You hear a loud pop in your left arm, followed by intense pain. You visit the doctor and sure enough, it's broken. As the doctor examines you, he or she will most likely be sitting at a computer during your visit typing notes, or writing down on a clipboard documenting what has happened to your arm. Once the visit is over, the doctor needs to get paid by the insurance company. This is where medical coding comes in. The doctor cannot simply send over the notes from your encounter. The insurance company requires a medical code. A medical code in this situation would look something like this:
There could be a handful of similar codes that help document the visit to your doctor.
Therefore, medical coding is the translation of medical reports into a short code used within the healthcare industry. This helps summarize otherwise cumbersome medical reports into efficient, data-friendly codes. While complex and detail-driven, coding really comes down to knowing how to navigate the three main code sets: CPT, ICD, and HCPCS. These code sets help coders document the condition of a patient and describe the medical procedure performed on that patient in response to their condition.
Medical coding can be full of unknown terminology and TLA's (three letter acronyms). It can be daunting and often times overwhelming to have a slew of words coming at you that might sound like Mandarin to an unfamiliar ear. Our staff’s experience combined would probably equal centuries of medical coding knowledge, yet at times we will still hear a word that we are not familiar with. We thought it would be useful for industry peers to create this resource full of medical coding vocabulary and key terms. Without further ado let’s get started:
This designation, created by the National Center for Health Statistics, is added to the ICD code sets when they are implemented in the United States. The ICD-10 code set went from 14,000 codes to over 68,000+ codes with the transition to ICD-10-CM. The term "CM" added to the end stands for "clinical modification".