How to Code Medical Records

Medical records consist of encounter forms for physician visits; medical, family and social histories; lists of allergies and immunizations; insurance information; labs and x-rays; medications; and other personal health information. These records are used by medical billers to code the physician notes and diagnosis to submit to the insurance company for payment or reimbursement. Codes for translating medical records are found in the International Classification of Diseases, 9th revision (ICD-9), the Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS) code books released by the American Medical Association and the Practice Management Information Corporation.

Things You'll Need

• ICD-9 code book
• CPT code book
• HCPCS code book
• Patient medical record

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Instructions

• 1

  Review the physician's notes for the patient encounter. Note any diagnoses listed as a reason for the patient's visit. Also note any procedures that were performed or any supplies that were used.

• 2

  Use the ICD-9 code book to translate the physician's diagnosis of the patient 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, double-check the code by looking it up in the numeric tabular section in volume one of ICD-9. Be sure to read all exclusion notes before identifying the proper code.

• 3

  Look up any procedures performed in the ICD-9 or CPT code book. Typically, hospitals will use the procedure codes from volume three of the ICD-9 book. Physicians's offices and other outpatient medical clinics will use the CPT code book for procedures. The HCPCS book is used to code medical supplies for Medicare and Medicaid patients.

• 4

  Enter the proper codes found for all diagnoses and procedures into the associated sections of the insurance claim form and submit for reimbursement.