Medical Record Coding

Medical Record Coding service envelops the entire history of the patient; even the cause of the medical aid is obligatory, as it is required for patient history and claims. These formalities are required to avoid any kind of healthcare fraud and abuse. As the basis for recompense, a suitable medical records coding company is essential, as healthcare providers seek to assure obedience with official coding guidelines. Medical coding the data also solves various purposes for internal use by institutions with respect to quality management activities, case-mix management, future planning, marketing processes, and other administrative and research activities.

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What Our Medical Coders Do

Medical record coding companies hire skilled medical records coders. They are responsible for:

  • Assembling and maintaining all the medical records of a patient.
    These records are crucially important in treating the patient, as records contain a collection of the important information like medical history of the patient, the observations records, surgical interventions, treatment outcomes, symptoms descriptions, examination results, X-rays and MRI report, laboratory test results, diagnoses, and treatment plans.
  • Medical coding technicians verify the patient’s initial medical chart, and make sure that all forms are filled out correctly, and authenticated.
  • These technicians regularly consult with physicians and health care professionals for patient diagnoses, and to obtain any other additional information that is required for a patient’s records, which in turn enables the medical coding to be correctly entered for billing and compensation.
  • Technicians also tabulate the record data for future analysis; provide documentation whenever if needed for any use in legal actions, and compile information to classify reimbursement status of medical procedures by the insurance companies in case the patient is covered by any medical insurance policy.
  • They review the accuracy of records, their completeness, and compliance with respect to applicable regulations ; medical coders enter data into computers concerning demographic characteristics, disease history, diagnoses and treatments.
  • Medical Coding Specialists make information available to persons and agencies according to regulations; they are responsible for protecting and securing medical records to ensure that confidentiality is maintained.
  • Develop health record indices, storage and retrieval systems in order to gather information.

In small facilities, a credentialed medical records technician typically assumes a variety of duties that often include management of a department. In larger or medium-sized facilities, each technician specializes in one aspect of health information management. These settings usually include administrator management duties. Some common specialists in this field are medical record coders and cancer registrars.

What We Require From our Medical Coders

In order to enter the field of medical record coding, an individual generally needs at least an associate degree from a community or junior college. Preferably, this degree program should be accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). There are various postsecondary educational institutions that offer course scheduling and/or online distance learning programs or courses. Specific support coursework is for students who desire work in this profession includes records structure, physiology, medical terminology, health data standards, data coding, statistics, etc.