Is medical transcription and medical coding same?

Although medical transcription and medical coding sound to be somewhat similar they have a significant difference in the role they play in medical documentation. Medical transcription can be defined as a healthcare service sector were in the medical reports that are recorded by the healthcare professionals are transcribed. It involves a manual conversion of the voice recorded medical reports to the textual format. In contrast medical coding, also a healthcare service sector, involves the conversion of the medical reports of the patient into alphabetical and numeric codes that can be universally decoded. Medical coding also involves coding the services and the diagnostic procedures that are available for better medical documentation. The significant difference between medical transcription and medical coding is solely based on their purpose and their usage.

Medical coding involves retrieving patient medical diagnosis details as well as their billing details and encoding them in codes that are recognized in the country of practice. This plays a great deal in medical insurance coverage of the patients. Medical transcription, on the other hand, entails the textual conversion of physician to patient consultations and diagnosis. However, there is an interlinking of this with medical coding because after transcription a professional coding is necessary for medical insurance coverage related claims. However medical transcription, as opposed to medical billing, plays a significant role in patient care, diagnosis, and treatment. Medical transcription can be attributed to form a niche in the healthcare service sector in contrast to the medical coding which is widespread in all hospitals and healthcare organizations. It is estimated that recording patient interaction being a crucial task all healthcare organizations do not offer this service whereas most of the healthcare organizations have a medical coder. In contradiction to this however medical transcription and medical coding are indispensable and interdependent on each other. This is because with proper transcription of the patient information the coding is easy and effective.

The core essence of medical transcription can be attributed to the dictation by the physician. The transcribed information can be given manually in textual format or in the form of an electronic medical report. Additionally, medical coding also helps in medical record keeping but does not involve any dictation but is based on patient charts and the standard medical documentation codes. In addition, medical transcription is a service that benefits directly the physicians and patients. On the other hand, medical coding service not only benefits the physicians but also aids the private companies working in collaboration with healthcare organizations in providing medical insurance.

Thus finally we can come to this conclusion that although medical transcription and medical coding have a different purpose and require different skills and settings both are aimed at improving digitization in the healthcare setting with focus at holistic patient care.

10 must know facts about ICD 10 documentation for medical transcription

The term documentation plays a significant role in the healthcare sector. This can be attributed to the need for properly arranged patient history and the diagnosis data. This  in turn helps in the insurance claims for the patients as well as gaining insight into the patient medical history for pharmacological interventions. The ICD 10 plays a significant role in this aspect in the US healthcare sector. The medical codes that are present can be termed as the “bible” for a medical coder or a transcriber as they form the guidelines for medical coding and transcribing. However the codes that are present are not clear enough and most of the codes does not clearly describe the diagnosis of the patient. This vagueness is thought to be resolved by the shift from ICD 9 to ICD 10. Now for maintaining this ICD 10 codes and working based these coding guidelines it is necessary to keep in mind some important facts-  

1. Laterality forms the core of ICD 10 coding. It is essential that a physician mentions the letrality while coding. The mentioning of the right or left or bilateral clearly helps in easier patient care. 
2. Upgradeable technology is another important aspect of ICD 10  as it enables the patients to have access and use the latest upgraded technology
3. Documenting the period of care is also an essential aspect of the ICD 10 medical coding guidelines
4. ICD 10 involves 50 codes that enables the documentation of disease due to foreign body faster. This helps in better reviewing of the coded medical records and effective holistic care of the patient. 
5. ICD 10 helps a physician in documenting the stage of the disease as well as their seriousness and their chronic nature
6. The medical codes specified by the ICD 10 guidelines enables the transcriber to properly document the anatomical details of the patient for better patient care and diagnosis. 
7.  The coding system being fully digitised enables the users to have full access of the medical facilities and helps the physician's to get the patient data at a go. Thus this helps in providing quality care to the patient. 
8.  In addition to these the ICD 10 documentation guidelines involves the usage of the glasgow coma scale. This scale enables the physician to document the verbal as well as the motor and visual response of the patient. 
9.  The aim of ICD 10 being the resolution of vagueness in coding involves the Gustilo-Anderson scale for describing the types of open fractures and enabling better holistic care for patient.  
10.  Lastly the main essence of ICD 10 medical documentation guidelines lies in the specific definition of the patient condition. Thus it includes the detailed description of Myocardial infarction and its acuteness. 

Thus as a conclusionary remark it can be stated that ICD 10 has well developed features so as to make sure that the patients get quality care along with digitised services. Maintenance of these 10 must known facts will enable the patients as well as the physicians communicate well and resolve critical conditions with easy therapeutic options.