A is for axilla. AAS is for atypical antibody screen. Thousands of abbreviations,
ranging right through the alphabet, stand for medical terms.
Medical coders need to recognize and understand all of the abbreviations
that doctors and nurses write on medical charts so that they can then apply
codes to them. Sound easy enough? Maybe if you come across abbreviations such
as w/c for wheelchair.
But coders also have to wrap their brains around much more complicated
terminology, such as TTN for transient tachypea of the newborn, or TPPL, trans
par plana lensectomy.
"You have to have a strong skill level for recognizing codes," says Shirley
Davis. She is a professor of health information management and medical coding
in Florida. She says the job entails much more than simply applying codes
to procedures.
"It's somewhat like being a medical detective," she says. "You have
to go in and make sure the documentation makes sense. You have to audit medical
records and make sure that what was written as a diagnosis really did happen."
She adds that this is detail work. "It can be a real challenge."
Medical coders learn how to code diseases by learning about medical procedures
and terminology -- and by learning a huge series of codes. The codes are found
in a book called the International Classification of Diseases (ICD). This
book, created by the World Health Organization, is used in almost every country
around the world.
"Almost every country in the world codes and abstracts clinical information,
which is submitted to the World Health Organization," says Gail Crook. She
is the executive director of a health record association.
In this way, medical coders help the World Health Organization track diseases,
outbreaks and treatments around the globe. These findings can also help the
WHO decide if it should recommend vaccinations in certain areas for certain
diseases.
Because coders have access to sensitive medical information, they must
be discreet. "The health record professional has the responsibility to ensure
that the patient's record is kept confidential and that no one breaches
the patient's confidentiality," says Crook.
Codes are used to determine how much to bill a patient or their insurance
company for a procedure.
There are changes coming in health care, however. "Coding was a little
simpler in the past," says Joe Santos. He is a certification specialist at
the American Health Information Management Association (AHIMA).
"Things may have been done by a medical secretary. But now the coding is
much more complicated."
Coding today must also be much more thorough and exact. "Some of the codes
are used for research, but reimbursement is what drives the entire industry,"
says Santos. "The codes equate to dollars spent.
"The federal government had deeper pockets in the past, and paid for more
things. Now there is less money to go around and codes are being reviewed.
They're certainly looking at coding with more scrutiny."
Technology is also changing the way coding is done. "As in all professions,
technology is changing how we will work in the future," says Crook.
However, she says that the computer won't eliminate jobs. "Health
record professionals will continue to have a role, but it will be in an electronic
versus a paper environment. But we have a ways to go before we are all in
a full electronic world."
"You need to have good computer skills," agrees Davis. "You don't
want to be a hunt and peck typer!"
The job entails more than assigning numbers. "It isn't that cut and
dry," says Davis. "There are real challenges and decisions that have to be
made."
"The field of health information management is extensive," adds Crook.
"The health-care arena absolutely needs trained people for interpreting and
analyzing health-care data. There are many wonderful opportunities."