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Clinical Coding is the translation of medical terminology, as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format. These codes, such as ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) and CPT® (Current Procedural Terminology), provide a common language for healthcare professionals, insurance companies, and regulatory agencies to communicate and understand patient care. The codes are then nationally and internationally recognised.
Accurate clinical coding is crucial for:
- Reimbursement: Proper coding directly impacts revenue generation for healthcare providers. By assigning the correct codes, you ensure that services rendered are accurately documented and billed, maximising reimbursement from insurance payers and government programs.
- Compliance: Healthcare organisations must adhere to regulatory guidelines and coding standards to maintain compliance. Accurate coding helps ensure proper documentation, supports medical necessity, and reduces the risk of audits, penalties, and legal repercussions.
- Data Analysis and Research: Coded data plays a vital role in healthcare analytics, research, and population health management. It provides valuable insights into disease patterns, treatment outcomes, and healthcare trends. Accurate coding ensures reliable data for quality improvement initiatives, clinical research, and public health reporting.
Understanding reimbursement is crucial for medical device innovators, as is dealing with it early. Reimbursement is where the ‘payer’ (public or private insurer) pays the health care provider for the costs the provider incurred in performing a medical procedure and/or using a medical device. Typically, payment occurs after the medical service has been received by the patient, hence the name ‘reimbursement’.
If your medical device is on a reimbursement list within the relevant country then it is said to be ‘covered’, however with no universal system for the reimbursement mechanisms within different countries it means you need to understand exactly what is required for your target country. A health care provider can often only offer new technologies if the new medical device can be reimbursable, and it will also depend on how much reimbursement is provided. As the device manufacturer, this may impact whether you can provide the device or not, hence why it is so important to focus on this early in the development process.
Your first step in planning is going to be identifying where your medical device will be used. This will enable you to find out if your device will fit into an existing mechanism or whether you need to embark on developing a new reimbursement mechanism. Remember, reimbursement is determined by (a) the coverage or payer’s motivation/willingness to pay for certain procedures or devices, (b) the device or procedure ‘code’, which has been developed to enable effective communication between payers and healthcare providers, and (c) the payment rate or how much will be paid for that procedure or device.
Providing payers and health care providers with evidence of clinical and economic effectiveness will help inform their decision making, and if a new reimbursement code is needed then this evidence and detailed research of the user base per county will be imperative.
With so much to consider in reimbursement and clinical coding, we recommend that you seek advice from specialists in this area. Odelle Technology has much experience in reimbursement and market access so feel free to get in contact with us to discuss your project.
To find out more and discuss your project, please contact us.