Anesthesiology coding is the use of standardized codes to report interventions provided by an anesthesiologist for the purpose of creating a patient record and bill. Medical coding is an extremely complex field, and professionals who specialize in it may work for hospitals, insurance companies, and other agencies with an interest in medical records and billing practices. One issue with medical coding is the use of different codes by different authorities; the coder must accurately record information on the basis of where it will be sent. An insurance company can reject a claim with the wrong anesthesiology coding, for instance.
In anesthesiology coding, a medical coder takes a record from a surgery with notes made by care providers and turns it into a cohesive and standardized report. In some medical facilities, cover sheets for medical procedures may divide different procedures into various coded boxes for care providers to check. This will make the billing process easier for the coder. With activities like surgery, however, the procedure can be complex, and care providers may need to make interventions that do not fit neatly into coded boxes.
One of the first steps in anesthesiology coding is the determination of what should be coded under anesthesia services, versus surgical services, nursing services, and other aspects of care. The coder will need to read through the record to identify services performed by the anesthesiologist or at his request. For example, intubation is an anesthesiology procedure, as is presurgical bloodwork ordered to plan the anesthesia. Likewise, administration of postoperative pain management may fall under the purview of the anesthesiologist.
Once the coder has a list of procedures to code, she must enter them in the system, assigning the appropriate code to each. A hospital may have a standardized system that can convert into other coding systems as necessary. This internal system allows the hospital to maintain accurate electronic patient records in addition to submitting bills with the appropriate codes. However, not all coding systems transfer easily between each other, and in some nations there has been a push for the adoption of a simple national standard used by all care providers, insurers, government agencies, and so forth.
Training in anesthesiology coding is available from technical and trade schools. These schools offer a certification to graduates who can use this qualification in applications for jobs. It is also usually necessary to pursue continuing education to keep pace with new trends in medical coding.