MEDICAL CODING
To expedite claims processing, diagnostic codes and procedure codes were utilizes beginning in early 1960’s learning these coding systems and proper use of the coding is the first step toward proper reimbursement. One digit, or one wrong code, can and will affect reimbursement.
GENERAL CODING GUIDELINE
Use both the alphabetic index and tabular list when locating and assigning a code. Reliance on only the Alphabetic index or the tabular list leads to errors in code assignments and less specific codes selection.
Locate each term in the alphabetic index and verify the code selected in the tabular lists. Read and be guided by instructional that appear in both the alphabetic index and tabular list.
Diagnostic codes are to be used at their highest level of specificity. Diagnosis coding is translating the medical terminology used for each service and or item provided by a provider or health care facility in to a code
Assign three –digit code only if there are no four-digit codes within that code category.
Assign four-digit codes only if there is no fifth –digit sub classification for that category.
Assign the fifth –digit subclassfication code for those categories were it exits.
A single code used to classify two diagnoses or a diagnosis with an associated secondary process or an associated complication is called a combination code. Combination codes are identified by referring to sub term entries in the alphabetic index and by reading the inclusion and exclusion notes in the tabular list.
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