Diagnostic Coding Vs Procedural Coding

931 Words4 Pages
Medical Coding Essay Academic Essay Diagnostic coding and procedural coding lend themselves well to the improvement of healthcare efficiency. Both have accurate recording for diagnoses and the procedures enable the analysis of information for the patient’s care, research, performance improvement, healthcare planning and facility management. The diagnosis codes are divided into chapters, sections, subsections, and subcategories (1). A coder should become familiar with all of the codes before the individual moves on. It is very important to understand when an additional code or codes are needed, what codes are secondary, and when additional information may be needed to complete the code (1). Also, the coder should always code the reason…show more content…
Those two types of bills are the CMS-1500-professional paper claim form and the UB-04-institutional paper claim form. The CMS-1500 is used by physicians, therapists, and other professionals (3). The UB-04 is used by facilities including hospitals, surgery centers, skilled nursing facilities, home health agencies, some transportation providers, and so forth (3). Diagnosis codes that are used for the CMS-1500 forms must describe, the patient’s condition, must always have at least one or more ICD-10-CM code on the form, applies to a particular visit, and does not generally affect reimbursement for professional services (3). The procedure codes physicians and most non0physician healthcare providers use CPT codes to show what services were done, a CPT code is assigned to each service that was done that day, Level II HCPCS codes are also used to reflect what was done, both of these codes determine reimbursement, and most of the payers have developed a fee schedule (3). The other codes would not be used on the CMS-1500 form. The UB-04 form uses ICD-10 diagnosis codes which describe the patient’s condition, assign at discharge for the entire encounter, the principal ICD-10 diagnosis is always required and can include additional codes if needed, and an admission diagnosis code is required for certain inpatient admissions (3). Also, the UB-04 has…show more content…
But a coder must realize that each type of plan and processing insurer has a different coding and billing “language”. When submitting a claim form with codes that are not in the insurer’s database and are not recognized by the insurer, it will be rejected as “not a covered benefit”(4). Then the procedure or procedures will not be covered because the coder is not speaking the same coding and billing language as the computer that is processing the information along with the claims adjudicator. For this reason it is important for the coder to familiarize themselves with both the medical ICD diagnosis and CPT procedure codes. Also, it is good to have knowledge about what constitutes correct completion of the medical claim form. This is essential in order to submit a clean claim. The CMS-1500 claim form has a top section that contains the information about the subscriber and the patient. The bottom section contains information about the provider and the patient’s treatment. CMS-1500 claim form needs to be filled out correctly. If the medical necessity is established by comparing the procedure codes to the diagnosis codes that were assigned (4). These can be determined not to be medically necessary, the charges will not be allowed and scrutinized (4). By providing
Open Document