Medical coding is nothing but transcribing the descriptions of medical diagnoses and events into universal medical code numbers. All medical services such as office visit, test and surgical procedure is associated with a numeric code, basically for statistical purposes and insurance reimbursement. The two types of Medical Coding are: outpatient medical coding and inpatient medical coding.
Outpatient Medical Coding
Outpatient Medical Coding includes coding charts for those patients who receives treatment and discharged from the hospital within 24 hours. The coding system usually used by Outpatient Medical Coders is Current Procedural Terminology (CPT).
Inpatient coding includes, Comorbidity: A condition that coexists at the time of admission that affects the treatment received or the length of stay. Complication: A condition that arises during the hospital stay that affects the treatment received or the length of stay. Major Complication or Comorbid Condition (MCC): represents the highest severity. Assignment of CC/MCC conditions equate to higher severity and higher weighted DRGs. To be reported when they affect patient care by requiring additional: clinical evaluation, therapeutic treatment; or diagnostic procedures, extended length of stay; or nursing care &/or monitoring.
Under general medical coding, coders cannot interpret lab values, coders cannot diagnose based on symptoms, coders must code possible, probable, likely, suspected and rule out diagnoses as though the conditions exist unless the conditions are ruled out prior to discharge (inpatient), coders must use documentation from current hospital visit, coders can query for additional clarification required to assign codes, physicians should always document why the patient is taking each medication.