The Critical Partnership: Why Physician-Coder Collaboration is Essential

While most doctors like to concentrate on patients, medical treatment generates necessary tasks, such as coding, or the process of assigning numbers to diagnoses. A coder is trained for this but will need assistance from the physician to be successful.

History

• The International Classification of Diseases (ICD) originated in Europe during the late 19th century and has been implemented in the United States since 1900. The American Medical Association developed the Current Procedural Terminology (CPT) code in 1966. The two codes work together to classify symptoms, diseases, tests and treatments.

Discussion

• When certified coders and physicians work together the result is more accurate coding. Because documentation is the basis for coding, physicians must be thorough and accurate in medical records. Accurate coding assists in billing, research and education.

Considerations

• A medical coder may not assume anything. If documentation is unclear, a coder should be able to ask the physician for clarification. This additional clarification may lead to better insurance reimbursement.