Health Records as the Basis of Clinical Coding

I feel the position of a medical coder enforces integrity by ensuring that all criteria are followed by clinical staff in regard to regulations and policies. This guarantees that the organization achieves their set goals and objectives. In addition, organizational, computer, and communication skills are crucial in the transcription of physician’s diagnoses to handy electronic medical records (Shepheard, 2020). Moreover, I feel that coders must consult with physicians on areas that require clarification and file reports on issues that emerge.

I think incomplete patient records are a major challenge when coding clinical data. Incomplete or faulty records can cause payment delays or even claim denials. Another challenge coders face is the wrong use of procedure codes (Alonso et al. 2020). For instance, up-coding may happen when patients are charged for the complicated procedure than those performed on them. In addition, physicians sometimes use abbreviations that coders are not conversant with, making the coding process more tedious.

It is essential for clinical staff to collaborate with coders to clarify coding discrepancies for several reasons. Patients often receive numerous treatments from various physicians. Therefore, collaboration with APRNs, who have an extensive understanding of the diagnosis and treatment that the patients have received can lead to the resolution of unclear medical codes. Also, collaboration can be achieved when consulting regarding medication and dosage that might seem extreme or incorrect.

Several occasions necessitate the consultation of a physician. For instance, the documentation may contain ambiguous, imprecise, conflicting, or inconsistent information (Fletcher, 2019). Further, in situations where a diagnosis lacks a fundamental clinical validation. Finally, further consultation should be conducted when related clinical indicators point to a given medication, which an attending physician might have overlooked.

References

Alonso, V., Santos, J., Pinto. M., Ferreira, J., Lema. I., Lopes. F., & Freitas, A. (2020). Health records as the basis of clinical coding: is the quality adequate? A qualitative study of medical coders’ perception. Scientific Advisory Group Emergencies Journals, 49(1), 28-37. Web.

Fletcher, T. (2019). The art of physician query. ICD10 monitor. Web.

Shepheard, J. (2020). Clinical coding and the quality and integrity of health data. Scientific Advisory Emergencies Journals, 49(1), 3-4. Web.