What is clinical coding?
Clinical coding is the translation of written clinical documentation about patient care into code format. For example, acute appendicitis is represented by the code ‘K35.8’.
The International Statistical Classification of Diseases and Related Health Problems based on the World Health Organisation ICD-10 system is applied in all South African health facilities with some additional coding specific to South Africa.
What does a clinical coder do?
A clinical coder is responsible for abstracting relevant information from the medical record and deciding which diagnoses and procedures meet criteria for coding as per the South African Coding Standards. The coder then assigns codes for these diagnoses and procedures based on the classification standards and conventions. Clinical coding is a specialised skill requiring excellent knowledge of medical terminology, disease processes, medical procedures, attention to detail, and analytical skills.
What is the coded information used for?
The assigned codes and other patient data are used to determine a Diagnosis Related Group (DRG) for the episode of care, which is used to determine hospital funding. This process allows patient needs to be matched to health care resources. Other common uses of coded data include:
- Clinical research and education
- Health services planning
- Statistical and epidemiological studies
- Clinical benchmarking