkup, he was found to have bilateral pedal oedema and also the onset of congestive heart failure. Although the main complaint was leg pain, the diagnosis of congestive heart failure is more severe and would be listed as the first diagnosis. However, if two or more conditions are equally severe, then the coding is done in the direction of head to toe.
Hence, when multiple codes are required the coding is always done in decreasing order of the seriousness of the condition.
The interpretation of physician's observations and diagnosis in a simple form is known as coding. To provide accurate code it is important to understand the physician's notes and look for precise information. To ensure accurate coding, the communication between the coding specialist and the health care provide should be clear and complete.
Abstracting physician's code refers to choosing keywords from the notes depicting the need for treatment. Three basic steps are followed for abstracting the physician's notes. The steps are as follows:
• Determining the reason for treatment and coding.
• Assigning more than one code to explain the complete diagnosis and treatment plan.
• Analyzing the diagnostic statement.
It is crucial to read the physician's notes thoroughly to understand what were the symptoms experienced by the patient as well as the diagnosis made by the physician. If the physician has attended to multiple complaints then it is important to note the primary diagnosis. Sometimes, there might be preoperative and postoperative notes with different findings, in such cases postoperative findings should be considered for coding. The physician's notes might have some keywords indicating the confirmed diagnosis. Thus, it is important to assign multiple codes for multiple diagnoses if required. After discovering all the relevant information from the notes separate the diagnostic statement and find out the word or words spotting the disease. The keywords selected must depict the reason for providing treatment to the patient. For example, if the keyword is "pulmonary necrosis" then it depicts the condition of "necrosis" meaning dead "pulmonary" tissues. The appropriate code must be selected according to the findings.
Therefore, abstracting the information in the form of keywords from the physician's notes is the primary job of every coding specialist. These keywords help in determining the chief complaints of the patients, diagnosis by the physician and treatment provided. The specific information derived from these details helps in assigning the accurate codes.
Disease is a condition of discomfort experienced by the human body. Various symptoms are experienced with different diseases. Diagnosis is made on the basis of symptoms experienced and specific codes are assigned for the same. If multiple ailments are diagnosed then coding should be done accordingly using primary code and additional codes.
Every disease has a specific code for itself. Some diseases result in additional illnesses as well. For example, diabetes is a disease which affects eyes and its circulation as well. So, the ailments with eyes might be due to diabetes. Such conditions are known as underlying conditions. The ailment caused due to some other disease is known as manifestation. The code first notation signifies that another code will be used for identification of underlying disease that leads to this condition. The notation helps in identifying the order of two codes. The first code depicts the underlying condition whereas the subsequent codes will represent the manifestations. The additional code will help us to understand the manifestations of the underlying disease.
The main purpose of coding is to give a complete idea about the symptoms, diagnosis and the treatment given to the patient in an accurate manner. In the case of multiple confirmed diseases, the coding should be done according to the severity of the disease. The first code depicts the most severe disease and the following codes depict the less severe ones in decreasing order. If someone has been diagnosed with both acute and chronic diseases then the first code should be for the acute condition.
Thus, additional codes can be used if a person is suffering for more than one disease or has ailments due to a primary disease. The assignment of codes varies for different cases.