This document provides a brief guide to medical coding, detailing its essential role in the healthcare industry where accurate communication and documentation are vital among various stakeholders. Medical coders translate providers’ notes into standardized codes for diagnoses and procedures that insurance companies use for payment processing. The guide emphasizes the need for coders to possess extensive knowledge of human anatomy, medical terminology, and insurance regulations.

1. A B R I E F G U I D E T O
L S Coding & Education LLC

2. Health care is a giant industry, made up of patients, files, hospitals, doctors, medicines,
insurance companies, procedures, government agencies, tests, forms, and administrators.
With all that going on, it is important to have a way of simply communicating to all the
parts through all the different pieces of paperwork. That’s where medical coding and
medical coders come into the picture.

3. FROM PATIENT
TO CODER
When a patient visits a hospital, the doctor will
run tests, create a diagnosis, and then assign a
treatment. The medical coder will issue a code
to each diagnosis and procedure.
For example, there is a
specific code for a pigmented
mole located on a patient’s
lower back:
ICD-9-CM Diagnosis Code 216.5
Benign neoplasm of skin of trunk,
except scrotum

4. MEDICAL
CODES
To code a patient’s file, the
coder will review the
medical provider’s notes and
translate them into ICD-9-CD
and HCPCS Level I and Level
II codes. Currently, there are
over 13,000 medical codes
in ICD-9-CD alone. The
doctor’s notes are usually a
brief description of the exact
diagnosis and procedure
that was administered.

5. INSURANCE
These codes are then sent to the patient’s
insurance company (including Medicare and
Medicaid) for payment. The insurance
company will evaluate the codes, and if they
are correct and are covered by the insurance
company, they will pay the provider for their
medical services.

6. ANALYZING
DOCTOR’S NOTES
The medical provider’s notes are as unique as the
patient’s diagnosis. Some notes can be quite simple
while others can be extremely difficult to code
correctly. Even some of the commonly used codes
can fall into gray areas amongst different coders.

7. DIFFICULT
CASES
Even the most experienced
coders may come across a very
complex or unusual case that
can be very difficult to
interpret. For these types of
situations, coders will rely on
peers and other professionals
to wade through the nuances of
the case to determine the
proper code.

8. EDUCATION
Most coders have their bachelor’s degrees and master’s degrees, although it is not
necessary. What is absolutely required is an extensive knowledge of the human
anatomy and medical terminology. Coders should also be familiar with insurance
plans and regulations.

9. L S Coding & Education LLC
For more information on medical coding education, please contact (866) 737-3701 or
visit http://cpc.certifiedcodertraining.com/ .
If you are looking for a professional and unique medical coding program L S Coding and
Education is the place. Instructor and President, Lynn Schoeler, has been providing an
AAPC Professional Medical Coding Curriculum for over two decades.

10. Summary
• With all the facets to consider amongst
patients, doctors, administrators, and
insurance companies it’s no wonder why the
health care industry needed a fast and precise
way to communicate. We have put together a
brief guide to medical coding to reveal what
goes on behind the nurse’s desk.