1-1INTRODUCTION

This chapter focuses on:

PART A – CAREER AS A CODER

 Coding career opportunities in health care,

 The importance of joining professional associations and obtaining coding credentials,
 The impact of networking with other coding professionals, and
 The development of opportunities for career advancement.

PART B

It also provides a CODING OVERVIEW that explains

 clinical documentation improvement,

 the physician query process, and
 the use of computer-assisted coding (CAC) and encoder software.

PART C

The DOCUMENTATION as a basis for the coding section includes a.) patient record formats and
2.) the importance of establishing medical necessity.

PART D

The HEALTH DATA COLLECTION SECTION covers the reporting of hospital and physician
office data using abstracting software, medical practice management software, and CMS-1500
and UB-04 claims.

PART E – SKILLS

Essential skills needed to become a medical coding and reimbursement specialist include:

 Attention to detail, which means an individual uses a meticulous and precise approach when
completing tasks, such as assigning medical codes, to ensure that results are perfect.
Attention to detail is crucial to avoid making errors, such as reporting incomplete medical
codes that result in denied claims.
 Effective communication, which relies on active listening to interact with patients,
providers, third-party payers, and others when determining and resolving issues. Excellent
writing skills are also needed to appeal denied claims or generate physician queries to
assign accurate medical codes.
 Knowledge about coding systems which requires medical coders to participate in
continuing education programs to learn about the most up-to-date official coding
guidelines, coding revisions, and software technology.
 Problem-solving, which uses analytical, critical, and creative thinking to identify problems
in the workplace and implement effective solutions. Medical coding and reimbursement
specialists do more than just assign/report codes and submit claims. They work with others
to address issues that need resolution, such as using available resources (e.g., medical
records) as evidence to support the appeal of a denied claim.
 Time management, which requires individuals to establish goals, prioritize tasks, and meet
deadlines. Making a to-do list of daily tasks to be completed along with a time estimate for
each task can be helpful.

Additional professional skills are covered throughout this chapter.

Note
This chapter does not require the use of ICD-10-CM, ICD-10-PCS, CPT, or HCPCS Level II coding manuals.
However, later chapters in this textbook do need them because learning how to code is easier when you use paper-
based coding manuals. (According to CAHIIM/AHIMA requirements, students should also learn how to use
encoder software and interpret the results of computer-assisted coding [CAC] software.)

1-2 CAREER AS A CODER

A coder acquires a working knowledge of
 coding systems (e.g., CPT, HCPCS Level II, ICD-10-CM, ICD-10-PCS),
 coding conventions and guidelines,
 government regulations, and
 third-party payer requirements
to ensure that all diseases, injuries, reasons for an encounter, services (e.g., office visits), and
procedures (e.g., surgery, x-rays) documented in patient records are coded accurately for
reimbursement, research, and statistical purposes.
Excellent interpersonal skills are required of coders because they communicate with providers about
documentation and compliance issues related to the appropriate assignment of ICD-10-CM and ICD-
10-PCS or CPT/HCPCS Level II codes.
1-2A EDUCATION AND TRAINING
Training methods for those interested in pursuing a coding career include college-based programs that
contain coursework in medical terminology, anatomy and physiology, health information
management, pathophysiology, pharmacology, ICD-10-CM, ICD-10-PCS, HCPCS Level II, and
CPT coding, and reimbursement methodologies. Many college programs also require students to
complete a nonpaid internship (e.g., 120 hours) at a health care facility.

Professional associations (e.g., the American Health Information Management Association) offer
noncredit-based coding training, usually as distance learning (e.g., Internet-based), and some health care
facilities develop internal programs to retrain health professionals (e.g., nurses) who are interested in a
career change.

Note
Pharmacology plays a significant role in accurate and complete coding. Coders review the medication
administration record (MAR) to locate medications administered that impact ICD-10-CM coding. For example,
upon review of the MAR, the coder notices that the patient received a course of Librium (chlordiazepoxide) during
inpatient hospitalization. Librium is classified as an antianxiety medication, but it can be also used to counteract
alcohol withdrawal symptoms. If a physician documents that the Librium was administered to counteract alcohol
withdrawal symptoms, the coder can assign an appropriate alcohol dependence ICD-10-CM code as well as alcohol
detoxification ICD-10-PCS codes.
CODING INTERNSHIP
The coding internship benefits the student and the facility that accepts the student for
placement. Students receive on-the-job experience prior to graduation, and the internship
assists them in obtaining permanent employment. Facilities benefit from the opportunity to
participate in and improve the formal education process. Quite often, students who
complete professional practice experiences (or internships) are later employed by the
facility at which they completed the internship.

The internship supervisor is the person to whom the student reports at the site. Students are
often required to submit a professional résumé to the internship supervisor and to schedule
an interview prior to being accepted for placement. While this experience can be
intimidating, it is excellent practice for the interview process that the student will undergo
prior to obtaining permanent employment. Students should research the résumé writing and
interview technique services available from their college’s career services office. This
office will review résumés and will provide interview tips. (Some even videotape mock
interviews for students.)

Note
Breach of patient confidentiality can result in termination from the internship site, failure of the internship course,
and even possible suspension and/or expulsion from your academic program. Make sure you check out your
academic program’s requirements regarding this issue.
The internship is on-the-job training even though it is nonpaid, and students should expect
to provide proof of immunizations (available from a physician) and possibly undergo a
preemployment physical examination and participate in facility-wide and department-
specific orientations. In addition, because of the focus on privacy and security of patient
information, the facility will likely require students to sign a nondisclosure agreement (to
protect patient confidentiality), which is kept on file at the college and by the professional
practice site. During the internship, students are expected to report to work on time.
Students who cannot attend the internship on a particular day (or who arrive late) should
contact their internship supervisor and program faculty. Students are also required to make
up any lost time. Because the internship is a simulated job experience, students are to be
well groomed and should dress professionally. Students should show interest in all aspects
of the experience, develop good working relationships with coworkers, and react
appropriately to constructive criticism and direction. If any concerns arise during the
internship, students should discuss them with their internship supervisor and/or program
faculty.

1-2B PROFESSIONAL CREDENTIALS

The American Health Information Management Association (AHIMA) and the AAPC
(previously called the American Academy of Professional Coders) offer certification in
coding.

Credentials available from AHIMA include the following:

 Certified Coding Associate (CCA)

 Certified Coding Specialist (CCS)
 Certified Coding Specialist—Physician-based (CCS-P)

The AAPC offers the following core coding certification exams:

 Certified Professional Coder (CPC)

 Certified Inpatient Coder (CIC)
 Certified Outpatient Coder (COC)
 Certified Risk Adjustment Coder (CRC)
 The AAPC also offers specialty certification credentials in response to a demand
for specialty coders who have obtained advanced training in medical specialties and
who are skilled in compliance and reimbursement areas, such as the Certified
Ambulatory Surgical Center Coder (CASCC) credential.

The type of setting in which you seek employment will indicate which credential(s) you
should pursue.
Inpatient and/or outpatient coders obtain CCS and CIC certifications, and physician
office coders choose the CCS-P and CPC credentials. Outpatient coders also have the
option of selecting the COC credential.

Risk adjustment/HCC coders would obtain the CRC credential. (HCC refers to hierarchical
condition category.)

Risk adjustment coding (or HCC coding) requires the assignment of ICD-10-CM codes based
on patient record documentation. It is part of a risk adjustment program that calculates
predictive risk scores based on HCCs so that providers are properly reimbursed according to
the medical complexity and utilization of health care resources required for a managed care
patient population.

Those who have not met requirements for field experience as a coder can seek apprentice-
level certification by pursuing AHIMA’s CCA credential; after obtaining necessary coding
experience, candidates can pursue other coding credentials. Once certified, professional
associations require maintenance of the credential through continuing education (CE)
recertification per two-year cycle.
1-2C EMPLOYMENT OPPORTUNITIES
Coders can obtain employment in a variety of settings, including clinics, consulting firms,
government agencies, hospitals, insurance companies, nursing facilities, home health
agencies, hospice organizations, and physicians’ offices. Coders also have the opportunity
to work at home for employers that partner with an Internet-based application service
provider (ASP), which is a third-party entity that manages and distributes software-based
services and solutions to customers across a wide area network (WAN) (computers that are far
apart and are connected via the Internet) from a central data center. Remote medical coders
may be provided with necessary equipment to work from home (e.g., laptop computer), or
they might be required to provide some of the necessary equipment. The Internet is used to
access software (e.g., encoder) using an employer-based secure login process, and proper
equipment must be in place to ensure a secure connection (e.g., cabled or wireless router).
Typically, the remote medical coder signs a telecommuting agreement, which allows an
employer to inspect the home-based workspace via videoconference (e.g., Zoom).
1-2D OTHER PROFESSIONS RELATED TO CODING
One profession that is closely related to a coder is that of a health insurance
specialist (or claims examiner). When employed by third-party payers, these specialists
review health-related claims to determine whether the costs are reasonable and medically
necessary based on the patient’s diagnosis reported for procedures performed and services
provided. This process involves verification of the claim against third-party payer guidelines
to authorize appropriate payment or to refer the claim to an investigator for a more thorough
review.

Another profession that is closely related to a coder is the medical assistant. When employed
by a provider, this person performs administrative and clinical tasks to keep the office and
clinic running smoothly. Medical assistants who specialize in administrative aspects of the
profession answer telephones, greet patients, update and file patient medical records, complete
insurance claims, process correspondence, schedule appointments, arrange for hospital
admission and laboratory services, and manage billing and bookkeeping.

When employed by a physician’s office, health insurance specialists and medical assistants
perform medical billing, coding, record keeping, and other medical office administrative
 duties. Health insurance specialists (or claims examiners) and medical assistants receive
formal training in college-based programs or at vocational schools. They also receive on-the-
job training.

 Health insurance specialists (or claims examiners) often become certified as a

Certified Professional Biller (CPB) (through the AAPC).
 Medical assistants often become credentialed as a Certified Medical Assistant (CMA)
through the American Association of Medical Assistants (AAMA) or as a Registered
Medical Assistant (RMA) through the American Medical Technologists (AMT).
Health insurance specialists (or claims examiners) and medical assistants obtain employment
in clinics, health care clearinghouses, health care facility billing departments, insurance
companies, physicians’ offices, and with third-party administrators (TPAs). When
employed by clearinghouses, insurance companies, or TPAs, they often have the opportunity
to work at home, where they process and verify health care claims using an Internet-based
application service provider (ASP).

