Clinical coding

Clinical coding is the translation of medical terminology, as written by the healthcare provider, into a standardized code. The code is used for data analysis, billing, and health planning.

Pronunciation

• Clinical: /ˈklɪnɪkəl/
• Coding: /ˈkoʊdɪŋ/

Etymology

The term "clinical" is derived from the Greek word "klinike" which means "bedside". The term "coding" comes from the Old English "codu", which means "tree trunk", symbolizing the systematic and structured nature of coding.

Definition

Clinical coding is a process in which medical and healthcare diagnosis, procedures, medical services, and equipment are translated into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc.

Purpose

The main purpose of clinical coding is to create a clear and concise medical history of patients. It helps in identifying the diagnoses and procedures performed on the patient. This information is used for research, funding, and planning purposes. It also plays a crucial role in health insurance claims.

Types of Clinical Coding

There are several types of clinical coding systems used worldwide. Some of the most common ones include:

• ICD
• CPT
• HCPCS
• SNOMED

Related Terms

• Medical classification
• Medical billing
• Health information management
• Medical record
• Health informatics

See Also

• Medical transcription
• Electronic health record
• Medical scribe

External links

• Medical encyclopedia article on Clinical coding
• Wikipedia's article - Clinical coding

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