Your Guide to Medical Coding and ICD-10

Medical Coding: What You Need to Know

There are few industries out there that are growing as fast as the health care sector. And within health care, a handful of specific careers are exploding in terms of growth. Medical assisting is one such example.

As of now, the Bureau of Labor Statistics (BLS) estimates that medical assisting will grow by a whopping 23% over the next decade. This is the equivalent of more than 130,000 new positions that will be created all across the country.

Medical assisting is varied, exciting, engaging, and important work. As a medical assistant, you have the opportunity to offer a range of services to patients in a wide variety of health care settings. You might work as a medical assistant for a family physician, helping patients settle in to their exam room, taking basic vital signs and recording them in patient charts, and assisting the primary care physician with a number of other tasks. Or, you may work in a hospital setting, balancing both clinical and administrative work as part of your day to day tasks.

Indeed, medical assistants are often tasked with a large number of responsibilities. These can include:

• Working with physicians during patient exams
• Helping to notate a patient’s information
• Answering basic questions from patients (within your scope of practice)
• Providing patients with information and educational materials related to post-visit care
• Communicating with pharmacies
• Collecting lab specimens and sending them to labs for analysis
• Taking patient vital signs and recording them as needed
• Answering phones, scheduling appointments, and helping patients check out

In addition to this long and growing list, however, medical assistants may also be expected to engage in some amount of medical coding. This means that you’ll need to be familiar with both medical coding in general, and with the ICD-10 system specifically.

But what is medical coding? What is ICD-10? And what does this have to do with being a medical assistant?

In the guide below, we’ll walk you through the medical coding process. You’ll develop a fuller and more complete understanding of what exactly medical coding is and how it works. You’ll also get a sense of what you’ll actually be expected to handle as a medical assistant, versus how much work will be handed off to specialized medical coders. Finally, we’ll offer a side-by-side comparison of medical assisting versus medical coding. This will help you understand the difference between these two distinct career paths.

Remember that regardless of how much medical coding you do as part of your daily routine in any given position as a medical assistant, you’ll need to first pass a medical assisting certification exam. This is an essential step towards landing a full-time position in a general practice, specialty practice, or hospital setting. We’ll talk more about the importance of exams like the CMA and RMA (and how to study and prepare for them effectively) at the end of this blog.

Ready to learn more about medical coding? Let’s get started!

What Is Medical Coding?

No matter what type of physician you see — whether it’s your family doctor or a highly specialized physician such as a cardiologist or pulmonologist — one of the major goals of your visit is to arrive at a diagnosis. Your doctor can’t provide you with treatment if they don’t first determine what it is that’s wrong, of course.

In order to arrive at a diagnosis, your physician might run any number of tests and engage in various other diagnostic procedures. These can include X-rays, blood tests, urinalysis, or any number of other approaches. At the end of the day, you’ll end up with both a diagnosis and a list of diagnostic procedures that were performed in order to arrive at that diagnosis.

All of this information is recorded into your chart. From there, it’s often passed along to a medical coder. But what exactly does that entail? What does the medical coder do?

As anyone who’s involved in health care can tell you, billing is a huge part of the health care process. It’s essential to the functioning of the industry. It doesn’t matter whether you’re talking about the public system (such as Medicare or Medicaid billing) or private health insurance companies, either. In both cases, it’s essential to submit a bill to the reimbursing party in question (whether it’s a public entity or a private insurer) in order to receive reimbursement for the services that the physician has performed.

However, you can imagine how complicated this process can quickly become. On any given day, a physician might see dozens of patients. Each of those patients could be suffering from one or more illnesses, and might require any number of different diagnostic procedures in order to arrive at a definitive conclusion about what’s going on with them. Many of the illnesses in question can be complex, overlapping, and extremely similar to (but distinct from) other issues. Similarly, there is a whole range of blood tests that a position might perform, and a urinalysis could be used to test for any number of things.

Each of these diagnostic tests and diagnoses is of a different sort of complexity, and brings with it a different level of reimbursement. For that matter, the type of visit that you engage in at the physician’s office (an annual wellness visit, a same-day appointment, an appointment with a specialist, and so on) can lead to a different level of reimbursement.

Just imagine how confusing this could become for insurers and public entities like Medicare and Medicaid. If each individual physician’s office simply wrote out a general description of what services they’d performed and which tests they’d ordered, and then requested reimbursement by naming these items off, it would be extremely time consuming both for the physician to detail the items and for the reimbursement entity to evaluate them.

That’s where medical coding comes in.

Essentially, medical coding involves taking all of the above described items — various diagnoses, services, tests, procedures, and the use of certain equipment — into a series of codes represented by numbers and letters. These codes are intended to be universal, and are both employed by every physician’s office and hospital on the one hand and interpreted and understood by every public and private insurer on the other. The most common coding system in use is the ICD-10 system.

