Medical Coding

 

Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses andprocedures into universal medical code numbers. The diagnoses and procedures are usually taken from a variety of sources within the health care record, such as the transcription of the physician's notes, laboratory results, radiologic results, and other sources.

Diagnosis codes are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers and others to process claims.

Medical classification systems are used for a variety of applications in medicine, public health and medical informatics, including:

• statistical analysis of diseases and therapeutic actions

• reimbursement; e.g., based on diagnosis-related groups

• knowledge-based and decision support systems

• direct surveillance of epidemic or pandemic outbreaks