Four Step Coding Process
What is it?
Step 1
Analyse medical terminology
In this step the coder must use the source document to analyse the clinical
statement describing the patient's diagnosis, complaint, problem, or other
reason for health care encounter. Then they must determine
what condition(s) or circumstance(s) need to be coded. And identify the lead
term(s) and modifiers in the statement provided by the clinician.
The source document usually used within clinical coding is the full set
of patient case notes. One of the most challenging aspects of the clinical
coding process is to identify relevant information in the case notes regarding the patient's hospital
stay to obtain a complete picture to support the diagnostic statement.
Step 2
Locate lead term(s) in the Alphabetical Index
The lead term identifying the patient's condition, problem, complaint, or other reason for encounter is used to locate the appropriate lead term in the Alphabetical Index. The lead term is always found in the bold face in the Alphabetical Index. Warning - the Alphabetical Index uses American Spelling so many conditions featuring "ae" in English are spelt only with the "e".
Step 3
Assign a tentative code using the Alphabetical Index
Once the appropriate lead term has been located, several conventions and principles used in the Alphabetical Index must be understood before a tentative code assignment can be made. These conventions include the use of:
- Modifiers: non-essential and essential
- NOS (not otherwise specified), i.e. no modifiers
- NEC (not elsewhere classified)
- Aetiology and manifestation (dagger and asterisk system
- Cross reference
- Order of modifiers
- Instructional notes
The tentative code assigned is the alphanumeric code following the:
- lead term
- subterm that is an essential modifier
- subterm for 'specified type NEC'
Step 4
Verify the code assignment by checking the Tabular List
This is the final step in the step-by-step coding process. The coder must now verify the tentative code assigned in step 3 in the Tabular List to ensure appropriate code section. This may be a case of verifying the tentative code is indeed correct, or in fact changing or adding to the tentative code.
