Clinical coder
Clinical coder
A Clinical coder (pronounced: /ˈklɪnɪkəl ˈkoʊdər/) is a health information professional whose main duties involve translating medical information from patient records into alphanumeric codes according to a health classification system. This coded information is used for research, funding, and planning in the healthcare sector.
Etymology
The term "Clinical coder" is derived from the words "clinical", which pertains to the observation and treatment of actual patients rather than theoretical or laboratory studies, and "coder", which refers to a person who transforms information into a coded form.
Duties
A Clinical coder's primary responsibility is to review and interpret medical documentation and translate this into ICD-10 (International Classification of Diseases, 10th Revision) codes, CPT (Current Procedural Terminology) codes, and HCPCS (Healthcare Common Procedure Coding System) codes. These codes are used for a variety of purposes, including billing, research, and population health statistics.
Related Terms
- Medical coding: The process of converting descriptions of medical diagnoses and procedures into universal medical code numbers.
- Health information management: The practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care.
- ICD-10: The 10th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization.
- CPT: Current Procedural Terminology, a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.
- HCPCS: Healthcare Common Procedure Coding System, a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology.
External links
- Medical encyclopedia article on Clinical coder
- Wikipedia's article - Clinical coder
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