Exercise 1.1 – Career as a Coder

Instructions: Complete each statement.

1. A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-CM, and
ICD-10-PCS coding systems.
2. The complexity and intensity of procedures performed, and services provided during an outpatient or
physician office encounter are captured as part of professional coding.
3. The intensity of services and severity of illness associated with inpatient care are captured as part of
institutional (or facility) coding.
4. When a multi-hospital system provides physician office services along with traditional inpatient,
outpatient, and emergency department hospital care, the concept of single-path coding is adopted to
facilitate professional and institutional billing.
5. A profession that is closely related to that of a coder is a health insurance specialist (or claims
examiner) who reviews health-related claims to determine whether the costs are reasonable and
medically necessary based on the patient’s diagnosis reported for procedures performed and services
provided.

1-3 Professional Associations

Students are often able to join a professional association (Table 1-1) for a reduced membership fee and
receive most of the same benefits as active members (who pay much more!). Benefits of joining a
professional association include the following:
 Eligibility for scholarships and grants
 Opportunity to network with members (for internship and job placement)
 Publications (e.g., professional journals)
 Reduced certification exam fees
 Website access for members only

Table 1-1
Professional Associations
 Career Professional Association

Coder AAPC (previously called American Academy of Professional Coders)

American Health Information Management Association (AHIMA)

Medical Assistant American Association of Medical Assistants (AAMA)

American Medical Technologists (AMT)

Attending professional association conferences and meetings provides opportunities to network (or
interact) with professionals, which can facilitate being placed for an internship or being considered for
employment after graduation. Another way to network is to join an online discussion
board (or listserv) (Table 1-2), which is an Internet-based discussion forum that covers a variety of
professional topics and issues.

Table 1-2
Internet-Based Discussion Boards (Listservs)
Discussion Website
Board

AHIMA Access AHIMA members can log in at www.ahima.org.

AAPC Go to www.aapc.com, click on Resources, click on the Forums link located below
News/Networking, and scroll down to Medical Coding.

Exercise 1.2 – Professional Associations

Instructions: Complete each statement.

1. Students who become members of a professional association(s) usually pay a

reduced membership fee and receive most of the same benefits as active members.
2. Attending professional association conferences and meetings provides
opportunities to network (or interact) with other professionals, which can facilitate
being placed for internship or job placement.
3. A medical assistant usually joins the American Medical Technologists (AMT) or the
AAMA.
4. An Internet-based discussion forum that covers a variety of professional topics and
issues is called an online discussion board or listserv.
5. A coder usually joins either the American Health Information Management
Association (AHIMA) or the AAPC.
 1-4Coding Systems and Coding
Processes
Coding systems and medical nomenclatures are used by healthcare facilities, healthcare providers, and
third-party payers to collect, store, and process data for a variety of purposes (e.g., healthcare
reimbursement).
A coding system (or classification system) organizes a medical nomenclature according to similar
conditions, diseases, procedures, and services, and it contains codes for each (e.g., ICD-10-CM arranges
these elements into appropriate chapters and sections).
A medical nomenclature includes clinical terminologies and clinical vocabularies that are used by
health care providers to document patient care.
Clinical terminologies include designations, expressions, symbols, and terms used in the field of
medicine, such as “pupils equal, round, and reactive to light,” commonly abbreviated as PERRL in a
patient’s physical examination report.
Clinical vocabularies include clinical phrases or words along with their meanings, such as
“myocardial infarction,” which is defined as the sudden deprivation of blood flow to the heart muscle
due to coronary artery blockage resulting in tissue damage (necrosis) and commonly called a “heart
attack.”
A code includes numeric (e.g., CPT) and alphanumeric (e.g., ICD-10-CM) characters that are
reported to health plans for health care reimbursement, to external agencies (e.g., state departments of
health) for data collection, and internally (acute care hospital) for education and research.
Coding is the assignment of codes to diagnoses, services, and procedures based on patient record
documentation.

Note
You are already familiar with a well-known coding system called the United States Postal Service ZIP
Code system, which classifies addresses as numbers (e.g., 12345-9876).

1-4a Coding Systems

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) was
adopted in 1979 to classify diseases, injuries, reasons for an encounter (Volumes 1 and 2), and
procedures (Volume 3).
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and
(ICD-10-PCS) replaced ICD-9-CM on October 1, 2015, to classify all diseases, injuries, and reasons for
an encounter whether patients are treated as inpatients or outpatients.
The International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-
PCS) was developed by the National Center for Health Statistics (NCHS) to classify inpatient
hospital procedures and services, and it was implemented on October 1, 2015 (replacing Volume 3 of
ICD-9-CM).
 Note
ICD-10-CM/PCS is the abbreviation used by the Centers for Medicare & Medicaid Services to identify both
classification systems.
The Current Procedural Terminology (CPT) is published by the American Medical Association annually.
CPT classifies procedures and services, and it is used by physicians and outpatient healthcare settings (e.g.,
the hospital ambulatory surgery department) to assign CPT codes for reporting procedures and services on
health insurance claims. CPT is considered Level I of the Healthcare Common Procedure Coding System
(HCPCS).
The Healthcare Common Procedure Coding System (HCPCS) also includes Level II (national) codes,
called HCPCS Level II (or HCPCS national codes), which are managed by the Centers for Medicare &
Medicaid Services (CMS), an administrative agency in the federal Department of Health & Human Services
(DHHS). HCPCS Level II classifies medical equipment, injectable drugs, transportation services, and
other services not classified in CPT. Physicians and ambulatory care settings use HCPCS Level II to report
procedures and services.
Note
HCPCS Level III local codes were discontinued in 2004. They had been managed by Medicare carriers and
fiscal intermediaries (FIs). You might come across their legendary use in healthcare facility or insurance
company databases. Some payers still use them.
HIPAA - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is federal legislation that
amended the Internal Revenue Code of 1986 to
 improve portability and continuity of health insurance coverage in the group and individual markets.
 combat waste, fraud, and abuse in health insurance and healthcare delivery.
 promote the use of medical savings accounts.
 improve access to long-term care services and coverage.
 simplify health insurance administration by creating unique identifiers for providers, health plans,
employers, and individuals.
 create standards for electronic health information transactions; and
 create privacy and security standards for health information.
To facilitate the creation of standards for electronic health information transactions, HIPAA requires adopting
two types of code sets to encode data elements (e.g., procedure and service codes).
This type of encoding is a process of standardizing data by assigning alphanumeric values (codes or
numbers) to text and collecting other information (e.g., gender).
Large code sets encode:
 diseases, injuries, impairments, and other health-related problems and their manifestations;
 causes of injury, disease, impairment, or other health-related problems;
 actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments; and
 substances, equipment, supplies, or other items used to perform these actions.

Example
The diagnosis of essential hypertension is assigned ICD-10-CM code I10.
Small code sets encode:
 race/ethnicity and sex;
 type of facility; and
 type of unit.
Example
A patient’s sex is assigned 1 if male, 2 if female, 3 if nonbinary, and so on.
HIPAA also requires the following code sets to be adopted for use by clearinghouses, health plans, and
providers:
 International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding
System (ICD-10-CM/PCS)
 Current Procedural Terminology (CPT)
 HCPCS Level II (national codes)
 Current DENTAL Terminology (CDT)
 National Drug Codes (NDC)
A clearinghouse is a public or private entity (e.g., billing service) that processes or facilitates the processing of
health information and claims from a nonstandard to a standard format.
A health plan (or third-party payer) (e.g., Blue Cross/Blue Shield, a commercial insurance company) is an
insurance company that establishes a contract to reimburse health care facilities and patients for
procedures and services provided.
A provider is a physician or another health care professional (e.g., a nurse practitioner or physician assistant)
who performs procedures or provides services to patients. Adopting HIPAA’s standard code sets has
improved data quality and simplified claims submission for healthcare providers who routinely deal with
multiple third-party payers. The code sets have also simplified claims processing for health plans. Health plans
that do not accept standard code sets must modify their systems to accept all valid codes or contract with a
health care clearinghouse that does accept standard code sets.
Note
A healthcare clearinghouse is not a third-party administrator (TPA), which is an entity that processes
healthcare claims and performs related business functions for a health plan. The TPA might contract with a
healthcare clearinghouse to standardize data for claims processing.
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) requires all code sets
(e.g., ICD-10-CM, ICD-10-PCS) to be valid at the time services are provided. This means that midyear (April
1) and end-of-year (October 1) coding updates must be implemented immediately so accurate codes are
reported on claims. However, coding updates do not require payment adjustments (e.g., diagnosis-related
groups) until the next fiscal year. As atualizações de codificação do meio do ano (1º de abril) e do final do ano (1º de
outubro) devem ser implementadas imediatamente para que códigos precisos sejam relatados sobre as declarações. No
entanto, as atualizações de codificação não exigem ajustes de pagamento (por exemplo, grupos relacionados ao
diagnóstico) até o próximo ano fiscal.
The purchase of updated coding manuals and updating of billing systems with coding changes is crucial so
that billing delays (e.g., due to waiting for new coding manuals to arrive) and claims rejections are avoided. If
outdated codes are submitted on claims, providers and healthcare facilities will incur administrative costs
associated with resubmitting corrected claims and delayed reimbursement for services provided.
For manual coding, coders should consider using updateable coding manuals, which publishers offer as a
subscription service. These coding manuals are usually stored in a three-ring binder so that coders can remove
outdated pages and add newly printed pages provided by the publisher.
Another option is to purchase encoder software, which publishers offer as a subscription service. Coders have
access to the most up-to-date encoder software, which contains edits for new, revised, and discontinued
codes. An encoder automates the coding process using computerized or web-based software; instead of
manually looking up conditions (or procedures) in the coding manual index, the coder uses the software’s
search feature to locate and verify diagnosis and procedure codes.
Automating the medical coding process is the goal of computer-assisted coding (CAC), which uses a
natural language processing engine to “read” electronic health records and generate ICD-10-CM, ICD-10-PCS,
HCPCS Level II, and CPT codes. Because of this process, coders become coding auditors (or coding editors),
responsible for ensuring the accuracy of codes reported to payers. (CAC can be compared to speech recognition
technology that has impacted the role of medical transcriptionists.)
Note
Coding manuals, encoders, and computer-assisted coding (CAC) are discussed in more detail later in this
chapter.

