How to Do Orthopedic Medical Coding

Medical coding is the process of assigning universal numerical codes to medical procedures, treatments and diagnoses. These codes are used by private and public health insurance companies for payment processing. Medical coding is an exact skill and must be performed correctly or insurance companies may not reimburse for provided services. Orthopedics is a medical specialty dealing with disease and injury of the skeletal system, and it requires its own process of medical coding. While basic steps can be taken to perform orthopedic medical coding, individuals should receive in-depth training on the process.

Things You'll Need

• Completed physician charge sheet
• Patient medical record
• ICD-9 book
• CPT book

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Instructions

• 1

  Ensure that the physician has completely filled out the patient’s charge sheet and has documented the patient’s visit in the medical record before coding delivered services. Determine whether the orthopedic services were performed as an outpatient, which allowed the patient to go home the same day, or as an inpatient, which required the patient to stay overnight in the hospital.

• 2

  Determine whether both ICD-9 and CPT codes are needed. Look for a physician’s diagnosis, a description of patient symptoms or an injury to determine ICD-9 codes. Look for medical procedures or services, such as an injection or surgical staple removal, to determine CPT codes.

• 3

  Compare the patient’s charge sheet with the physician documentation of the patient’s visit to collaborate appropriate diagnosis and procedures, if applicable. Ask the physician to clarify any documentation needed to appropriately code the patient’s visit.

• 4

  Locate the correct orthopedic codes for both ICD-9 and CPT in your coding books or by using orthopedic coding software, if applicable. Determine whether a modifier is needed. Document the appropriate codes on the patient charge sheet or record.