Clinical coding is one of our best-selling offerings. With our experience in the healthcare industry, we have realized that accurate and efficient coding is vital for reimbursement, compliance, and healthcare analytics. Our Clinical coding service involves the translation of medical diagnoses, procedures, and services into universally recognized codes that are used for billing, documentation, and data analysis.
Clinical Coding
Our Clinical coding service involves the translation of medical diagnoses, procedures, and services into universally recognized codes that are used for billing, documentation, and data analysis.
We provide the following solutions
Medical Documentation Review
Our Clinical coding process begins with a thorough review of medical documentation, including physician notes, operative reports, diagnostic test results, and other relevant records. Our coder understands the patient’s condition, the services provided, and any procedures performed.
Code Selection
Based on the medical documentation, our clinical coder selects the appropriate codes from standardized code sets such as the International Classification of Diseases (ICD 10) for diagnoses and the Current Procedural Terminology (CPT) for procedures and services. The coder carefully matches the documented information with the most accurate and specific codes.
Code Classification and Assignment
After code selection, our clinical coder classifies them following guidelines and performs a validation step to ensure accuracy. This involves cross-referencing, error-checking, and finalizing codes for the patient’s medical record or billing system—a standardized representation of their condition and services.
Documentation Clarification
We also provide additional check to ensure accurate coding and proper documentation of the patient’s conditions and procedures. In cases where the medical documentation is incomplete or unclear, the clinical coder may need to seek clarification from the healthcare provider.
Compliance and Regulatory Considerations
We prioritize compliance with Health Insurance Portability and Accountability Act (HIPAA) and Centers for Medicare and Medicaid Services (CMS) guidelines to safeguard privacy, ensure security, and achieve accurate reimbursement. Our commitment to regulatory requirements ensures quality healthcare solutions.
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