Certified medical coding specialists deal with a wide range of data related to patient healthcare and billing. Are you worried about your coders spending time on manual data entry in your EMR system?

In this blog post, we’ll take you through the types of data certified coding specialists have to work on and how to eliminate manual data entry. We’ll also shed light on how AI is playing a crucial role in the medical coding space.

What do professional medical coders do?

A certified coding specialist is a healthcare professional responsible for translating medical diagnoses, treatments, and procedures into alphanumeric codes. These codes are used for various purposes, including reimbursement, statistical analysis, and research.

Certified medical coders play a vital role in the healthcare industry as they ensure accurate and consistent documentation of patient information. They review medical records, decipher physicians’ notes, and assign the appropriate codes using standardized classification systems such as ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) and CPT (Current Procedural Terminology). By accurately coding medical data, coders facilitate efficient billing processes, contribute to quality improvement initiatives, and support research efforts.

Here are some key types of data that medical coders have to work with:

1. 1. Patient Information: Medical coding specialists handle sensitive patient information, including demographic details (name, age, address), insurance information, and medical history. This information is crucial for accurately assigning appropriate codes for procedures, diagnoses, and treatments.
   2. Medical Charts and Documentation: Professional medical coders review medical charts, physician notes, operative reports, and other clinical documentation to extract relevant details for coding purposes. They analyze this information to identify procedures performed, diagnoses made, medications administered, and any other relevant healthcare services provided.
   3. Healthcare Codes: Certified medical coders work extensively with various coding systems, such as International Classification of Diseases (ICD) codes, Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes. These codes are used to classify medical diagnoses, procedures, treatments, and services rendered.
   4. Insurance Claims and Reimbursement Data: Medical coders deal with insurance claims and reimbursement data, including patient billing information, claim forms, and coding-related documentation required by insurance companies. They ensure that the claims submitted accurately reflect the services provided to facilitate timely reimbursement.
   5. Compliance and Regulatory Data: Clinical coders must stay up to date with healthcare regulations, such as HIPAA (Health Insurance Portability and Accountability Act) and CMS (Centers for Medicare and Medicaid Services) guidelines. They utilize this data to ensure coding practices adhere to compliance standards and regulatory requirements.
   6. Coding Guidelines and References: Certified professional coders rely on coding manuals, guidelines, and references provided by authoritative organizations like the American Medical Association (AMA), the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC). These resources assist coders in accurately assigning codes based on standardized protocols.
   7. Electronic Health Records (EHR): With the widespread adoption of electronic health record systems, medical coders access and analyze patient data stored in digital formats. EHRs contain a wealth of information, including lab results, diagnostic imaging reports, medication lists, and progress notes, which aid in accurate coding.
   8. Quality Assurance and Auditing Data: Medical coding professionals often participate in quality assurance initiatives and coding audits. They review coded data, identify discrepancies or errors, and provide feedback to ensure coding accuracy, consistency, and compliance with coding guidelines.

Medical coders need to maintain the confidentiality, accuracy, and integrity of the various types of data they handle. Adhering to strict data protection and privacy protocols is crucial to ensure patient confidentiality and compliance with applicable laws and regulations.

Addressing the Medical Coder Data Entry Challenges

Medical coders face several challenges when it comes to data entry in their day-to-day tasks. One of the major challenges is the complexity and ever-evolving nature of medical codes. The healthcare industry utilizes various coding systems, such as ICD-10-CM and CPT, which contain a vast number of codes that need to be accurately assigned to diagnoses, procedures, and treatments. Staying updated with the latest code changes and guidelines requires continuous learning and attention to detail.

Additionally, the volume of patient records that need to be coded can be overwhelming, leading to time constraints and potential errors. The data entry process itself can be tedious, as coders must meticulously review medical documentation, interpret information, and input codes into electronic health record systems accurately. Moreover, coding for specialized medical fields or complex cases requires in-depth knowledge and expertise, making the task even more challenging. Despite these hurdles, medical coders play a crucial role in ensuring accurate documentation and billing, which directly impacts healthcare reimbursement and patient care.

This is where MEDICODIO’s AI-powered medical coding software comes in.

MEDICODIO’s AI-powered medical coding tool eliminates the need for manual data entry in an EMR system. The tool uses AI technology to automatically extract the necessary information and convert it into accurate medical codes. The benefits of using MEDICODIO’s tool include improved accuracy, increased productivity, and reduced workload and stress on medical coders.

How does Codio work? 

• • Codio makes use of API and RPA to read patient data from EHR systems and physicians’ notes/charts.  

• • RPA takes care of the Data entry in the Client EMR system post-coding in the MEDICODIO Application.

• • The collected data is analyzed and processed using AI algorithms, ML and NLP.  

• • By referring to analyzed data, Codio suggests medical codes (CPT, ICD 10, HCPCS, Modifiers). All credits to AI and deep learning, Codio can pick codes accurately considering all the parameters.  

• • MEDICODIO allows the medical coders to review codes generated upon reading the charts. 

• • These selected codes are then sent to claim & billing systems. If there are any errors, MEDICODIO flags the record for review.  

• • Codio learns and adapts over time leveraging machine learning. 

You can now try CODIO firsthand by scheduling a demo. Click here to try.

To learn more about MEDICODIO’s AI-powered medical coding tool, please schedule a free demo.