Government Guidelines for Medical Coding

Medical coding is the designation of numerical or alphanumerical codes to a patient’s conditions and treatments. The government sets forth specific coding guidelines for uniformity of reimbursement, tracking and research.

Highest Coding Level

• Coders must code to the highest level of specificity. If a fifth digit explanation is available for a code, a fourth digit level cannot be assigned.

Signs and Symptoms

• Signs or symptoms can only be reported if cause is undetermined. A patient with chest pain symptoms diagnosed later as heart attack is coded as heart attack.

Multiple Code Assignment

• Generally, two codes are not used when one will suffice. Exceptions apply for conditions like infections, where an additional code identifies bacterial cause.

Acute and Chronic Conditions

• If a condition is documented as acute and chronic, then assign both codes for the condition.

Combination Codes

• On occasion, one combination code covers multiple conditions. In order to assign a combination code, the patient must meet all requirements in the code description.

Late Effects

• Late effects are conditions that arise from a previous illness or injury. They are generally reported by two codes, with the “nature of the late effect” first, followed by the late effect code. For example, abnormal gait due to an old hip fracture would code to gait first followed by hip fracture.