Though you will be required to complete a 2-4 year accredited degree program in order to become a certified medical coder, you can teach yourself the basics by utilizing the manuals and information you can find online, including medical coding practice worksheets. In order to learn the basics of medical coding, you must also have a basic understanding of a few key fundamentals.
Explanation of Medical Coding
The AHIMA, or American Health Information Management Association, describes coding as converting a verbal description of an injury, procedure, or disease into a numeric/alphanumeric code to allow medical records to be accessed according to the diagnosis or procedure. The codes are used to ensure reimbursement, research, clinical care, and instruction. Data such as physician’s notes, records, test results and more are reviewed by medical coders so that the proper code can be assigned.
Since these records are most likely to contain words and jargon that many not necessarily be familiar to you, the very first step in learning how to do medical coding is to make yourself familiar with human anatomy & physiology and medical terminology.
Basics of Medical Terminology
Professionals in the health care field use medical terminology to describe the body, the systems of the body, conditions, diagnoses, procedures, developments, and treatments. Medical terms are rooted in Greek and Latin, and adhere to a structure that methodically divides terms into specific elements. Learning to recognize these elements/parts of the term is crucial. The word is a combination of the word root, prefix, and suffix. To get started, you must learn where each of the parts of the word is located, as well as the purpose it has.
Pay attention to the fact that the root word is typically in the center of the term. The prefix comes first and the suffix is at the end. If you can recognize elements that are most often used, you will be able to more readily identify the terms. You can practice these terms by writing them on index cards and making changes to their elements. This will help you to understand the impact it has on the term’s meaning.
Take some time to review medical documents to see how the terms appear and how they are most often used. You can do this by visiting websites that contain an inclusive list of medical terminology and demo the methods used in the construction of the term.
Basics of Human Anatomy & Physiology
Next, you are definitely going to need an understanding of the key concepts that are related to human anatomy and physiology. This is critical knowledge to have because when the codes are assigned, you’ll use a code manual that is manual that is divided up into the various parts and systems of the body. Keep in mind that the term anatomy is used in reference to the body parts and their relationship to each other and the term physiology is used in reference to the way the body works. Instead of learning the body as a whole, you need to know the groups of system the body is broken down into:
- Nervous system
- Muscular system
- Skeletal system
- Cardiovascular system
- Endocrine system
- Lymphatic system
- Urinary system
- Reproductive system
- Digestive system
- Respiratory system
You can find websites that allow you to explore human anatomy by looking at each individual system.
Basics of Coding Systems
Medical coding/classification systems have a variety of functions in the field. For example, classification codes fall under the following categories:
In addition, you will find a variety of coding systems that can be used, depending on the particular practice or field.
The coding systems that you will want to become the most knowledgeable in are:
- HCPS, or Healthcare Common Procedure Coding System
- CPT (Current Procedural Terminology)
- ICD (International Statistical Classification of Diseases and Related Health Problems)
Other Things to Keep in Mind
Even if you’re not in a medical coding course, you can still access the various the materials and guides used in the courses. You can create your own flashcards and study guide to review the information you learn- and you can get your hands on a variety of medical documents that you can practice with.
You will find that it’s definitely worth taking the time to understand medical terms, as well as human anatomy and physiology, as it will give you a foundation to help you look up and identify the proper code in the coding manuals. You should also utilize the medical coding practice worksheets, tutorials, assessments, guides, and quizzes that you can easily obtain for free online.