Translating Medical Documentation Into Code Medical Billing, Medical Coding

Translating Medical Documentation Into Code


Professional medical coding experts should get certified training to know their job very well and perform it accurately. They have to be excellent in the knowledge of standard medical codes and their applications as well as they also need to be expert in reading a patient’s report so that they can use codes correctly. Some private training centers and universities offer certified training in medical billing and coding. Additionally, you can also choose self-study programs through correspondence or online.

A certified coding expert performs his professional duties with the thorough understanding of patient’s health record. The medicinal language is created with unique concepts and technical terms. When a doctor creates a document for the patient meeting, the details related to the medical report have to be precise and accurate. By using specialized terms, doctors and other healthcare experts along with coders, comprehend a patient’s condition and his treatment procedures.

Know about the medical terms

In the human body, all the anatomical structures are given some specific names. The technical names are developed from Latin and Greek words. Various terms can be decoded by knowing the meanings of different affixes and roots. Medical records and reports can have strings of these Latin and Greek based words. Understanding the detail of the medical terms, he or she will be able to assign the correct code for the medical procedure.

Medical Abbreviations

Medical Abbreviations are a common factor in medical terminology. They help doctors and other medical experts to document a report faster. Several terms that can be applied to one abbreviation, which can cause mistakes or errors. Thus it is very important to be careful while using medical abbreviations. There is a long list of these abbreviations, only a certified training can help you to get proper knowledge about it.

Accuracy of the codes

Medical coding experts specialize in a significant part of healthcare information. These experts translate the written documents into the readable codes. If they do not get a practical and strong knowledge about the medicinal codes, they may find it hard to differentiate between two different denotations for the same medical abbreviation.

With an in-depth knowledge of medical documentation standards, a coder performs his responsibilities efficiently and correctly. Accuracy is significant after assigning the final codes, but doing it faster is valued by a company. Some medical coders can translate more than 200 records throughout the day into the correct industry-standard code.

Coding Audits

In auditing process, the accuracy of the codes in medical claims is tracked by comparing them to the medical record documentation. This task is either done by a medical facility prior claim submission or by a third party. If submitting claims are not matched with the detailed documentation, it can cause a legal liability, resulting in reimbursement fraud and abuse charges. A certified and trained medical coder’s efficient and accurate coding job ensures that claims are submitted with legal justification.

Commercial health insurers and federal government authorities regularly perform claims auditing. The medical report is reviewed by a trained coding expert who scrutinized the available documentation to make sure it’s accurate.

Training is Vital

When a patient goes through his medical report or record, he cannot understand it because of its specialized language. A coding expert learns this language by going through a comprehensive study program, so they can easily understand the written language, later they utilize their professional understanding of applicable coding structures to translate the report. If a third party is reviewing the records and assigning them correct codes, the third party team also need to be well informed and trained in understanding the codes.

A medical record is a legal document, and same is the case with medical bills and codes. With the professional and expert knowledge, medical coding experts ensure a transparent and correct reimbursement process. They also make sure that the reports are only about the certain services that are offered for the patient health conditions.