Clinical coding

How it is used

'Clinical coding' is the British term; Americans usually say 'medical coding'. Coders use classifications such as ICD for diagnoses. Poor documentation leads to coding errors, which can lower income and distort hospital statistics.

Example sentences

1. A clinical coding audit showed that many complications were not being recorded.

2. Accurate clinical coding depends on doctors writing clear discharge summaries.

Common collocations

• clinical coding team
• clinical coding audit
• coding error
• medical coding

Related terms

• ICDShort for International Classification of Diseases: the World Health Organization's standard system of codes for diagnoses and causes of death.
• DRGShort for diagnosis-related group: a category of hospital cases with similar diagnoses and procedures, used to pay hospitals a fixed amount per case.
• billingThe work of recording the services a patient received, turning them into charges and sending bills or claims to patients and payers.
• discharge summaryA document written when a patient leaves hospital that summarises the diagnosis, treatment, medicines and follow-up plan, mainly for the patient's family doctor.
• medical recordThe official record of a patient's health and care, including their history, diagnoses, test results, treatments and the notes written by staff.

More terms: Billing and Coding

• claim
• claim denial
• accounts receivable