What type of coding involves translating the medical record's narrative into a structured format?

The process of translating the medical record's narrative into a structured format is referred to as coding. This involves converting the detailed descriptions of a patient's diagnosis, procedures, and other medical information into standardized codes. These codes, such as those found in the ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) coding systems, enable healthcare providers to organize clinical data, streamline communication among healthcare systems, and ensure accurate billing and insurance reimbursement.

Unlike data entry, which primarily focuses on inputting data into an electronic health record without transforming or interpreting the information, coding requires a deeper understanding of clinical terms and the coding system's structure. Insurance verification and claim submission are later steps in the healthcare billing process that rely on the accuracy of the coding but do not involve the actual translation of the narrative into structured codes.