What is the meaning of clinical coding?

Answer 1

Clinical Coding is the translation of medical information relating to a patient's encounter with a health care provider into alphanumeric code. This code makes it possible to perform analysis on health care activity by grouping diagnoses and procedures together. Clinical Coders are the professionals that perform the act of Clinical Coding. In the US and other parts of the world they are often referred to as Medical Coders or Diagnostic Coders.

In the UK two main systems of classification are in use. ICD-10 is used to capture and code diagnostic information about a patient's encounter with a health care provider; diagnosis, symptoms, reason for examination or therapy for example. OPCS-4.5 is used to capture and code information about medical and surgical procedures or other interventions performed in the course of treating a patient.

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An example:

A patient presents at hospital with a headache, in the course of investigations doctors order and perform a CT scan. The CT scan shows nil of note.

The diagnostic ICD-10 code for this admission could be:

R51.x [Headache]

The procedural OPCS-4.5 codes for this admission could be:

U05.1 [CT Head] and Y98.1 [Radiology of one body area]

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ICD-10 is issued by the World Health Organisation and is used worldwide in a number of different languages. ICD-9, an earlier version, is currently used in the United States (ICD-9 codes are predominantly numeric rather than alphanumeric).

OPCS-4.X is used in the UK; there are slight local variations in the manner in which certain procedures are coded.