Medical Coding

standardized codes to medical terms, procedures, and products. Medical coding is used to ensure consistency and accuracy in the collection, analysis, and reporting of clinical data. The following are some of the ways in which medical coding is used in clinical research:

Adverse event coding: Adverse events (AEs) are coded using standardized coding dictionaries such as MedDRA (Medical Dictionary for Regulatory Activities) or WHO Drug Dictionary. This allows for consistent reporting and analysis of AEs across different studies and databases.

Medical history coding: Medical history information is coded using the International Classification of Diseases (ICD) system, which allows for standardized and consistent coding of diseases and medical conditions.

Procedure coding: Procedures performed during clinical trials, such as surgeries or imaging studies, are coded using standardized coding systems such as the Current Procedural Terminology (CPT) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

Product coding: Medical products used in clinical trials, such as drugs and devices, are coded using standardized coding systems such as the Anatomical Therapeutic Chemical (ATC) classification system or the National Drug Code (NDC) system. This allows for consistent reporting and analysis of product-related data across different studies and databases.

Quality control: Medical coding is also used as a quality control measure to ensure the accuracy and completeness of clinical data. Double coding and consistency checks are used to minimize errors and ensure data quality.

1. Welcome MEDICAL CODING LIKHITHA N MSc BIOTECHNOLOGY 033/022023 www.clinosol.com | follow us on social media @clinosolresearch

2. INDEX Introduction Brief history Types of codes Basic steps in coding Skills required by a coder Reference www.clinosol.com | follow us on social media @clinosolresearch

3. INTRODUCTION www.clinosol.com | follow us on social media @clinosolresearch Medical coding is defined as the transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alpha-numeric codes. It standardizes the language and presentation of all these elemants so they can be easily understood, tracked and modified. It is performed all over the world, with most countries using ICD. IMPORTANCE Collection of general medical statistical data Medical reimbursement Hospital payment Quality review Benchmarking measurement

4. BRIEF HISTORY Originated in England during 17 TH century. Statistical data was collected from a system called the London Bills of Mortality, and the data was organized into numerical codes. The codes were then used to estimate the most recurrent causes of death. Statistical examination of the mortality rate was the organized into “International list of causes of death”. WHO uesd this list in tracking the mortality rates and the international health developments. The list was later developed into the International Classification of Diseases, its 10 th edititon is ICD-10-CM. In 1997, the global medical community accepted the ICD system, which compelled the NCHS to extend ICD by including cause of death and clinical diagnosis This way to catalog the medical records, make medical evaluations quick and easier. www.clinosol.com | follow us on social media @clinosolresearch

5. TYPES OF CODE www.clinosol.com | follow us on social media @clinosolresearch

6. ICD (International Classification of Diseases) This code was established by the WHO in late 1940s These are diagnostic codes that create a uniform vocabulary for describing the cause of injury, illnes and death. It has been updated several times since its inception. For eg, ICD-10-CM. The code that’s currently in use in the United States is ICD-10-CM. This means it’s the 10th revision of the ICD code. The “-CM” at the end stands for “clinical modification.” ICD codes are used to represent a doctor’s diagnosis and the patient’s condition. In the billing process, these codes are used to determine medical necessity. www.clinosol.com | follow us on social media @clinosolresearch

7. CPT (Current Procedure Terminology) CPT are used to document the majority of the medical procedure performed in a physician’s office . Published and maintained by American Medical Association (AMA). CPT codes are 5 digi tnumeric codes that are divided into 3 categories: Category 1: used most often, and divided into 6 ranges that corresponds to 6 major medical fields. Category 2: corresponds to performance measuremnet, laboratory or radiology test results . Categoty 3: corresponds to emerging medical technology. www.clinosol.com | follow us on social media @clinosolresearch

8. HCPCS (Healthcare common procedure Coding System) Developed by CMS (Centre for medicine and medicaid services) and maintained by AMA Corresponds to services, procedures and equipments not covered by CPT. It is the official code set for outpatient hospital care, chemotherapy drugs, among other services HCPCS code set is divided into 2 levels: Level 1: identical to CPT Level 2: set of alphanumeric codes that is divided into 17 sections, each based on area of specificity, like medical and laboratory or rehabilitative services. www.clinosol.com | follow us on social media @clinosolresearch

9. BASIC STEPS IN CODING Review the health record Identify the principle diagonses and procedures to be coded. Identify the main terms in the alphabetic index Review any sub terms under the main term in the index Follow any cross reference instructions, such as “see also” Verify in the tabular list the codes selected from the index Refer to any instructional notation in the tabular column Assign codes to the highest level of specificity. Assign codes to the diagnoses and procedures, reporting all aplicable codes and sequences in accordance with the guidelines www.clinosol.com | follow us on social media @clinosolresearch

10. SKILLS REQUIRED BY A CODER Medical terminology Anatomy and physiology basics ICD-9, ICD-10, CPT and HCPCS coding LCD and NCCI guidelines HIPAA compliance Medical billing concepts Detail oriented and self motivated www.clinosol.com | follow us on social media @clinosolresearch

11. REFERENCES https://www.slideshare.net/MushtaqAhmadWani3/medical-coding-71919467 https://www.aapc.com/medical-coding/medical-coding.aspx www.clinosol.com | follow us on social media @clinosolresearch

12. Thank You! www.clinosol.com (India | Canada) 9121151622/623/624 [email protected] www.clinosol.com | follow us on social media @clinosolresearch