What is Clinical Coding?
Clinical coding is the translation of clinical information into codes. When a patient comes to hospital, the main condition the patient was treated for, the secondary diagnosis, and any other relevant procedures and interventions are coded in accordance with the relevant coding rules, conventions and clinical standards.
Medical aid schemes require the submission of clinical codes as part of a patient’s account to reimburse the services rendered by healthcare providers. All diagnoses, procedures and interventions pertaining to the treatment of a patient are translated by a clinical coder into clinical codes.
Other than for reimbursement purposes, clinical coding can also be used to facilitate storage, retrieval and statistical analysis of clinical information for comparison and decision-making.
Clinical coding ensures consistency in the reporting and capturing of patient clinical information across the healthcare industry in South Africa, which means that there is also consistency in reporting to South African legislative bodies.
Clinical coders are typically highly organised and detail-driven individuals who must be able to identify codes in a systematic and structured manner. They are expected to interpret medical information for the purpose of translating said information into clinical codes. Clinical coding requires technical and analytical skills; although a medical background is helpful, it is usually not a prerequisite for such a position.
Given the high demand for qualified clinical coders, several career opportunities are available in a variety of settings; these include hospitals, clinics, medical practices, medical aid schemes, law firms, and public and government agencies.