Ironically, the functional language of health care is not “human readable.” Rather, it is a set of medical codes. These include the diagnosis codes that summarize a patient’s illness burden, and service codes and their modifiers that describe the treatment and clinical context. The reason for this is simple: for care to be reimbursed, the clinician’s (roughly) English-language medical note must be translated into a universally accepted set of alphanumeric codes. Computers at health insurance companies cannot run business rules on paragraphs of text—at least not now. Thus, the medical coding workflow has evolved.
Once the clinical data have been summarized in an analyzable form by the medical coding process, the data can be repurposed beyond payment automation. For example, medical codes now underpin quality management, care standardization, clinical decision support, fraud and abuse policing, physician productive measurement, and other clinical workflows.
With new technologies, medical coding will expand dramatically in the coming years. More data of higher quality will be captured, providing greater value to the care team and enhancing clinical analytics. Fortunately, such expansion will not require more clinician time. Instead, it will become easier and less disruptive for providers. Improvements in coding will reduce health care administrative costs for both providers and payers, ensure appropriate payment, enhance care quality, and support value-based care. We call this end-state vision Value-Based Coding.