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Step-by-Step Coding

Coding is a term used to refer to the assignment of codes for the purposes of billing a patient's insurance. These codes identify medical diagnoses, procedures, supplies and services. Three medical coding books --- the "International Classification of Diseases, 9th Revision" (ICD-9), the "Current Procedural Terminology" (CPT) and the "Health Care Procedure Coding System" (HCPCS) code books --- are used to identify the proper billing codes in order to obtain the maximum reimbursement for services.

Things You'll Need

  • ICD-9 code book
  • CPT code book
  • HCPCS code book
  • Patient encounter form
  • Insurance claim submission form
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Instructions

    • 1

      Review patient encounter form. Identify all diagnosis codes assigned by the physician at the visit. Also identify any CPT office visit, supply or procedure codes that may be listed, as well.

    • 2

      Fill in the insurance claim submission form with the patient's personal and insurance information. Claims are filed on a CMS 1500 form, also referred as a HCFA 1500 form. This form can be filed electronically or via U.S. mail.

    • 3

      List diagnosis codes from the encounter form in box 21 of the insurance claim form. Up to four diagnosis codes may be listed. If there is no diagnosis code on the encounter form, look for what the doctor identifies as the conclusion of the encounter. Once you have identified the condition or symptoms, use the ICD-9 code book to translate the physician's conclusion into a code. First, look up the disease or symptoms in the alphabetical section of the ICD-9. Once you've obtained the numeric code, reference that code by looking it up in the numeric tabular section in volume one of ICD-9. Read all of the exclusion notes before assigning the proper code.

    • 4

      Use the CPT code book to look up procedures performed if you are coding for a physician's office or outpatient clinic. If the procedure was performed in a hospital, the code would be found in Volume 3 of the ICD-9 code book.

    • 5

      Use the HCPCS book to code medical supplies for Medicare and Medicaid patients. HCPCS works similar to the ICD-9, except that the codes in HCPCS are alphanumeric. Look up the main term in the index, then reference the code in the tabular section.

    • 6

      Enter the correct codes for all diagnoses and procedures into the associated sections of the insurance claim form. Fill in all of the physician or medical facility's information. Then submit the insurance claim form for reimbursement.

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