Take a step back, and this is suddenly a lot of very specific information.
In a straightforward case like this, the doctor will only officially report his diagnosis, but that still means the portion of that report that will be coded contains a diagnosis, a procedure, and a prescription. If you go into the doctor with a sore throat, and present the doctor with symptoms like a fever, sore throat, and enlarged lymph nodes, these will be recorded, along with the procedures the doctor performs and the medicine the doctor prescribes. To answer that, we have to look at the massive amount of data that every patient visit entails. Let’s start with a simple question about medical coding: Why do we code medical reports? Wouldn’t it be enough to list the symptoms, diagnoses, and procedures, send them to an insurance company, and wait to hear which services will be reimbursed? Coders take medical reports from doctors, which may include a patient’s condition, the doctor’s diagnosis, a prescription, and whatever procedures the doctor or healthcare provider performed on the patient, and turn that into a set of codes, which make up a crucial part of the medical claim. Medical coding is a little bit like translation.
