Glossary, documentation
What is clinical coding?
Clinical coding is the translation of diagnoses, procedures and other clinical information in a patient record into standard codes, such as ICD-10 for diagnoses or SNOMED CT for clinical terms. The codes let insurers pay claims, health systems count activity and researchers compare outcomes.
Updated . Defined by the wai team for clinics, groups and health systems.
Also called medical coding, diagnosis coding or procedure coding.
Why Clinical coding matters to a clinic
Codes are how a consultation becomes revenue. Payers read the code as well as the note, and a code the record does not support becomes a rejected claim or a clawback later. In the United States, ICD-10 applies to every party covered by HIPAA,1 and to more than the providers who bill Medicare or Medicaid.
Coded data is also how health systems plan. WHO describes ICD-coded information as the basis for resource allocation and payments,2 so the same codes that pay a clinic feed national statistics.
Coding works best from a signed note. A code drafted from the record, with the lines that support it, is quicker to check and easier to defend in an audit.
Questions
Who is responsible for a clinical code?
The clinician and the billing team who accept it. Software can propose codes, and a person checks each one against the record before a claim goes.
What is the difference between ICD-10 and SNOMED CT?
ICD-10 is a classification used for statistics and claims. SNOMED CT is a detailed clinical terminology used inside the record. See ICD-10 coding and SNOMED CT.
Sources
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