Coding References
Professional organizations that are recognized as national authorities on CPT, HCPCS Level II, ICD-10-CM,
and ICD-10-PCS coding publish references and resources that are invaluable to coders.
To ensure the development of excellent coding skills, make sure you become familiar with and use the
following references and resources:
 AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, and AHA Coding Clinic for HCPCS, quarterly
newsletters published by the American Hospital Association and recognized by the CMS as official
coding resources
 Conditions of Participation (CoP) and Conditions for Coverage (CfC), Medicare regulations
published by CMS
Note
Official coding policy is published in the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, AHA Coding
Clinic for HCPCS, and AMA CPT Assistant, and as National Correct Coding Initiative (NCCI) edits.
The AAPC and AHIMA publish coding newsletters, journals, and so on, but such publications do not contain
official coding policy.
 CPT Assistant Online, a monthly newsletter published by the AMA and recognized by CMS as an
official coding resource
 National Correct Coding Initiative (NCCI), code edit pairs that cannot be used in the same claim
(developed by CMS and published by the federal government’s National Technical Information Service
[NTIS])
 Compliance program guidance documents, and guidelines published by the DHHS OIG
 ICD-10-CM Official Guidelines for Coding and Reporting, guidelines provided by CMS and NCHS to
be used as a companion document to the official version of ICD-10-CM
 ICD-10-PCS Official Guidelines for Coding and Reporting, guidelines provided by CMS and NCHS to
be used as a companion document to the official version of ICD-10-PCS
 Outpatient Code Editor with Ambulatory Payment Classification (OCE/APC), software developed
by CMS, distributed by NTIS, and used by hospitals to edit outpatient claims to help identify possible
CPT/HCPCS Level II coding errors and assign Ambulatory Payment Classifications (APCs) that are
used to generate reimbursement

Avoiding Fraud and Abuse in Coding

Incorporating the use of coding references and resources assists coders in avoiding the following abusive
and fraudulent (dishonest and illegal) coding practices, depending on intent.
Abuse involves mistakenly submitting incorrect codes, and fraud involves intentionally submitting
incorrect codes to increase reimbursement.
Unbundling: Reporting multiple codes to increase reimbursement when a single combination code should
be reported.
Upcoding: Reporting codes that are not supported by documentation in the patient record to increase
reimbursement.
Overcoding: Reporting codes for signs and symptoms in addition to the established diagnosis code.
Jamming: Routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the
coding manual to select the appropriate code.
Downcoding: Routinely assigning lower-level CPT codes for convenience instead of reviewing patient
record documentation and the coding manual to determine the proper code to be reported.

ICD-11 Classification System

The International Classification of Diseases, 11th Revision (ICD-11) was developed by the
World Health Organization (WHO) and released in 2018 to facilitate the implementation
process, such as translation into languages other than English. Implementation of ICD-11 for
member states was on January 1, 2022. (A planned USA implementation date has not been
announced.)

ICD-11 was revised for the purpose of recording, reporting, and analyzing health information. It
contains improved usability, which means it contains more clinical detail and requires less
training time. Other improvements include classifying all clinical detail, readying eHealth for
the electronic health record, linking to other classifications and terminologies (e.g., SNOMED-
CT), multilingual support, and updating scientific content.

The structure of ICD-11 is different from ICD-10, with the biggest changes focused on stem
codes; extension codes; a supplementary section for the assessment of (patient) functioning;
multiple parenting; and pre coordination, post coordination, and cluster coding. The number of
chapters was expanded from 22 in ICD-10-CM to 26 in ICD-11, and while the ICD-11 coding
scheme remains alphanumeric, codes range from 1A00.00 through ZZ9Z.ZZ.

The second character of ICD-11 always contains a letter to differentiate the codes from ICD-
10, and the third character is always a number (referred to as a forced number) so that the
spelling of “undesirable words” is prevented. The first character of an ICD-11 code indicates
 the related chapter, and letters “I” and “O” are omitted to prevent confusion with numbers “1”
and “0” (just like in ICD-10-PCS).

Multiple parenting allows a condition to be correctly classified in two different places (e.g., site or
etiology). For example, esophageal cancer is classified in both the neoplasm chapter and the
digestive system chapter. Thus, stem code 2B70.Z (malignant neoplasms of esophagus) appears
in each chapter.

Stem codes are clinical conditions described by one single category to ensure the assignment of
one code per case, resulting in the (data) collection of a meaningful minimum of information.

Pre coordination coding is the assignment of stem codes, which contain all pertinent information in
a pre-combined manner. For example, pneumonia due to Mycoplasma pneumoniae includes the
disease and its histopathology in ICD-11 stem (or standalone) code CA40.04.

Extension codes standardize the way additional information (e.g., anatomy, histopathology) is
added to a stem code, begin with the letter “X,” and can never be reported without a stem code.

Cluster coding is used to indicate that more than one code is reported together using either a
forward slash (/) or an ampersand (&) to separate multiple codes that describe a clinical case.

Post coordination coding is the process of combining or linking multiple (stem and extension)
codes to completely describe a clinical case. For example, duodenal ulcer with acute
hemorrhage is classified as stem codes DA63 (duodenal ulcer) and ME24.90 (acute
gastrointestinal bleeding, NEC), and extension code XA9780 is added to indicate duodenum
as the anatomic location. The codes are reported as DA63/ME24.90&XA9780.

Coding conventions such as code also, use additional code, includes, excludes, NEC, NOS, residual
categories (e.g., certain, other, unspecified), and/or, due to, and with also appear in ICD-11 to
provide additional information.

While ICD-11 was ready for distribution in 2018 and adopted by member states for
implementation on January 1, 2022, there is no timeline established for its adoption by the
United States.

1-4b Medical Coding Process

The medical coding process requires the review of patient record documentation to identify diagnoses,
procedures, and services for the purpose of assigning ICD-10-CM, ICD-10-PCS, HCPCS Level II, and/or CPT
codes. Each healthcare covered entity (e.g., hospital, medical clinic, physician office) implements a unique
medical coding process, which requires adherence to the following:
1. Code of ethics
2. Accurate coding
3. Coding quality
4. Avoiding assumption coding
5. Professional, Institutional, and Single-Path Coding
6. Physician query process
7. Clinical documentation improvement
 8. Coding compliance programs

1. Code of Ethics
Professional associations establish a code of ethics to help members understand how to differentiate between
“right” and “wrong” and apply that understanding to decision-making.
The AAPC publishes a code of ethics, and AHIMA publishes standards of ethical coding; both serve as
guidelines for ethical coding conduct, and they demonstrate a commitment to coding integrity.

2. Accurate Coding
Regardless of a healthcare setting, the steps to accurate coding begin with a A.) review of the entire patient
record (manual or electronic) before selecting diseases, injuries, reasons for an encounter, procedures, and
services to which codes are assigned. Depending on the setting, coders perform retrospective coding,
concurrent coding, or a combination of both.
Retrospective coding is the review of records to assign codes after the patient is discharged from the
healthcare facility (e.g., hospital inpatient) or released from same-day outpatient care (e.g., hospital outpatient
surgery unit). It is most commonly associated with inpatient hospital stays because accurate coding requires
verification of diagnoses and procedures by reviewing completed face sheets, discharge summaries, operative
reports, pathology reports, and progress notes in the patient records.
Concurrent coding is the review of records and use of encounter forms and chargemasters to assign codes
during an inpatient stay (e.g., hospital) or an outpatient encounter (e.g., hospital outpatient visit for laboratory
testing or x-rays, physician office visit). It is typically performed for outpatient encounters because
encounter forms (e.g., physician office) and chargemasters (e.g., hospital emergency department visit, hospital
outpatient visit for laboratory testing) are completed in “real-time” by healthcare providers as part of the charge-
capture process.
Encounter forms are used to record data about procedures and services provided to patients.
Chargemasters contain a computer-generated list of procedures, services, and supplies, and corresponding
revenue codes along with charges for each.
Note
Information about encounter forms and chargemasters is located in Chapter 20 of this textbook, along with
samples of each.

