In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters.
The various classifications have a focus towards a particular patient encounter type such as emergency, inpatient, outpatient, mental health as well as surgical care.
The principal diagnosis, additional diagnoses alongside intervention codes essentially depict a patient's admission to a hospital.
A number of factors can contribute to the overall accuracy coding which includes medical record legibility, physician documentation, clinical coder experience, financial decision making, miscoding, as well as classification system limitations.
Factors that contribute to a medical records quality are physician documentation, handwriting legibility, compilation of forms, duplication and inaccurate patient data.
[7] The following criteria should be used as a guideline when creating a medical record specific to the aid of providing clear documentation for diagnostic coding.
Generally a coder with years of experience is able to extract all the relevant information from a medical record whether it is paper, scanned or semi-electronic.
An experienced coder may incorrectly assign codes due a lack of application of a classification systems relevant standards.