Medical terminology and anatomy and physiology are foundational for anyone starting their medical record coding career.

When I started in medical coding, I was overwhelmed with this new language because it felt quite foreign. Are you familiar with the word, obdormition? Do you know what it means? Its definition is the numb feeling that you wake to when you have slept on your arm wrong. What about aphthous stomatitis, which is another word for canker sores? It is hard enough to pronounce and spell, so why is canker sores not sufficient? To some physicians, it is, but to some, it is not.

Next, I needed to focus on anatomy and physiology to understand how the body is made and how it works. While the term ileum refers to the distal portion of the small bowel, the ilium is a bone and part of the innominate bone that makes up the bony pelvis. These two words are separated by one letter, the second vowel. If the coder is not paying attention or is unfamiliar with the terms and definitions, an incorrect code could easily be assigned.

Understanding medical terminology and anatomy and physiology are important. As coders, it is our responsibility to ensure that the medical diagnoses and procedure codes are correct and the resulting reimbursement is appropriate and complies with legal and regulatory requirements. The repercussions of incorrect coding affect the coder professionally,  can affect reimbursement for the provider and facility, and may affect continuing patient care based on claims submitted to payers. I don’t want to be the one who assigns an incorrect code because I don’t understand what I am seeing documented in the record.

Wherever you are as you begin your coding career journey, start by looking up definitions, watch YouTube videos of procedures, and read discussions of medical diagnoses. There are so many avenues to improve your understanding of medical terms. No one is expected to know and memorize all there is to know about medical terminology and A&P. However, we are expected to exhaust all resources available when something we do not understand can potentially affect the patient’s continuing care and the provider or facility’s reimbursement and compliance status.

Gaining this foundational knowledge for your coding career is a stepping stone to success as a medical coder.

Medical Coding Foundational Skills
Medical record coders require foundational knowledge in certain key areas: anatomy, physiology, medical terminology, pharmacology, and pathophysiology. The Medical Coding Foundational Skills program equips you with the knowledge needed for a successful medical record coding career.
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