5. Professional, Institutional, and

Single-Path Coding
A.) Professional coding captures the complexity and intensity of procedures performed and services provided
(CPT and HCPCS Level II) during an outpatient or physician office encounter.
B.) Institutional coding captures the severity of illness (ICD-10-CM) and the intensity of services (ICD-10-
PCS), both of which are used to justify an inpatient facility admission, such as to an acute care hospital.
Severity of illness (SI) is the extent of organ system loss of function or physiological decompensation, and it
establishes an inpatient’s physiologic status or “how sick the inpatient is.”
Severity of illness (SI) is an indicator that is used to estimate an inpatient facility's length of stay and justify a
patient’s need for that level of care. For example, a patient diagnosed with end-stage renal disease (ESRD) and
kidney failure would be classified as having a severe acuity of illness that justifies inpatient admission to an
acute care hospital.
Intensity of services (IS) includes the frequency, number, and type of procedures and services needed to
diagnose and treat patients during an inpatient facility stay and is based on an established acuity of illness. For
example, a patient diagnosed with a severe acuity of illness (e.g., ESRD and kidney failure) would require an
increased level of services, such as inpatient dialysis and kidney transplant surgery.
SI/IS criteria are used by utilization management review specialists to review patient record documentation
when assessing inpatient medical conditions. For example, Interqual® publishes SI/IS criteria as part of an
“evidence-based clinical decision support solution to ensure clinically appropriate medical utilization'
decisions.”
SI/IS criteria are used to determine patient evaluation and treatment plans, medical and surgical
interventions, and anticipated outcomes.
C.) An increase in multi-hospital systems that provide physician office services along with traditional
inpatient, outpatient, and emergency department hospital care has resulted in the introduction of a concept
called single-path coding, which combines professional and institutional coding to improve productivity and
ensure the submission of clean claims, leading to improved reimbursement. Instead of employing separate
professional and institutional coders (who are typically employed at different health care settings), a single-path
coder manages both professional and institutional coding for the same patient using computer-assisted
coding (CAC) software and accessing all documents required for inpatient institutional (ICD-10-CM and
ICD-10-PCS) and outpatient professional (ICD-10-CM, CPT, and HCPCS Level II) coding. This process also
facilitates professional and institutional billing by the organization, resulting in increased coding accuracy and
reduced claims denials.
Example
Early in her career, as a health information manager in Florida, your author implemented a process to provide
the hospital’s medical staff with copies of discharged inpatient record face sheets, which contained diagnosis
(and procedure) codes that were reported on the hospital’s UB-04 institutional claim. Physician offices
generated CMS-1500 claims to obtain reimbursement for professional services provided to hospital inpatients,
and these professional claims reported the same diagnosis codes assigned by the health information
management (HIM) department’s coders. The hospital’s HIM committee approved the process because it
improved the accuracy of reporting diagnosis codes on CMS-1500 claims. (Physicians and outpatient settings
report CPT and HCPCS Level II codes for procedures and services, while inpatient hospitals report ICD-10-
PCS codes.)
Inpatient Hospital Coding Quality
According to the American Hospital Association, “The importance of understanding and following the basic
ICD-10-CM, and ICD-10-PCS coding principles cannot be overemphasized in the training of coders and in
quality control activities undertaken to improve the accuracy of data reported for internal and external hospital
use.
The measures for coding accuracy include
(a) adherence to ICD-10-CM and ICD-10-PCS coding principles and instructions,
(b) attention to specificity in code selection where indicated by physician documentation in the medical record
[patient record],
(c) grasp (COMPREENSAO) of medical terminology, and
(d) absence of clerical-type errors, such as those due to carelessness in reading or in transposing [letters and]
numbers.
Auditing of coded diagnostic and procedural information for accuracy should not be confused with the
review for relevancy in sequencing of the codes at hand. They are separate tasks linked together in the data
reporting process.”
The statement located in (b) of the aforementioned quote is significant because it means that coders are
expected to review the entire record when assigning codes to diagnoses and procedures/services documented
on the face sheet and in the discharge summary, which are located in the hospital inpatient record. Thus, coders
should review the face sheet, discharge summary, and other documentation (e.g., progress notes,
operative reports, pathology reports, laboratory data) to assign the most specific codes possible.
EHR Results in Greater Implementation of Concurrent Coding
Concurrent coding was introduced for inpatient coding just after the inpatient prospective payment system
(using diagnosis-related groups) was implemented on October 1, 1983. Coders from the health information
department worked part of the day on nursing units, accessing paper-based manual medical records to begin the
process of assigning codes to diagnoses and procedures. On discharge of the patient from the hospital, the
coders performed a final review of the patient record to ensure accuracy of reported codes. Because the paper-
based manual patient record can be handled by just one individual at a time, coders “competed” with nurses,
physicians, and other healthcare providers for access to the record. As a result, concurrent coding as a process
was discontinued in some facilities because it was inefficient.
Today, implementation of the electronic health record (EHR) has resulted in a resurgence of concurrent
coding practices because coders (still located in the health information department) access patient records in an
electronic format. They no longer “compete” with other healthcare providers for access to the record and, as a
result, efficiency associated with the concurrent coding concept has been realized. In practice, coders
remain at their workstations in the health information department (and remote coders use their at-home
workstations) to access patient EHRs to begin the discharge coding process. Rising health care costs created an
impetus for concurrent coding processes because it is a much faster method for coders to review and verify the
accuracy of codes on discharge of inpatients based on concurrent coding work performed (according to an
established schedule) up until the date of discharge. For tertiary-care facilities that provide complex healthcare
(e.g., transplant surgery) and quaternary-care facilities that provide highly specialized care (e.g., experimental
medicine), both of which are also characterized as providing high-cost care (e.g., transplant surgery), having the
ability to submit codes for reimbursement purposes within hours (instead of days) of inpatient discharge
significantly and positively impacts their accounts receivables (and their “bottom line”). In addition,
community-based hospitals also realize the benefits of concurrent coding.
Remember! Coders must avoid assumption coding, and when a problem with documentation quality is noted
(e.g., conflicting diagnostic statements on the discharge summary, face sheet, and elsewhere in the record) the
physician query process is initiated (discussed below).
Example 1
The provider documented congestive heart failure on the face sheet of the patient record. On review of
progress notes that document the patient’s response to treatment, the coder finds documentation of acute and
chronic diastolic and systolic congestive heart failure in the discharge progress note. Instead of reporting a
code for congestive heart failure, report the more specific code for acute and chronic diastolic and systolic
congestive heart failure.
Example 2
The provider documented malnutrition on the discharge summary in the patient record. On review of progress
notes, the coder finds documentation of moderate malnutrition. Instead of reporting the nonspecific code
for malnutrition, report the more specific code for moderate malnutrition.

4. Assumption Coding
Coders are prohibited from performing assumption coding, which is the assignment of codes based on the
presumption, from a review of clinical evidence in the patient’s record, that the patient has certain diagnoses
or received certain procedures/services even though the provider did not specifically document those diagnoses
or procedures/services. According to the Compliance Program Guidance for Third-Party Medical Billing
Companies, published by the Department of Health and Human Services’ Office of the Inspector General,
assumption coding creates risk for fraud and abuse because the coder assumes certain facts about a
patient’s condition or procedures/services, although the physician has not specifically documented the
level of detail to which the coder assigns codes. Coders can avoid fraudulent assumption coding by
implementing the physician query process discussed in the following section.
Example
An older adult patient is admitted to the hospital for treatment of a fractured femur. Upon examination, the
physician documents that the skin around the fractured femur site has split open. X-ray of the left femur reveals
a displaced fracture of the shaft. The patient underwent fracture reduction and full-leg casting. The physician
documents open Type I fracture of shaft, left femur as the final diagnosis.
The coder assigns code S72.302B for the open Type I fracture of shaft, left femur, which is correct. The
coder assigns code 0QS90ZZ for the fracture reduction and full leg casting procedure. This is incorrect because
its code description is repositioned left femoral shaft, open approach (no device), femur (shaft). Although the
patient has an open fracture, the physician did not perform an open reduction procedure. (An open
reduction involves making a surgical incision to align displaced bones, and it may require external fixation to
heal properly.) In this case, the coder incorrectly “assumed” that an open reduction was performed because the
patient’s open fracture was treated. The code that should be assigned for this procedure is 0QS9XZZ because its
code description is reposition left femoral shaft, external approach. (A closed reduction involves casting the
affected limb to stabilize the fracture for healing, and it might also require the physician to pull back two ends
of bone that are touching each other and/or to correct any wide angles.)

6. Physician Query Process

When coders have questions about documented diagnoses and procedures or services, they use a physician
query process to contact the responsible physician to request clarification about documentation and the code(s)
to be assigned. The electronic health record (EHR) allows for development of an automated physician query
process, which is used by utilization managers (or case managers), clinical documentation improvement
specialists, and coders to obtain clarification about patient record documentation. Integrating the automated
physician query process with the EHR allows physicians to more easily receive and reply to queries, which
results in better and timely responses from physicians.
Note
The query should not lead the physician to a desired outcome. A leading query would be phrased as, “Is the
patient’s anemia due to blood loss?” and leads the physician to add due to blood loss to the anemia diagnosis for
more specific code assignment and possible increased reimbursement.
A nonleading query would be phrased as, “Can the cause of the patient’s anemia be specified? The history
documents symptoms of fatigue, headaches, inflamed tongue, and lightheadedness. The CBC reveals low
hemoglobin levels.” This query allows the physician to determine whether the anemia can be qualified
according to type.
The following guidelines should be followed when activating the physician query process:
1.) Establish a policy to indicate when a coder should generate a physician query, such as when
documentation in the patient’s record fails to meet one of the following five criteria (according to AHIMA’s
practice brief, entitled Managing an Effective Query Process):
1.1.) Legibility (e.g., illegible handwritten patient record entries)
1.2.) Completeness (e.g., abnormal test results but clinical significance of results is not documented)
1.3.) Clarity (e.g., signs and symptoms are present in the patient record, but a definitive diagnosis is not
documented)
1.4.) Consistency (e.g., discrepancy among two or more treating providers regarding a diagnosis, such as a
patient who presents with shortness of breath and the consulting physician documents pneumonia as the
cause while the attending physician documents congestive heart failure as the cause)
1.5.) Precision (e.g., clinical documentation indicates a more specific diagnosis than is documented, such
as a sputum culture that indicates bacterial pneumonia and the diagnosis does not indicate the cause of the
pneumonia).
2.) Query the physician when the coder notes the following and when provider documentation in the patient
record is not present (according to AHIMA’s practice brief, entitled Managing an Effective Query Process):
2.1.) Clinical indicators of a diagnosis (e.g., lab, x-ray) but the diagnosis is not documented
2.2.) Clinical evidence for a higher degree of specificity or severity (e.g., progress notes) but specificity or
severity is not documented in the diagnosis
2.3.) Cause-and-effect relationship between two conditions but the relationship is not documented in the
diagnosis (e.g., due to, with)
2.4.) An underlying cause when a patient is admitted with symptoms (e.g., shortness of breath is documented
instead of diagnosed pneumonia)
2.5.) Treatment is documented without a corresponding diagnosis for medical necessity (e.g., antibiotics
for a secondary diagnosis of UTI, which is not documented as a diagnosis)
2.6.) Lack of present on admission (POA) indicator status (e.g., history did not indicate diagnoses that were
present on admission, such as chronic asthma) (The POA indicator status is discussed in Chapter 20 of this
textbook.)
Note
Utilization managers (or case managers) are responsible for coordinating inpatient care to ensure the appropriate
utilization of resources, delivery of health care services, and timely discharge or transfer. They usually have a
bachelor’s degree (e.g., nursing), professional licensure (e.g., RN), and clinical practice experience.
Utilization managers work closely with physicians daily, and they are a logical choice to facilitate the physician
query process. In this role, they serve as the liaison for coders (and physicians) by helping coders write
appropriate queries and clarifying queries for physicians so that responses are timely and complete.
3.) Determine whether the query will be generated concurrently (during inpatient hospitalization) or
retrospectively (after patient discharge).
4.) Designate an individual who will serve as the physician’s contact during the physician query process
(e.g., coding supervisor, utilization manager). Remember that the coder’s role is to assign codes based on
documentation and that asking for clarification is appropriate, but assuming codes to be assigned is considered
fraud. That means that coders should ask physicians open-ended questions to avoid leading the physicians
by indicating a preference for a particular response. Coders do not make clinical assumptions—that is the
sole responsibility of the physician.
5.) Use a physician query form (Figures 1-1A and 1-1B), not scrap paper, to document the coder’s query and
the physician’s response. If the completed query form is filed in the patient’s record, determine whether it is
considered an official part of the record and subject to disclosure by those requesting copies of records or
whether it is an administrative form that is not subject to disclosure. The query form could also be stored in
an administrative file in the coding supervisor’s office and the information resulting from the query
documented kept in the patient record by the physician (e.g., as an addendum to the discharge
summary). The length of time that the completed query form is retained is determined by each health
care organization.

