Coders use ICD codes from patient documentation to assign codes for procedures, which are found in health records and death certificates. These codes help clinicians, labs, and insurance companies manage diagnosis, treatment, and billing processes. Coders must consider costs, patient quality of life, and privacy when creating coding policies.
When coders have questions regarding patient documentation and assigning codes, they might consult the International Classification of Diseases (ICD) codes. For instance, if a patient is treated for a viral infection, the clinician will use ICD codes to prescribe treatment and order appropriate laboratory tests to confirm the diagnosis.
These codes are later used by laboratories, health-care management systems, medical coders, and billers for various purposes including reimbursement claims, vital records, and epidemiological statistics. One can find ICD codes documented within health records and on death certificates handled by vital-records keepers.
The complexity and urgency of medical cases can sometimes lead to challenges in applying knowledge correctly, which necessitates clear policies and systematic coding for efficient handling of patient documentation and care. Medical coders must balance treatment costs, patient quality of life, and privacy risks when developing policies for assigning codes.