In healthcare, an encoder is a software tool or system that assigns alphanumeric codes to medical diagnoses, procedures, and services according to standardized code sets such as ICD-10-CM, CPT, and HCPCS. These codes are essential for accurate billing, reimbursement, and statistical analysis.
A standardized system healthcare providers use to classify and code all diagnoses, symptoms, and procedures documented in medical records.
A set of medical codes maintained by the American Medical Association (AMA) that describe medical, surgical, and diagnostic services performed by healthcare providers.
A standardized coding system primarily used for Medicare and Medicaid services to represent medical procedures, supplies, products, and services not covered by CPT codes.
A defined list of codes used to represent specific medical diagnoses, procedures, and services within healthcare documentation and billing processes.
The process of recording patient encounters, including symptoms, diagnoses, treatments, and outcomes, in a structured format suitable for encoding.
A document used by healthcare providers to collect and record patient information during an encounter, facilitating accurate coding and billing.
A systematic naming convention used within healthcare coding to ensure consistency and accuracy in the representation of medical terminology and procedures.
A classification system used to group patients with similar clinical conditions and treatment requirements for Medicare reimbursement.
Adherence to regulatory requirements and coding guidelines established by organizations such as the Centers for Medicare & Medicaid Services (CMS) and the American Health Information Management Association (AHIMA) to ensure accurate and ethical coding practices.