Figure 1-1A
Sample open-ended physician query form

Figure 1-1B
Sample multiple choice physician query form
Example
A patient is admitted with severe dyspnea (shortness of breath), chest pain, and fever. Upon physical
examination, the physician documents rhonchi (gurgling sound in the lungs), wheezing, and rales (clicking,
bubbling, or rattling sounds in the lungs). Laboratory data during the hospitalization include a culture and
sensitivity report of sputum that documents the presence of gram-negative bacteria. A review of the physician
orders reveals documentation of appropriate medications to treat pneumonia due to gram-negative bacteria. The
medication administration record (MAR) documents the administration of the medications, and the physician
progress notes document the patient’s positive response to medications (and resolution of the pneumonia). The
physician documents viral pneumonia as the final diagnosis. Generate a physician query to request clarification
about the diagnosis of viral pneumonia, given patient record documentation that pneumonia due to gram-
negative bacteria appears to have been treated.
Depending on the health care facility’s coding policy and procedure, the coder has two options.
a.) If the coding policy and procedure allow coders to use the entire patient record as the basis of assigning
codes to final diagnoses and procedures, because documentation in the record supports a final diagnosis
of pneumonia due to gram-negative bacteria (instead of viral pneumonia), the coder would assign the code for
that condition.
b.) If the coding policy and procedure require coders to generate a physician query when the final diagnosis (on
the face sheet or in the discharge summary) differs from documentation found in the patient record, the coder
would submit the following query to the physician, which allows the physician an opportunity to correct the
documented final diagnosis if warranted. In this case, the physician changed viral pneumonia to pneumonia due
to gram-negative bacteria (using the proper procedure for amending the patient record).
The assignment of a code to pneumonia due to gram-negative bacteria results in reimbursement of about
$3,500, and the assignment of a code to viral pneumonia results in reimbursement of about $2,500. Not
querying the physician would have resulted in a loss of $1,000 to the facility.
This case also includes documentation of signs and symptoms, which are due to the pneumonia. Thus, the coder
would not assign codes to symptoms of dyspnea, chest pain, fever, or signs of rhonchi, wheezing, and rales.

7. Clinical Documentation Improvement

(CDI)
Clinical documentation improvement (or clinical documentation integrity) (CDI) helps ensure accurate and
thorough patient record documentation and identifies discrepancies between provider documentation and
codes to be assigned.
Coders who have questions about documented diagnoses, procedures, and services use a physician query
process to request clarification about documentation that impacts appropriate code assignment. For the
physician query process, medical coders may coordinate with utilization management employees who routinely
meet with providers about the medical necessity of continued patient stays. Thus, it is easier for utilization
management employees to meet with providers for CDI purposes. (Medical coders are routinely located in a
remote part of a facility, including off-site buildings, or they work from home). The result is a resolution of
documentation and coding discrepancies. (Coders also review patient record documentation and use coding
guidelines and other guidance, such as the NCCI program, to assign the most specific codes possible.)
The purpose of a clinical documentation improvement (CDI) program is to help healthcare facilities comply
with government programs (e.g., RAC audits) and other initiatives (e.g., Joint Commission accreditation) with
the goal of improving healthcare quality. As part of a CDI program, the CDI specialist initiates concurrent and
retrospective reviews of inpatient and outpatient records to identify conflicting, incomplete, or nonspecific
provider documentation. Concurrent reviews are performed on patient care units (to access paper-based
patient records) or remotely (to access EHRs). The CDI program helps ensure that patient diagnoses and
procedures are supported by ICD-10-CM and ICD-10-PCS codes, and CDI specialists use a physician query
form to communicate with physicians (and other healthcare providers) with the intended result of
improving documentation, coding, reimbursement, and severity of illness (SOI) and risk of mortality (ROM)
classifications. CDI programs are usually associated with acute health care facilities; however, they are also
implemented in alternate health care settings (e.g., acute rehabilitation facility, skilled nursing facility).
A clinical documentation improvement (CDI) specialist is responsible for performing inpatient record
reviews for the purpose of:
 implementing documentation clarification and specificity processes (as part of the physician query
process);
 using and interpreting clinical documentation improvement statistics;
 conducting research and providing education to improve clinical documentation; and
 ensuring compliance with initiatives that serve to improve the quality of health care, which include:
complying with fraud and abuse regulations;
enforcing privacy and security of patient information; and
monitoring a health information exchange (HIE).

8. Coding Compliance Programs

A coding compliance program ensures that the assignment of codes to diagnoses, procedures, and services
follows established coding guidelines, such as those published by the Centers for Medicare & Medicaid
Services (CMS). Healthcare organizations write policies (guiding principles that indicate “what to do”)
and procedures (processes that indicate “how to do it”) to assist in implementing the coding compliance stages
of detection, correction, prevention, verification, and comparison.
Detection is the process of identifying potential coding compliance problems. For example, a coder notices that
some patient records contain insufficient or incomplete documentation, which adversely impacts coding
specificity. The coder brings these records to the attention of the coding compliance officer (e.g., coding
supervisor), who implements the next stage of the coding compliance program.
Correction is based on the review of patient records that contain potential coding compliance problems, during
which specific compliance issues are identified and problem-solving methods are used to implement necessary
improvements (corrections). For example, the coding compliance officer conducts a careful review of the
patient records that contain insufficient or incomplete documentation. It is determined that all of the records are
the responsibility of a physician new to the practice. Educational material specific to documentation issues
noted during the review process is then prepared.
Prevention involves educating coders and providers so as to avoid coding compliance problems from
recurring. For example, the coding compliance officer schedules a meeting with the physician responsible for
insufficient or incomplete documentation and educates the physician about the specific areas of insufficient or
incomplete documentation that adversely impact medical coding. This meeting is conducted in a
nonconfrontational manner, with education and correction as its goals.
Verification provides an “audit trail” that the detection, correction, and prevention functions of the coding
compliance program are being actively performed.
For example, the coding compliance officer maintains a file that contains the following:
 Original codes assigned based on insufficient and incomplete documentation
 Educational materials prepared specific to the documentation issues
 Minutes of the educational meeting with the responsible physician
 Final codes assigned based on sufficient and complete documentation
 Remittance advice from a third-party payer, which contains adjudication (decision about reimbursement,
including possible claims denial)
Comparison requires the analysis of internal coding patterns over specified periods of time (e.g., quarterly) as
well as the analysis of external coding patterns by using external benchmarks (trends). For example, the coding
compliance officer reviews reports of quarterly medical audits to determine whether the new physician’s
documentation has improved. Such reports contain the results of claims submission, which indicate the number
of claims denials based on nonspecific codes submitted as a result of insufficient and incomplete
documentation. In addition, the coding compliance officer obtains benchmark data (reports) from third-party
payers and compares the coding practices in the facility with those of similar providers; if reimbursement to
similar providers is significantly higher (or lower) than that paid to the provider, the detection process is
initiated in an attempt to identify related coding compliance problems.
An effective coding compliance program monitors coding processes for completeness, reliability, validity,
and timeliness.
Completeness ensures that codes are assigned to all reportable diagnoses, procedures, and services documented
in the patient record. For example, coders review the entire patient record to assign the most specific codes
possible.
Reliability allows for the same results to be consistently achieved. For example, when the same patient record
is coded by different coding professionals, they assign identical diagnosis and procedure/service codes.
Validity confirms that assigned codes accurately reflect the patient’s diagnoses, procedures, and services. For
example, coders do not assign codes to diagnoses that were not medically managed or treated during an
encounter.
Timeliness means that patient records are coded under established policies and procedures to ensure timely
reimbursement.

Coding Manuals, Encoders,

1-4c
and Computer-Assisted Coding
(CAC)
Many publishers produce their own versions of the ICD-10-CM, ICD-10-PCS, and HCPCS Level II coding
manuals. (The AMA publishes CPT.)
Companies also publish encoders, which automate the coding process by using the search feature to locate and
verify medical codes.
Example
ICD-10-CM codes are assigned to justify the medical necessity of procedures and services provided by
physicians, which are reported with CPT and HCPCS Level II codes. (ICD-10-PCS codes are reported for
inpatient hospital procedures only.) If the reason for a patient encounter is the “flu,” the patient’s
respiratory symptoms are also documented. Optum 360’s EncoderPro.com Expert software can be used to
select ICD-10-CM as the Code Set Search, entering “flu” in the search box.
A list of ICD-10-CM codes generated results in selection of “J11.1 Influenza due to unidentified influenza virus
with other respiratory manifestations” based on review of its tabular list entry. The tabular entry includes the
J11.1 code and its description and notes (e.g., Use additional code). J11.1 is then selected as the code to be
reported on the claim. (Codes associated with the “Use additional code” notes were not documented in the
patient record and, thus, not reported.)

Source: Optum360
Computer-assisted coding (CAC) uses software to automatically generate medical codes by analyzing clinical
documentation located in the electronic health record (EHR) or electronic medical record (EMR) (and provided
by health care practitioners) (Figure 1-2). CAC uses “natural language processing” technology to generate
codes that are reviewed and validated by coders for reporting on third-party payer claims. Similar to the medical
editor’s role in ensuring the accuracy of reports produced from speech recognition technology, the coder’s role
changes from that of data entry to validation or audit. The coder reviews and approves the CAC-assigned codes,
improving efficiency and offering expanded career opportunities for enthusiastic coders. Coders use data
analytic skills to review CAC-generated codes and determine which are to be reported. Data analytic skills
allow coders to review codes generated by CAC software, compare codes to documentation in the electronic
health record, and select appropriate codes to report for reimbursement purposes. Thus, coders use basic data
analytic skills to turn data (e.g., CAC-assigned code) into action (coder-reviewed and approved code) using a
logical and efficient method.

Figure 1-2
Computer-assisted coding (CAC)
Coding auditors perform evidence-based coding, also referred to as evidence-verification coding, which
involves clicking on codes that CAC software generates (Figure 1-3) to review electronic health
record documentation (evidence) used to generate the code. When it is determined that documentation supports
the CAC-generated code, the coding auditor clicks to accept the code. When documentation does not support
the CAC-generated code, the coding auditor replaces it with an accurate code. For example, when the CAC-
generated ICD-10-CM code does not indicate laterality or does not include a manifestation code, the coding
auditor edits codes to ensure accurate reporting.

