Inpatient medical coding involves assigning codes to medical diagnoses, procedures, and services for billing and reimbursement purposes. The codes are based on standardized classification systems, such as the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT).
A typical inpatient medical record may include the following information:
- Patient demographic information, such as name, date of birth, and address
- Admission and discharge dates
- Medical history, including previous illnesses, surgeries, and medications
- Current medical condition and symptoms
- Vital signs, such as blood pressure, heart rate, and temperature
- Results of diagnostic tests, such as blood tests, imaging studies, and biopsies
- Diagnosis and treatment plan, including medications, procedures, and surgeries
- Progress notes from healthcare providers
- Discharge instructions and follow-up care recommendations.
Based on this information, medical coders can assign appropriate codes to each diagnosis, procedure, and service provided during the patient’s hospitalization. These codes are used to bill insurance companies or government programs, such as Medicare or Medicaid.