What is Clinical Coding

The representation of an inpatient stay or outpatient visit using codes using the International Classification of Diagnoses (The ICD version used in a specific country or region) for diagnosis, procedures, injuries and their cause. These codes are used as the basis for hospital funding and for public health trend monitoring and decision making in the healthcare system from local to international levels.

A clinical coder (sometimes known as a clinical coding officer, medical coder or nosologist) is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system (in Australia the code system is currently ICD-10-AM 11th edition and the Australian Classification of Healthcare Interventions ACHI).

Where do coders work?

In hospitals, healthcare services, insurance agencies, government agencies. Coders allocate codes the skills of coders are also used today in the analysis of clinical data and in information systems using such code systems.

What people make great coders?

The best coders are detail people who are able to investigate the content of a record and apply their clinical knowledge and knowledge of the classification system to explain the patient’s health status and care for the episode using codes.

A coder is a detail loving detective.