Figure 1-3
Sample screen from Optum360 Enterprise computer-assisted coding (CAC) software
Example of Computer-Assisted Coding
A physician office EMR note is pasted into the Code-A-Note CAC product (published by Find-A-Code, LLC),
and the Scan Notes link in the software is clicked to generate a list of possible ICD-10-CM, CPT, and HCPCS
Level II codes. The software’s list of ICD-10-CM codes requires the coder to compare patient record
documentation of diagnoses and conditions to select codes for reporting on the health insurance claim.
Likewise, the software’s list of CPT and HCPCS Level II codes requires the coder to compare patient
record documentation of procedures and services to select codes for reporting on the health insurance
claim. (In this case, the provider had already selected the appropriate CPT evaluation and management
service code from the encounter form.)
Source: www.findacode.com

Exercise 1.3 – Coding Systems and Processes

Instructions: Complete each statement.

1. A medical nomenclature that is organized according to similar conditions, diseases, procedures,

and services, and contains codes for each is called a CODING (or classification) system.
2. All diseases, injuries, and reasons for an encounter, whether patients are treated as inpatients or
outpatients, are coded using the ICD-10-CM classification system.
3. Inpatient hospital procedures and services are coded using the ICD-10-PCS classification system.
4. A public or private entity that processes or facilitates the processing of health information and
claims from a nonstandard to a standard format is called a healthcare CLEARINGHOUSE.
5. Routinely assigning lower-level CPT codes for convenience instead of reviewing patient record
documentation and the coding manual to determine the proper code to be reported is called
DOWNCODING.
6. Reporting codes that are not supported by documentation in the patient record for the purpose
of increasing reimbursement is called UPCODING.
7. Reporting codes for signs and symptoms in addition to the established diagnosis code is called
OVERCODING.
8. Reporting multiple codes to increase reimbursement when a single combination code should
be reported is called UNBUNDLING
9. Coders should always avoid assumption coding and can do so by generating a physician QUERY
when documentation needs clarification before the assignment of codes.
10. Software that automatically generates medical codes by analyzing clinical documentation in the
electronic health record or electronic medical record is called CAC.
 1-5 Other Classification Systems,
Databases, and Nomenclatures
In addition to the ICD-10-CM, ICD-10-PCS, HCPCS Level II national, and CPT coding systems, healthcare
providers use the following classifications, clinical vocabularies, databases, and nomenclatures:
 Alternative Billing Codes
 Clinical Care Classification System
 Current Dental Terminology
 Diagnostic and Statistical Manual of Mental Disorders
 Health Insurance Prospective Payment System Rate Codes
 International Classification of Diseases for Oncology, Third Edition
 International Classification of Functioning, Disability and Health
 Logical Observation Identifiers Names and Codes
 National Drug Codes
 RxNorm
 Systematized Nomenclature of Medicine Clinical Terms
 Unified Medical Language System
Note
A database allows for the storage of comprehensive and accurate information that serves a critical function in
healthcare, including
 Administration (e.g., financial data)
 Education and research (e.g., cures for disease)
 Patient care (e.g., improving treatment methods)

1-5a Alternative Billing Codes

The Alternative Billing Codes (ABC codes) classify services not included in the CPT manual to describe
the service, supply, or therapy provided; they may also be assigned to report nursing services and alternative
medicine procedures. Codes are five characters in length, consisting of letters, and are supplemented by
two-digit code modifiers to identify the practitioner performing the service.
HIPAA authorized the Secretary of DHHS to permit exceptions from HIPAA transaction and code set standards
to commercialize and evaluate proposed modifications to those standards. The ABC code set was granted that
exception in 2003, and the codes were being commercialized and evaluated through 2005. The intent was for
ABC codes to be adopted as part of the electronic code set (as HCPCS Level I and Level II were in 2000);
however, in 2006, ABC codes could no longer be used in electronic claims processing.
Example
During an office visit, an acupuncture physician assessed the health status of a new client and developed a
treatment plan, a process that took 45 minutes. ABC code ACAAC-1C is assigned.
 1-5b Clinical Care Classification
System
The Clinical Care Classification (CCC) System includes care components that classify each of three
interrelated CCC terminologies:
CCC of Nursing Diagnoses
CCC of Nursing Interventions and Actions
CCC of Nursing Outcomes
CCC care components represent behavioral, functional, physiological, and psychological patterns of clinical
nursing care. CCC codes classify the standards of the American Nurses Association (ANA), which include
assessment, diagnosis, evaluation, implementation, outcome identification, and planning.
Example
73-year-old female patient discharged from the hospital after treatment for acute myocardial infarction presents
today for the scheduled outpatient cardiac rehabilitation sessions. Assign CCC code C08.1.4 (manage cardiac
rehabilitation).

1-5cCurrent Dental Terminology

The Current Dental Terminology (CDT) is published by the American Dental Association (ADA) as an annual
revision. It classifies dental procedures and services. Dental providers and ambulatory care settings use the CDT
to report procedures and services. CDT codes are also included in HCPCS Level II, beginning with the first
digit of D. The CDT also includes the Code on Dental Procedures and Nomenclature (Code), instructions for
use of the Code, questions and answers, ADA dental claim form completion instructions, and tooth numbering
systems.
Example
Patient underwent incision and drainage of intraoral soft tissue abscess. CDT code D7510 is assigned.

1-5dDiagnostic
and Statistical
Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric
Association as a standard classification of mental disorders used by mental health professionals in the United
States. The first edition was published in 1952, and the most current edition (DSM-5) was published in 2014.
DSM-5 is designed for use in a variety of healthcare settings and consists of three major components:
 Diagnostic classification
 Diagnostic criteria sets
 Descriptive text
According to the Substance Abuse and Mental Health Services Administration (www.samhsa.gov), DSM-5
focuses on a “lifespan perspective [by] recognizing the importance of age and development on the onset,
manifestation, and treatment of mental disorders.” DSM-5 eliminates “the multi-axial system, removing
the Global Assessment of Functioning (GAF score) and reorganizing the classification of disorders and
changing how disorders that result from a general medical condition are conceptualized.” DSM-5 categorizes
“disorders into classes with the intent of grouping similar disorders (particularly those that are suspected to
share etiological mechanisms or have similar symptoms) to help clinicians and researchers use the manual. [In]
DSM-5, there has been a reclassification of many disorders that reflects a better understanding of the
classifications of disorders from emerging research or clinical knowledge.”
Example
DSM-5 separately classifies bipolar and related disorders, depressive disorders, and anxiety
disorders (instead of incorporating them as mood disorders in a previous edition of DSM).
DSM-5 eliminated the class of disorders usually first diagnosed in infancy, childhood, or adolescence and
placed such disorders within other classes. For example, Tic Disorders are classified as Neurodevelopmental
Disorders in DSM-5 (instead of Disorders usually first diagnosed in infancy, as in a previous edition of DSM).

1-5eHealth
Insurance Prospective
Payment System Rate Codes
The Health Insurance Prospective Payment System (HIPPS) rate codes are alphanumeric codes consisting of
five digits. Each HIPPS rate code contains intelligence, with certain positions of the code indicating the case-
mix group itself and other positions providing additional information (e.g., information about the clinical
assessment used to arrive at the code). HIPPS was created as part of the prospective payment system for skilled
nursing facilities in 1998. Additional HIPPS rate codes were created for other prospective payment systems,
including a system for home health agencies in October 2000, and one for inpatient rehabilitation facilities in
January 2002. HIPPS represents specific sets of patient characteristics (or case-mix groups) on which payment
determinations are made under several prospective payment systems. HIPPS rate codes are not assigned from a
coding manual; they are created when information for a data set is entered into software.
Example
The home health prospective payment system (HHPPS) requires entry of the Outcome and Assessment
Information Set (OASIS) data set into grouper software, which generates the five-digit alphanumeric HIPPS
code that is entered on the UB-04 claim. For example, HIPPS rate code HAEJ1 is entered on the UB-04 claim.

1-5fInternational Classification of
Diseases for Oncology, Third
Edition
The International Classification of Diseases for Oncology, Third Edition (ICD-O-3) was implemented in 2001
as a classification of neoplasms used by cancer registries throughout the world to record the incidence of
malignancy and survival rates. The data produced are used to provide information for cancer control programs
(e.g., National Comprehensive Cancer Control Program), research activity, treatment planning, and health
economics. (The first edition of ICD-O was published in 1976, and a revision of topography codes was
published in 1990.) ICD-O-3 codes classify a tumor in the following way:
 Primary site (four-character topography code)
 Morphology (six-character code)
 Four-digit histology (cell type) code
 One-digit behavior code (such as malignant, benign, and so on)
 One-digit aggression code (differentiation or grade)
Example
Fibrosarcoma of the left knee. ICD-O-3 codes C49.2 (Knee, NOS) and M8810/39 (Fibrosarcoma, NOS) are
assigned.
The International Classification of Diseases for Oncology, Fourth Edition (ICD-O-4) will publish in 2023
and includes new codes, such as the addition of a fifth-digit “0” where there is no need for a more specific code
and other fifth-digit values to indicate a more specific code. The new fifth digits allow codes to collapse to ICD-
O-3 edition categories and subcategories to ensure ease of conversion and consistency with ICD-O-3. It is
unknown when the United States will adopt ICD-O-4.
ICD-O Morphology Codes indicate the type of cell that has become neoplastic and its biologic activity; in
other words, the kind of tumor that developed and how it behaves. There are three parts to a complete
morphology code:
M as the first character of each morphology code
4-digit cell type (histology) (e.g., 8010)
1-digit behavior (e.g., /o)
1-digit grade, differentiation, or phenotype (e.g., /x1)
A common root codes the cell type of a tumor, an additional digit codes the behavior, and yet another additional
digit codes the grade, differentiation, or phenotype to provide supplementary information about the tumor.
Cancer and Carcinoma The words cancer and carcinoma are often (incorrectly) used interchangeably. For
example, squamous cell cancer is often used for squamous cell carcinoma. Both conditions happen to have the
same ICD-10-CM code. However, a condition such as “spindle cell cancer” could refer to “spindle cell
sarcoma” or “spindle cell carcinoma.” Each condition has an entirely different ICD-10-CM code assigned to it.
Behavior The behavior of a tumor is the way it acts within the body. Pathologists use a variety of observations
to characterize the behavior of a tumor. A tumor can grow in place without the potential for spread (/0, benign);
it can be malignant but still growing in place (/2, noninvasive or in situ); it can invade surrounding tissues (/3,
malignant, primary site); or it can disseminate from its point of origin and begin to grow at another site (/6,
metastatic).
Fifth-Digit Behavior Codes for Neoplasms

