Clinical Coding
Clinical coding is the process of translating medical diagnoses, procedures, and services into standardized codes. These codes are derived from medical records and are used for various purposes, including billing, research, and healthcare statistics. The coding system helps ensure that healthcare providers are accurately reimbursed for their services and that patient data is organized for analysis.
The most commonly used coding systems are ICD (International Classification of Diseases) for diagnoses and CPT (Current Procedural Terminology) for procedures. Accurate clinical coding is essential for effective communication among healthcare professionals and for maintaining the integrity of patient records.