Who identifies the diagnoses procedures and services provided in a patient's health care record and assigns specific codes to each?

The process of identifying diagnoses, procedures, and services in a patient's health care record and assigning specific codes is typically carried out by medical coders. These professionals review clinical documentation and translate the information into standardized codes, such as ICD (International Classification of Diseases) for diagnoses and CPT (Current Procedural Terminology) for procedures. Accurate coding is essential for billing, insurance claims, and maintaining comprehensive health records.