Code Behavior of Neoplasm

/0 Benign
 Code Behavior of Neoplasm

/1 Uncertain whether benign or malignant

Borderline malignancy
Low malignant potential
Uncertain malignant potential

/2 Carcinoma in situ
Intraepithelial
Noninfiltrating
Noninvasive

/3 Malignant, primary site

/6 Malignant, metastatic site

Malignant, secondary site

/9 Malignant, uncertain whether primary or metastatic site

Note
Cancer registries collect data on malignant and in situ neoplasms, or /2 and /3 behavior codes. They do not
collect data about behavior codes /6, malignant, metastatic site, or /9, malignant, uncertain whether primary or
metastatic site. For example, carcinoma that has spread to the lung and for which the site of origin is unknown
is assigned ICD-10-CM code C80.1 (unknown primary site) and ICD-O code M-8010/3 (carcinoma). (The /3
signifies the existence of a malignant neoplasm of a primary site.)
Use of Behavior Code in Pathology Laboratories
Pathologists are usually interested in “specimen coding” (whereas a cancer registry identifies just the primary
tumor). A pathologist receives the following tissue specimens on the same patient:
Biopsy of supraclavicular lymph node
Resection of fundus of stomach
Resection of upper lobe bronchus
The pathologist has to track each of these specimens (while the cancer registry tracks only the primary cancer).
Each pathological specimen is coded with the appropriate topography and morphology; for example, the term
“metastatic” in the pathological diagnosis for tissue specimen, “supraclavicular lymph node (biopsy),” results in
assignment of behavior character /6.
 Tissue Specimen Pathological Diagnosis Codes

Supraclavicular lymph node Metastatic signet ring cell adenocarcinoma, most likely from C77.0
(biopsy) stomach (metastatic site)
M8490/6

Fundus of stomach Signet ring cell adenocarcinoma (primary site) C16.1

(resection)
M8490/3

Upper lobe bronchus Metastatic signet ring cell adenocarcinoma (metastatic site) C34.10
(resection)
M8490/6

Code for Histologic Grading and Differentiation

The highest grade code is assigned according to the description documented in the diagnostic statement. The
sixth digit of the morphology code is a single-digit code number that designates the grade of malignant
neoplasms. Only malignant tumors are graded. The practice of assigning codes for histologic grading varies
greatly among pathologists throughout the world, and many malignant tumors are not routinely graded.
Sixth Digit Code for Histologic Grading and Differentiation

Code Grade Differentiation

1 I Well differentiated
Differentiated, NOS

2 II Moderately differentiated
Moderately well differentiated
Intermediate differentiation

3 III Poorly differentiated

4 IV Undifferentiated anaplastic

9 Grade or differentiation not determined, not stated or not applicable

Differentiation describes how much or how little a tumor resembles the normal tissue from which it arose.
There is great variability in pathologists’ use of differentiation descriptors. In general, adverbs such as well,
moderately, and poorly indicate degrees of differentiation, which map to grades I, II, and III. Adjectives such
as undifferentiated and anaplastic usually map to grade IV. Grading codes are assigned to all malignant
neoplasms listed in ICD-O if the diagnosis documents the grade and/or differentiation.
Example
The diagnosis squamous cell carcinoma, grade II, which is described as moderately well differentiated
squamous cell carcinoma, is assigned morphology code M-8070/32.
When a diagnosis indicates two different degrees of grading or differentiation, the higher number is assigned as
the grading code.
Example
Moderately differentiated squamous cell carcinoma with poorly differentiated areas is assigned grading code 3,
and the morphology code is M-8070/33.
This same sixth-digit column is also used to indicate cell lineage for leukemias and lymphomas, which provides
useful ICD-O-3 comparison data (with ICD-O-2). Cell lineage is implicit in the four-digit histology code, and
an additional grade of differentiation (sixth digit) code is not required. However, some registries assign the sixth
digit to identify cases in which the diagnosis is supported by immunophenotypic data. In such instances, the
immunophenotype code takes precedence over other diagnostic terms for grade or differentiation (e.g., well
differentiated, grade III).
Sixth Digit for Immunophenotype Designation for Lymphomas and Leukemias

Code Designation

5 T-cell

6 B-cell

Pre-B

B-precursor

7 Null cell

non-T, non-B

8 NK cell

Natural killer cell

9 Cell type not determined, not stated, or not applicable

 1-5gInternationalClassification of
Functioning, Disability and Health
The International Classification of Functioning, Disability and Health (ICF) classifies health and health-related
domains that describe body functions and structures, activities, and participation. (The ICF was originally
published as the International Classification of Injuries, Disabilities, and Handicaps (ICIDH) in 1980.) The ICF
complements ICD-10, looking beyond mortality and disease.
Example
A trauma patient is evaluated two years after the initial injury, and the physician determines that the patient has
a severe impairment in mental function as well as a severe impairment of the upper extremity. The patient
experiences moderate difficulty in bathing without the use of assistive devices. Products for education are a
moderate barrier for this patient. The following ICF codes are assigned:
b175.3 (severe impairment in mental function)
s730.3 (severe impairment of the upper extremity)
a5101.2 (moderate difficulty bathing without use of assistive devices)
e145.2 (products for education are a moderate barrier)

1-5hLogical
Observation Identifiers
Names and Codes (LOINC)
Logical Observation Identifiers Names and Codes (LOINC®) is an electronic database and universal standard
that is used to identify medical laboratory observations and for clinical care and management. Developed in
1994, it is currently maintained by the Regenstrief Institute, a U.S. nonprofit medical research organization.
Healthcare providers use LOINC® codes when reportable disease results are sent to state and federal public
health laboratories.
The Centers for Disease Control and Prevention (CDC) has developed a LOINC® panel specifically for public
health case reporting called the Reportable Condition Mapping Tool (RCMT). This panel should be of
considerable assistance to healthcare providers in identifying the correct LOINC® code for their reports.
Laboratories are also required to archive LOINC® codes for test results they receive from other laboratories to
which they have referred specimens and, similarly, referral laboratories should provide their clients with
LOINC® codes when sending results.
Example
The complete blood count (CBC) laboratory test of blood (without differential) is assigned LOINC® code
24317-0.

1-5iNational Drug Codes

The National Drug Codes (NDC) is published by a variety of vendors, and the coding system is in the public
domain. It is managed by the Food and Drug Administration (FDA) and was originally established as part of an
out-of-hospital drug reimbursement program under Medicare Services as a universal product identifier for
human drugs. The current edition is limited to prescription drugs and a few selected over-the-counter
(OTC) products. Pharmacies use NDC to report transactions, and some healthcare professionals also report
NDC on claims.
Example
Aspirin tablets, 800 milligrams, is assigned NDC code 64125-*106-01. (There are many different NDC codes
for aspirin, depending on dosage, manufacturer, and so on.)

1-5jRxNorm
RxNorm is a nomenclature that provides normalized names for clinical drugs and links drug names to many of
the drug vocabularies commonly used in pharmacy management and drug interaction software, including
those of First Databank, Micromedex, MediSpan, Gold Standard Drug Database, and Multum. By providing
links among these vocabularies, RxNorm can mediate messages among systems that do not use the same
software and vocabulary.
RxNorm is a normalized naming system for generic and branded drugs, and it is a tool for supporting
semantic interoperation among drug terminologies and pharmacy knowledge base systems. The National
Library of Medicine (NLM) produces RxNorm. The NLM receives drug names from many data sources,
analyzes and processes the data, and outputs the data into RxNorm files in a standard format.
Purpose of RxNorm
RxNorm is a terminology built on and derived from other terminologies. RxNorm reflects and preserves the
meanings, drug names, attributes, and relationships from its sources. Hospitals, pharmacies, and other
organizations use computer systems to record and process drug information. Because these systems use many
different sets of drug names, it can be difficult for one system to communicate with another. To address this
challenge, RxNorm provides normalized names and unique identifiers for medicines and drugs. The goal
of RxNorm is to allow computer systems to communicate drug-related information efficiently and
unambiguously.
Scope of RxNorm
RxNorm contains the names of prescription and many OTC drugs available in the United States.
RxNorm includes generic and branded:
Clinical drugs (pharmaceutical products given to or taken by a patient with therapeutic or diagnostic intent)
Drug packs (packs that contain multiple drugs, or drugs designed to be administered in a specified sequence)
Radiopharmaceuticals, bulk powders, contrast media, food, dietary supplements, and medical devices,
such as bandages and crutches, which are out of scope for RxNorm
Note
RxNorm also includes the National Drug File—Reference Terminology (NDF-RT), created for the Veterans
Health Administration. NDF-RT is a terminology used to code clinical drug properties, including
mechanism of action, physiologic effect, and therapeutic category.
Example
When Synthroid is entered in the RxNorm database, results display levothyroxine as the ingredient and
levothyroxine sodium as the precise ingredient. In addition, all possible dosages of the ingredient and
brand name are listed under the clinical drug component, branded drug component, clinical drug or
pack, and branded drug or pack. Oral product or pill is listed below the dose form group, with expanded
information listed below the clinical dose form group and branded dose form group.

1-5kSystematized Nomenclature of
Medicine Clinical Terms
The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) is a comprehensive and
multilingual clinical terminology of body structures, clinical findings, diagnoses, medications, outcomes,
procedures, specimens, therapies, and treatments. It combines the content and structure of a previous
revision of SNOMED with the following medical nomenclatures:
 United Kingdom’s National Health Service’s Clinical Terms Version 3 (formerly called Read Codes,
developed in the early 1980s by Dr. James Read to record and retrieve primary care data in a computer)
 Logical Observation Identifier Names and Codes (LOINC®) database, which provides a universal code
system for reporting laboratory and other clinical observations
SNOMED CT supports the development of comprehensive high-quality clinical content in patient records; it
provides a standardized way to represent clinical phrases documented by clinicians, facilitating automatic
interpretation (e.g., computer-assisted coding).

