Medical Record Coding - What are the Steps?

Learn medical record coding based on doctor's notes with this tutorial...

Depending on what type of job you get in medical coding, you may have to code doctor's visits not from already assigned codes but from the doctor's notes themselves.

This means that you have to...

  1. read what the doctor has written
  2. translate this difficult language into an intelligible visit
  3. and assign all of the appropriate codes.

Many doctor's offices have a set of typical codes which they assign on a daily basis. Because family practice physicians, medical specialists, and primary care physicians perform pretty much the same services on a daily basis, these codes are easy to identify.

A lot of doctor's offices organize these codes into encounter forms or superbills, which they use at the patient's visit.

During the visit, the doctor circles or marks the appropriate codes based on what was done at the visit and why, then gives the encounter form to the coder to enter the claim.

Click for more information on encounter forms and superbills.

But unfortunately not all doctors are so organized! Some primary care physicians simply don't waste their time coding their own claims, and rely on the coders to do this for them. But this is rare.

Most of the time, coders have to code the most medical records from hospital notes.

There are many different types of services performed in hospitals, ranging from surgeries, diagnostic exams, and delivering of babies, to emergency care, follow-up care, and intensive therapies. Because of this, there is no way of creating one page of common codes which each and every doctor can use for their visits and procedures.

Medical Record Coding

If you can code  surgery from doctor's notes, you're one of the top medical coders around!

In other words, if you work in the hospital setting, you'll most likely find yourself coding patient visits and encounters based off of doctor's notes.

This comes with all the great confusions of trying to read the doctor's handwriting, figuring out the primary diagnosis, and making sure you've coded the claim completely.

This is where coding is at its hardest.

If you can correctly code a complex surgery from difficult-to-read surgery notes, you're one of the most highly skilled of all coders - and deserve the biggest paycheck.

It's also why you've got to really know your stuff. You have to make sure your coding education, including your medical coding certification, goes to good use.

Determining the Diagnosis

When you're presented with a transcription of a complex procedure, or procedures, start by determining the diagnosis. Sometimes, there's only one relevant diagnosis, so this is the only one that you have to worry about.

Also, luckily, often when a patient presents to the hospital or other facility for a complex procedure or surgery, they already have a primary diagnosis determined.

For example, if your patient is presenting for removal of a cancerous tumor, you'll already know her primary diagnosis: the cancerous tumor.

If the visit is an emergency room consultation, however, there may be multiple diagnoses. These could range from the patient's acute physical symptoms to situational problems or mental disturbances. These codes will be much more difficult to determine.

Furthermore, you have to use your coding expertise to make sure you code the diagnoses in the correct order.

Determining the procedures

After you've figured out the diagnosis codes, determine which procedures, supplies, or additional services need to be billed.

Sometimes this is easy. For instance, if the doctor only saw the patient in the emergency room for a consultation, gave them a prescription for an ear infection, and sent them on their way, then the codes will be straightforward to figure out.

If, however, the patient visit was for anything more complicated, the coding will become much more difficult.

There's a reason why coders receive so much education and why it's such a plus to be certified. It's because coding based on complex doctor's notes is difficult. Using the diagnosis will help you, as will a good understanding of medical terminology and anatomy of the human body.

This all goes without mentioning that a deep understanding of CPT and HPCS is a necessity!

Extra tips

You may have to code patient visits from doctors' handwritten notes - sometimes a tricky task

Here are some questions you should ask, which will help to make sure you coded the claim correctly:

  • Does is make sense? Go back and read the claim you created.

    Do the procedures that were performed match up with the reason why the patient presented to the office or hospital?

    Go over each and every line to make sure that each procedure or supply code is matched up to the correct diagnosis, and that each procedure code is correctly assigned.

    Check and double-check your work. It's better to spend twice as much time before you send the claim than hours afterwards trying to send a correction or appeal a denied claim.

  • Do any additional codes need to be added to make the claim complete? Some procedures need to be sent with multiple codes.

    For example, a CBC (complete blood count), 85025, cannot be sent all by itself. An inherent component of a CBC is a way to obtain the blood, so you'd also need the code for blood draw or venipuncture (36415, 36416).

    Go over your codes to make sure that each component of the procedure was coded, and that no additional components need to be added.

  • Were there any additional procedures or labs done? Go over the entire chart to make sure that no additional labs, supplies, or services need to be billed.

    Sometimes, doctors and nurses will forget to include some things in notes, or to include them in the chart. This is where your expertise as a coder comes in, so that you can make sure that the doctor get fully reimbursed for all the services that were performed.

  • Do you need any additional information? Sometimes, doctor's notes are entirely illegible. If this is the case then ask your doctor to clarify the procedure or diagnosis instead of guessing.

Coding a claim from medical records is where the expertise of the medical coder comes in. This is what you were trained for!

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