Questions

• What is the role of the clinical coder in an organization?

• What terminology do coders work with? Are the coders dedicated to only one terminology?

• Do coders have a role in auditing the SNOMED-to-ICD mapping processes?

• Are the coding processes all automated and mapped automatically between SNOMED and ICD/reimbursement catalogs or does the coder have to actually code?

• When code discrepancies are found by the coder, does she have to get physicians to co-sign on all changes done by the coder?

10.1 What is the role of the clinical coder in an organization?

Clinical coders review the coded data in the EHR or clinical notes, and provide a definitive discharge diagnosis. A coder will use all knowledge in the clinical notes to define the required classification code(s).

10.2. What terminology do coders work with? Are the coders dedicated to only one terminology?

Coders can work with a range of terminologies, including ICD-10, OPCS-4 and SNOMED CT. However, because SNOMED CT is designed for use by clinicians, a clinician will typically record the diagnosis as a SNOMED CT concept, and this will be mapped to a classification (e.g. ICD-10) by a coder (with the help of the default maps).

10.3. Do coders have a role in auditing the SNOMED-to-ICD mapping processes?

Coders can provide feedback on the SNOMED-to-ICD mapping.

10.4. Are the coding processes all automated and mapped automatically between SNOMED and ICD/reimbursement catalogs or does the coder have to actually code?

In many cases, the coding process to generate ICD codes from SNOMED CT codes is semi-automated. The maps define a default code, which is reviewed and agreed/changed by the coder.

10.5. When code discrepancies are found by the coder, do they have to get physicians to co-sign on all changes done by the coder?

This will be dependent on the organization, but in most cases the coder has autonomy to make the required changes.