What Is ICD-10?

ICD-10 is the 10th revision of the International Classification of Diseases, and has been in use since 2015.

Simply put, the ICD-10 system is a comprehensive list of health problems, diseases, physician findings, symptoms, causes of injury, and more. ICD-10 was designed to replace ICD-9, an older version of the coding system which had been in use since the 1970’s.

As you can imagine, the ICD-10 database of codes is huge. In fact, there are nearly 70,000 individual codes within the system, each of which is unique. The use of this extensive code database is now mandatory for any and all health care practitioners that fall under the Health Insurance Portability Accountability Act, or HIPAA. In the United States, this includes all insurance companies, doctors, physicians’ offices, and hospitals.

Wondering how ICD-10 coding works in action> The American Academy of Professional Coders, or AAPC, has put together a number of documentation examples. For example, a patient who has suffered an injury as a result of being struck by a falling object would receive code W20.8xxA. If this same patient lost consciousness for a short period of time (less than 30 minutes), code S06.0x1A would also be attached to their history. There are also codes to account for where the injury occurs (for example, Y92.010 indicates the kitchen of a single-family home) and what the patient was doing at the time of the injury (again, as another example, Y93.g3 indicates that the patient was engaged in cooking or baking). The diagnosis in such a case might be M54.2, cervicalgia, and M99.01, segmental and somatic dysfunction in the patient’s cervical region.

As you can see, medical coding can be extremely complex and varied. With over 69,000 different and completely distinct codes, there’s a lot to learn. This raises a common question: are medical assistants and medical coders the same? Or are these different jobs?

Are Medical Assistants and Medical Coders the Same?

The above example should give you a sense of just how complicated medical coding can be. With this in mind, a lot of medical assistants are concerned that they’ll be tasked with this level of complexity as part of their day to day tasks.

In fact, though, medical assistants and medical coders are distinct from one another. While it is indeed common for medical assistants to engage in some level of medical coding as part of their day to day tasks, particularly in ambulatory care and general billing settings, most physicians’ offices and hospitals have dedicated medical coders who have the knowledge and expertise needed to accomplish the complicated task before them.

Medical Assisting and Medical Coding: A Side-By-Side Comparison

So, medical assistants and medical coders may have some overlapping responsibilities — but at the end of the day, they’re two different jobs. The busier and more specialized a practice or clinical setting is, the more likely you are to encounter dedicated medical coders working there — and the less likely that a medical assistant will be involved in this work.

In some respects, though, medical assistants and coders have a lot in common. For one thing, both careers are expected to experience significant job growth in the coming decade. As mentioned earlier, medical assistant positions are expected to grow by 23 % in the coming years. Meanwhile, the Bureau of Labor Statistics anticipates that medical coding positions will grow by 15 % during the same time period.

When it comes to average pay, medical assistants and medical coders are also quite similar. Being a medical assistant comes with a median pay of $31,540 per year, while medical coders with expertise in ICD-10 codes can expect to earn $38,040 per year on average. It’s also quite common for both certified medical assistants and medical coders to receive postsecondary education and receive certification through a national governing body of some kind.

On the other hand, though, there are quite a few differences between medical assistants and medical coders. Medical assistants typically focus on a mixture of clinical and administrative work, or may choose to pursue one or the other exclusively. This can include a wide range of tasks: everything from taking patient vitals, drawing blood, and collecting urine samples to handling billing, scheduling, and recordkeeping. Meanwhile, the work of medical coders is purely administrative in scope. This means that as a medical coder, you won’t be working side by side with patients on a daily basis. Instead, you can expect your work to center around assessing physician notes and assigning ICD-10 codes to patient records.

Preparing for Your Medical Assistant Certification Exam

As we’ve seen, then, medical assistants can expect to encounter some amount of medical coding as part of their work. It may be the case that exclusively clinically-focused CMAs don’t actually engage in much medical coding, and therefore won’t need to be familiar with ICD-10. Still, though, the more knowledge you have under your belt, the better qualified you’ll be to fulfill a variety of roles on the job.

Before you can become a medical assistant, though, you’ll need to prepare for your certification exam. This involves studying a wide range of information, and trying to keep track of it all can be daunting. Fortunately, though, ScopeNotes™ is here to help! We offer unlimited practice test opportunities for a range of medical assistant certification exams, including the CMA exam, the RMA exam, and more. With ScopeNotes, the test content you’re presented with adapts to your individual needs as a student. This means that you’ll maximize your study time during each and every session. Want to learn more? Click here to take a look at our affordable study packages!