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
See Wai on your own clinic.
A 15 minute video call on your own diary, notes and inbox. Prices for clinics, groups and hospitals are on the pricing page.
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.