#Meat acronym for medical coding manual#
#Meat acronym for medical coding free#

It is a branch of computer-assisted coding (CAC) 9.

Usually, it can take months or longer to train an expert clinical coder in the NHS (National Health Service) in the UK, and worldwide 7.Īutomated clinical coding is the idea that clinical coding may be automated by computers using AI techniques, e.g., NLP and machine learning 8. There are regularly updated guidelines and standards for coding (e.g., in Public Health Scotland 6). The process minimises the risk of introducing variations caused by artefacts (potentially leading to wrong decision making), thus collecting and analysing data and applying the standard is important.

#Meat acronym for medical coding manual#

There is a standard process for manual coding to ensure data consistency: textual analysis, summarisation, and clearly defined steps to classification into codes (or the four steps of analyse, locate, assign, and verify as suggested by the NHS digital in the coding standard of 2021 ). For example, coding in the US adopts the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), which has around 68,000 diagnosis codes 5 ICD-10 is also the main classification for coding in the UK. More specifically, an expert clinical coder is expected to decipher a large number of documents about a patient’s episode of care, and to select the most accurate codes from a large classification system (or an ontology), according to the contexts in the various documents and the regularly updated coding guidelines. The process of coding usually includes data abstraction or summarisation 4.

For introductory slides about clinical coding in the UK provided by NHS Digital, see Clinical coding for non coders 3.Ĭlinical coding is a non-trivial task for humans. Also, codes are mainly used for billing purposes in the US 2. The resulting national data are used to support areas, such as health improvement, inform healthcare planning and policy and add to the epidemiological understanding of a wide variety of conditions, so confidence in the data is essential. The purpose of clinical coding is to provide consistent and comparable clinical information across units of care and over time. For example, in Scotland, this means to apply a standard process to classify information about patients into appropriate diagnosis and procedure codes in ICD and OPCS (OPCS Classification of Interventions and Procedures), finally contributing to the Scottish Morbidity Records (SMR01) national data set 1.

#Meat acronym for medical coding free#

There is much to achieve to develop and deploy an AI-based automated system to support coding in the next five years and beyond.Ĭlinical coding is the task of transforming medical records, usually presented as free texts written by clinicians, into structured codes in a classification system like ICD-10 (International Classification of Diseases, Tenth Revision). Coders are needed to be involved in the development process. Automated clinical coding is a promising task for AI, despite the technical and organisational challenges. Knowledge-based methods that represent and reason the standard, explainable process of a task may need to be incorporated into deep learning-based methods for clinical coding. Our research reveals the gaps between the current deep learning-based approach applied to clinical coding and the need for explainability and consistency in real-world practice.

We introduce the idea of automated clinical coding and summarise its challenges from the perspective of Artificial Intelligence (AI) and Natural Language Processing (NLP), based on the literature, our project experience over the past two and half years (late 2019–early 2022), and discussions with clinical coding experts in Scotland and the UK. Clinical coding could potentially be supported by an automated system to improve the efficiency and accuracy of the process.

This is a cognitive and time-consuming task that follows a standard process in order to achieve a high level of consistency. Clinical coding is the task of transforming medical information in a patient’s health records into structured codes so that they can be used for statistical analysis.