It is vital to have a professional team of well-trained medical coders to perform medical Coding. Let us see below how medical Coding works.
• Write an Abstract –First and foremost, the medical coder must write an abstract about the case after carefully reviewing the clinical documentation, either presented by paper or electronic health records.
• Ask for missing or incorrect information –At times, certain crucial information may be missing in the clinical documents and records, or they could be unclear. It would affect the quality of Coding. In such situations, the medical coder must ask for that vital information by referring to the meant physician.
• Prepare the Diagnostic Codes –As mentioned in the clinical documentation, the medical coder needs to start coding the diagnosis (Usually ICD codes), and they must ensure that the applicable code for the particular diagnosis is given. This step is quite crucial while submitting the claim to the payer.
• Prepare the Procedure Codes –Next, the medical coder must begin coding the various procedures and examinations, if any, performed for the patient. It must be most precise, as it gets compared to the Diagnosis Code for checking if the procedure was relevant to the particular case.
• Compliance Confirmation –Following this, they must confirm compliance between the diagnosis and procedure codes. This step is essential to ensure that the required medical procedures stated in the case were performed and also provide a suitable justification for the necessity to perform these medical procedures, as it is crucial for submitting the claim to the payer for reimbursements.
• Verify the integrity of the code –Finally, to validate the integrity of your code, carefully re-check and verify the written codes to make sure they are precise and correct.