Why Is Medical Coding Necessary during processing a case

The need for coding however, continues and the reason being that in order to perform statistical analysis, clinical trial data needs to be structured in such as way that a computer program or human being are able to count data items that are “identical” (in clinical terms) and to be able to group items that are “similar” (in categorical terms). One of the requirements for being able to do this is found in the labeling that must be provided for all prescription medications. The labeling provides the consumer with information concerning possible adverse reactions they might experience in terms of probabilities, that is, the percentage of people that have experienced a particular reaction. In order to calculate these percentages, it is necessary to be able to count “identical” experiences and divide them by the total number of subjects that were in the clinical trial(s) that collected this safety information.

Counting these unintended reactions (i.e., experiences) is hard to do when data are collected in “free text” form. It is perhaps unfortunate that, by and large, the descriptions of unintended reactions or experiences incurred during a clinical trial need to be captured and entered into the clinical trial database in “free text” form. Adverse events such as “Slight headache”, “Very bad headache”, “Debilitating Migraine”, “Sinus headache”, “Stress headache”, “Earache”, “Achy right knee” may not be a description of the same thing in clinical terms, but how does one report on the occurrence of headaches, infections, and muscle and/or joint pains (as in our example) given the wide variety and variations in reporting adverse events? The answer is to code the verbatim terminology using a medical terminology dictionary that gives synonymous terms the same code (known as “equivalence”) and provides a mechanism whereby grouping and classification of terms can be performed.

Furthermore, it is necessary to provide a preferred wording for synonymous terms to use for reporting purposes, for example, “Headache” might be used for “Slight headache”, “Very bad headache”, and “Debilitating Migraine”. At a higher level, one might want to classify these terms based on the body system (or organ class) that they impact. For “Headache”, this might be the central nervous system. Coding, of course, is not limited to adverse event verbatim terminology. It is desirable to code other medical terminology such as medication names, medical procedures such as surgeries, and physical conditions.