Steps to Take in Coding Medical Procedures

The health care industry has created a system of numeric and alphanumeric codes to record various aspects of health data. The job of a medical coder is to assign the codes to a patient's diagnoses and procedures following a visit to a doctor, hospital stay or other health care event. To accurately code medical procedures, a person must follow a number of steps and guidelines.

Understanding What the Codes Are used for & Different Coding Systems

• According to the American Health Information Management Association, medical codes are used for reimbursement claims, to calculate the practices and outcomes of health care-related services, as well as for health care management activities, research and planning purposes. Different health care facilities, including hospitals, clinics and doctors' offices, use numeric or alphanumeric procedure codes to record the specific health services performed by health care providers. The standard coding systems are intended to regulate the classification of these procedures and the fees or charges for them.

  Depending on the type of procedure or healthcare establishment, different coding systems may be used. For example, the medical procedure coding system used can be the: Current Procedural Terminology (CPT), International Statistical Classification of Diseases and Related Health Problems (ICD), Healthcare Common Procedure Coding System (HCPS), and Diagnosis Related Group (DRG). Chances are you'll be using either CPT or ICD-9 (the nine stands for the revision).

Reviewing Medical Documents & Assigning a Code

• Look over all of the medical documentations put forward by the health care provider. These documents may consist of patient records, evaluations, and other like reports that provide detailed data concerning a patient's illness, injuries, surgical procedures and more. After identifying the medical procedure, you must then assign and categorize the correct procedural code(s) by using one of the standard coding systems. The accuracy of the code is critical, as it must abide by all insurance requirements and federal regulations.

Medical Procedures Codes & Categories & Identification

• Consult the manual for the coding system that you are using in order to locate the corresponding code. As noted by the Centers for Disease Control and Prevention, ICD-9 is centered on the World Health Organization's Ninth Revision, International Classification of Diseases, and serves as the authorized method of conveying codes to diagnoses and procedures.

  The ICD-9-CM is made up of an arranged numerical directory of the code numbers for all of the diseases, an alphabetized directory to where the disease code is located in within the manual, and a taxonomy structure used for surgical, diagnostic, and therapeutic procedures.

  Current Procedural Terminology is developed and maintained by the American Medical Association (AMA). CPT is divided into Category I CPT Codes, Category II CPT Codes, and Category III CPT Codes. According to the American Medical Association, CPT I Codes are used to signify definite services or procedures, and the entries are made up of a five digit numeral code and definition. Category I, codes are also divided by: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. Category II codes have a set of supplemental tracking codes that may be employed for performance measurement. Category II code entries are made up of a four digit numeric code following the letter F. Category III is a temporary set of codes used for emerging technologies, services, and procedures. These code entries are made up of a four digit numeric code that's followed by the letter T. Similar to ICD, the CPT Manual is also includes: Section Headings, Subsections, Categories, Subcategories, Guidelines, Symbols, Colons & Semi-colons Modifiers, Appendices, Indices and Examples. The classes and grouping within the manuals are intended to make it easier for you to locate and assign the correct code.

Additional Tips

• When it comes to coding medical procedures, it's critical to familiarize yourself with the way coding systems work and their classification schemes. You'll also want to have a fundamental knowledge of medical terminology, anatomy and physiology to help you when it comes time to locate the area in which a code is situated. For example, let's say that you're looking to find the CPT code for a specific surgical procedure. In CPT, surgery codes are included in the numbers 10000-69999. Next, you'll have to search in the category's subheading to discover the type of procedure that was performed, the body part or system it was done on, and supplementary data, like the dimension of an incision that was made.