Medical Coding has Evolved and will Continue to Evolve

Medical bill with coins and stethoscopeThe technological world is changing and that means it is changing for medical coding professionals.

Just within the past 20 years, medical coding has evolved quite a bit. Internal medical transcription operations and medical transcription services are not the same as they were. In the 1980s, a great deal of documentation was either written down by hand or it was transcribed through an electric typewriter. Since then, the technological advancements have become more affordable for the professional world and the consumer.

Those that were hired into medical practices as medical assistants were trained to cover all aspects of operations within the medical office, such as reception, patient care, medical coding and billing, transcription, filing, insurance verification, and many important operations within the practice. The medical coder was actually a rare commodity, as the CPT codes were still in the midst of evolving. It was rather normal to walk into a medical practice and find rooms of large file cabinets that housed the medical charts of patients. These charges were pulled on a daily basis for the patients that were being seen and then filed again after the patient was seen. The charts contained everything from labs and test results to hospital and office notes. Basically, they contained all of the information regarding the patient’s care, as well as personal information.

These files had to be kept under lock and key because of the confidential nature of the information contained within them.

The actual medical coding was done through chargemaster or superbill, which was marked by the doctor. Surgical services and procedures were entered into a computer’s software billing system and the claims would be printed and mailed to the insurance companies. At one time, the claims process took much longer than it does now. When a patient or insurance company would make a payment via the postal service, those payments would be entered into the same software program that created the statements, which would then show the patient’s balance.

Problems With Old Medical Billing and Coding

The older methods of medical transcription and medical billing and coding were full of issues. Information could be entered incorrectly, causing patients to be billed wrong. Claims could be filled out incorrectly, resulting in the insurance company having to ask a lot of questions. The issues were many and that is why something had to be done. When the technology boom began in the 1980s, enormous changes did occur.

Now, there are still some providers that are using the paper medical chart, but there is a huge surge in providers now using electronic medical records. Eventually, paper medical charges will be completely phased out.

Just to show how the times have changed, consider this:

Information is hardly ever exchanged by FAX anymore. Information is now transmitted through secure computer networks. Nearly all patient information can be electronically gathered nowadays and it is instant.

The Evolution

Coding that was once performed manually now uses iCD-9 and, soon, this will change to ICD-10. ICD-10 implementation is scheduled for October 2015. There are software programs in place to ensure that the coding is done properly. The programs allow a coder to do a simple search of a specific term, allowing the program to go through a process of elimination to generate the correct code more efficiently and much faster than before.

So where the dot-matrix printer was once a major tool in medical billing and coding services, they haven’t been the standard for quite some time. If something has to be printed ,the laser printer now takes care of that.

And while insurance payments are still received in the mail, sometimes they are direct deposited into a bank account because of technological updates.

When ICD-10 Begins

When ICD-10 begins, it will require coders to have a great deal of knowledge of the organ systems and overall anatomy. Providers will also need to document in great detail so that all codes are accurate.

What does this mean for medical practice efficiency?

This means that physicians and their staff members will need to find more efficient ways to run their practices. In other words, they may need to get somewhat creative to ensure that patient care is not compromised because of paperwork. But just like with every other technological advance, physicians, nurses, and other staff members have evolved as well.


ICD-10 will soon be the standard and those not ready will need to be by October 2015. With the help of an experienced medical practice consultant, you can be ready to go and also establish a medical practice model that works. Call us today at 508-946-1665 or fill out our contact form.