Translating Medical Documentation Into Code
Professional medical coders need to have certified training under their belts in order to perform their jobs accurately. This means that they not only have to be fluent in the varieties of industry-standard medical codes and their uses, but they must also be able to read and understand a patient’s medical record, in order to assign codes accurately.
Accredited training in medical coding can be achieved through private or public universities, usually in conjunction with an advanced degree in health information management. More and more community colleges, and private two-year schools are offering programs in professional medical coding and billing. Additionally, there are self-study programs available online or through correspondence courses. What all these have educational paths have in common is that they are all founded on a basis of medical terminology before actual coding training begins.
A certified medical coder cannot perform his or her professional duties without being able to review and understand a patient’s medical record. The language of medicine is made up technical terms and concepts unique to the industry. When physicians or other healthcare providers document a patient encounter, the information contained in the medical record needs to be precise. By utilizing specialized terminology, other healthcare professionals, including medical coders, understand exactly what was happening to the patient at the time they were seen and treated.
Every anatomical structure in the human body has been given a name. Some of them, such as liver or brain, are common in laypeople’s terms. Others, such as myocardium, which refers to the heart muscle, are more obscure. The technical language of medicine is based on Greek and Latin root words that have been inherited when these languages were used at the beginning of medical science.
The root “hepato-” comes from the Greek word for liver. In medical parlance, the hepatic artery is differentiated from other arteries because it is the one that serves the liver. A cerebral vascular accident (CVA) begins with the Greek word for the brain. A CVA is called a stroke by laypeople, but medical terminology requires a more precise phrase to describe a patient’s diagnosis.
Medical records can contain strings of these Greek and Latin root words. For instance, a medical coder can read about a bilateral salpingo-oopherectomy. He or she is expected to understand that the patient has undergone the removal of the tubes and ovaries from both sides of the uterus. Knowing that information, because of their professional training, they can then assign the proper code for the procedure.
When a physician writes a prescription, he or she may direct the patient to take a drug q.d. Medical coders recognize that the patient is directed to take the medication once daily, from the Latin phrase quaque die, “every day.” Some medical abbreviations derive from ancient languages, even when the abbreviated words are never used, such as the abbreviations a.c. and p.c. which mean before or after meals.
Other medical abbreviations refer to strings of English words that can be used but, for brevity’s sake, the abbreviations are employed more often than the terms they represent. GVHD stands for graft-versus-host disease, the body’s rejection of transplanted tissue. ORIF is a common orthopedic surgical procedure that is abbreviated from “open reduction with internal fixation.” More often than not, a medical abbreviation will appear in the medical record without explanation, it being assumed that whoever is reading the medical record, such as a professional medical coder, is already familiar with the abbreviation’s meaning.
Efficiency versus Accuracy
There are, of course, resources available to certified medical coders after they have graduated from a formal program of study. Every coder has a medical dictionary and a dictionary of abbreviations within reach, and they refer to these often. Medical coders specialize in a very specific field of health care information. They translate the available documentation into understandable code. Without a solid educational foundation, though, they may have a hard time discerning between two different meaning for the same abbreviation. Or, when looking up a term, they may stumble on the terminology looking in the wrong place to find a definition or a code.
With a thorough understanding of medical documentation standards, medical coders perform their duties quickly and accurately. Accuracy is always essential once the final codes have been assigned, but being able to do it quickly is highly valued by employers. Some coders translate over 200 medical records a day into meaningful, industry-standard code.
Medical Coding Audits
In order to track the accuracy of medical claims, the codes they contain are compared to the documentation in the medical record by comparing. This is called an audit. It can be done by a healthcare facility prior to claims being submitted, or it can be done by third-party payers, either before or after payment is made. Submitting claims that are not supported by the available documentation can result in legal liability, with resulting charges of healthcare reimbursement fraud and abuse. A highly trained medical coder’s successful completion of his or her duties ensures that legally justified medical claims are submitted.
The federal government, particularly, but also commercial health insurers, regularly perform retroactive audits of claims. The medical record is reviewed by a certified medical coder with experience in the medical specialty being examined. These coders scrutinize the provided documentation to ensure that it is complete, and that the codes accurately describe the services provided, and the reasons for providing them.
Training is Essential
When a patient reads his or her medical record, it is often unintelligible due to the specialized language employed. When professional medical coders have earned their credentials through a thorough program of structured study, they understand what is written, and then they exercise their professional knowledge of the applicable coding systems to translate that information. A third party should be able to read the assigned codes and find them documented in the medical record. The third party should also be able to review the medical record and be able to assign the same exact codes.
The medical record is a legal document, admissible in a court of law. So is the medical bill and its assembled codes. By applying their training, medical coders ensure that the reimbursement process is transparent, and that what they report are only the services that were provided for the conditions the patient suffered at the time.