The technicians start with the medical charts and ensure that all the forms are complete, identified and signed and fed into their history file. The communication with physicians or other healthcare professionals are regular to clarify the diagnoses or to obtain additional information. These Medical Records are assigned a code to each diagnosis and procedure. There are computer software’s which are used to assign the patient to one of the diagnosis-related groups or DRGs.

The Medical Records Coding covers the entire history; even the cause of the medical aid is required as this reflects tremendously on the claims. All the formalities are required to be met to avoid the problem of healthcare fraud and abuse. As the basis for reimbursement, appropriate medical records coding has become crucial as healthcare providers seek to assure compliance with official coding guidelines. Medical Records Coded data are also used internally by institutions for quality management activities, case-mix management, planning, marketing and other administrative and research activities.