1-5lUnified Medical Language

System
The Unified Medical Language System (UMLS) is a set of files and software that allows many health and
biomedical vocabularies and standards to enable interoperability among computer systems. UMLS can be used
to enhance or develop applications, including electronic health records, classification tools, dictionaries, and
language translators. The UMLS is used to link health information, medical terms, drug names, and billing
codes across different computer systems.
Example 1
UMLS is used to link billing codes, drug names, medical terms, and health information across different
computer systems, such as among a patient’s health care provider, pharmacy, and third-party payer or patient
care coordination among several departments within a hospital.
Example 2
UMLS uses include search engine retrieval, data mining, public health statistics reporting, and medical
terminology research.
The UMLS contains three tools, called Knowledge Sources, which include the following:
 Metathesaurus (terms and codes from many vocabularies, including CPT, ICD-10-CM, LOINC®,
MeSH®, RxNorm, and SNOMED CT) (MeSH is the National Library of Medicine’s controlled
vocabulary thesaurus.)
  Semantic network (broad categories, which are semantic types, and their relationships, which are
semantic relations)
 SPECIALIST lexicon and lexical tools (natural language processing tools)
Exercise 1.4 – Other Classification Systems and Databases
Instructions: Complete each statement.
 The classification of neoplasms used by cancer registries throughout the world to record incidence of
malignancy and survival rates is called the ICD-O-3.
 Specific sets of patient characteristics (or case-mix groups) on which payment determinations are made
under several prospective payment systems are represented by the HIPPS.
 The set of files and software that allows many health and biomedical vocabularies and standards to
enable interoperability among computer systems is called the UMLS.
 The coding system that is used to classify dental procedures and services is called the CDT.
 The system that classifies health and health-related domains to describe body functions and structures,
activities, and participation is called the ICF.
 The system that classifies services not included in the CPT manual to describe the service, supply, or
therapy provided and may also be assigned to report nursing services and alternative medicine
procedures is called ABC CODES.
 The nomenclature that provides normalized names for clinical drugs and links its names to many of the
drug vocabularies commonly used in pharmacy management and drug interaction software is called
RXNORM.
 An electronic database and universal standard that is used to identify medical laboratory observations
and for the purpose of clinical care and management is called the LOINC.
 The American Psychiatric Association published a standard classification of mental disorders called the
DSM−5.
 The system that provides a new standardized framework and a unique coding structure for assessing,
documenting, and classifying home health and ambulatory care is called the CCC System.

1-6Documentation as the Basis for Coding

Documentation includes dictated and transcribed, keyboarded or handwritten, and computer-generated
notes and reports recorded in patient records by a health care professional.
Documentation must be dated and authenticated (with a legible signature or electronic authentication).
Health care providers are responsible for documenting and authenticating legible, complete, and timely
patient records in accordance with federal regulations (e.g., Medicare CoP) and accrediting agency
standards (e.g., The Joint Commission). The provider is also responsible for correcting or editing errors in
patient record documentation.
A patient record (or medical record) is the business record for a patient encounter (inpatient or outpatient) that
documents healthcare services provided to a patient.
It stores patient demographic data*** and documentation that supports diagnoses and justifies treatment
provided. It also contains the results of the treatment provided.
***Demographic data includes patient identification information collected according to facility policy and
includes information such as the patient’s name, date of birth, and mother’s maiden name.
The primary purpose of the record is to provide for continuity of care, which involves documenting patient
care services so that others who treat the patient have a source of information on which to base additional care
and treatment.
The record also serves as a communication tool for physicians and other patient care professionals. It assists in
planning individual patient care and documenting a patient’s illness and treatment.
Secondary purposes of the record do not relate directly to patient care and include:
 Evaluating the quality of patient care
 Providing data for use in clinical research, epidemiology studies, education, public policy making,
facilities planning, and health care statistics
 Providing information to third-party payers for reimbursement
 Serving the medicolegal interests of the patient, facility, and providers of care
Documentation for Teaching Hospitals
In a teaching hospital, documentation must identify the service provided, how the teaching physician
participated in providing the service, and whether the teaching physician was physically present when the
service was provided. A teaching hospital is engaged in an approved graduate medical education (GME)
residency program in medicine, osteopathy, dentistry, or podiatry. A teaching physician is a physician (other
than another resident physician) who supervises residents during patient care. A resident physician is an
individual who participates in an approved GME program.
A hospitalist is a physician who provides care for hospital inpatients. They are often internists (e.g., internal
medicine specialists) who handle a patient’s entire admission process, including examining the patient,
reviewing patient history and medications, writing admission orders, counseling the patient, and performing
other tasks that would have required the primary care physician to travel to the hospital to coordinate the
inpatient admission. Similar to the concept of emergency physicians practicing in the hospital’s emergency
department, hospitalists are based in the hospital and provide inpatient care. Thus, their practice is location-
based instead of body system-centered (e.g., neurology) or age-centered (e.g., gerontology).

1-6aMedical Necessity
Documentation in the patient record serves as the basis for coding.
The information in the record must support codes submitted on claims for third-party payer reimbursement
processing. The patient’s diagnosis must also justify diagnostic and therapeutic procedures or services
provided. This is called medical necessity and requires providers to document services or supplies that are
proper and needed for the diagnosis or treatment of a medical condition; provided for the diagnosis, direct care,
and treatment of a medical condition; consistent with standards of good medical practice in the local area;
and not mainly for the convenience of the physician or health care facility.
It is important to remember the familiar phrase, “If it wasn’t documented, it wasn’t done.”
The patient record serves as a medicolegal document and a business record.
If a provider performs a service but does not document it, the patient (or third-party payer) can refuse to pay for
that service, resulting in lost revenue for the provider.
In addition, because the patient record serves as an excellent defense of the quality of care administered to a
patient, missing documentation can result in problems if the record has to be admitted as evidence in a court of
law.
Example of Missing Patient Record Documentation
A representative from XYZ Insurance Company reviewed 100 outpatient claims submitted by the Medical
Center to ensure that all services billed were documented in the patient records. Upon reconciliation of claims
with patient record documentation, the representative denied payment for 13 services (totaling $14,000)
because reports of the services billed were not found in the patient records. The facility must pay back the
$14,000 it received from the payer as reimbursement for the claims submitted.
Example of Medical Necessity
The patient underwent an x-ray of the right knee, and the provider documented “severe right shoulder pain”
in the record. The coder assigned a CPT code to the “right knee x-ray” and an ICD-10-CM code to the
“right shoulder pain.” In this example, the third-party payer will deny reimbursement for the submitted claim
because the reason for the x-ray (shoulder pain) does not match the type of x-ray performed. For medical
necessity, the provider should have documented a diagnosis such as “right knee pain.”

1-6bPatient Record Formats

Healthcare facilities and physicians’ offices usually maintain either manual or automated records, and
sometimes they maintain a hybrid record.
A manual record is paper-based, while an automated record is computer-based. A hybrid record contains
both paper-based and computer-based (electronic) documents. This means the facility or office creates and
stores some reports as paper-based records (e.g., handwritten progress notes, physician orders, and graphic
charts) and some documents using a computer (e.g., transcribed reports and automated laboratory results).
A variety of formats are used to maintain MANUAL records, including the source-oriented record (SOR),
problem-oriented record (POR), and integrated record.
Automated record formats include the electronic health record (EHR) (or computer-based patient record,
CPR), electronic medical record (EMR), and document imaging (to scan paper-based reports, such as
patient-signed consent forms). Hybrid records use a combination format, such as the POR for paper-based
reports and EMR for computer-based reports.
Note
True EHRs are generated by multiple providers using specialized software, and results are stored electronically
in a format that is easily retrievable and viewable by users.
Manual Record Formats
Manual record formats include the source-oriented record (SOR), problem-oriented record (POR), and
integrated record.
Source-Oriented Record
Source-oriented record (SOR) (or sectionalized record) reports are organized according to documentation (or
data) source (e.g., ancillary, medical, and nursing). Each documentation (or data) source is located in a labeled
section.
Problem-Oriented Record
The problem-oriented record (POR) systematic method of documentation consists of four components:
 Database
 Problem list
 Initial plan
 Progress notes
The POR database contains the following patient information collected on each patient:
 Chief complaint
 Present conditions and diagnoses
 Social data
 Past, personal, medical, and social history
 Review of systems
 Physical examination
 Baseline laboratory data
The POR problem list serves as a table of contents for the patient record because it is filed at the beginning of
the record and contains a numbered list of the patient’s problems, which helps to index documentation
throughout the record. The POR initial plan contains the strategy for managing patient care and any actions
taken to investigate the patient’s condition and to treat and educate the patient. The initial plan consists of three
categories:
 Diagnostic/management plans: Plans to learn more about the patient’s condition and the management
of the conditions.
 Therapeutic plans: Specific medications, goals, procedures, therapies, and treatments used to treat the
patient.
 Patient education plans: Plans to educate the patient about the conditions for which the patient is being
treated.
The POR progress notes are documented for each problem assigned to the patient, using the SOAP structure:
Subjective (S): Patient’s statement describes how the patient feels, including symptomatic information (e.g., “I
have a headache.”).
Objective (O): Observations about the patient, such as physical findings, or lab or x-ray results (e.g., chest x-
ray negative).
Assessment (A): Judgment, opinion, or evaluation made by the healthcare provider (e.g., acute headache).
Plan (P): Diagnostic, therapeutic, and educational plans to resolve the problems (e.g., patient to take Tylenol as
needed for pain).
A discharge note is documented in the progress notes section of the POR to summarize the patient’s care,
treatment, response to care, and condition on discharge—documentation of all problems is included. A transfer
note is documented when a patient is being transferred to another facility. It summarizes the reason for
admission, current diagnoses and medical information, and the reason for transfer.
Integrated Record
Integrated record reports are arranged in strict chronological date order (or in reverse date order), which allows
for observation of how the patient is progressing (e.g., responds to treatment) based on test results. Many
facilities integrate only physician and ancillary services (e.g., physical therapy) progress notes, which require
entries to be identified by appropriate authentication (e.g., complete signature of the professional documenting
the note such as Mary Smith, RRT).
Automated Record Formats
The electronic health record (EHR) is a collection of patient information documented by many providers at
different facilities regarding one patient. It is a multidisciplinary (many specialties) and multi-enterprise (many
facilities) approach to record keeping. The EHR provides access to complete and accurate health problems,
status, and treatment data; it contains alerts (e.g., of drug interaction) and reminders (e.g., prescription renewal
notice) for health care providers. According to the Journal of Contemporary Dental Practice, February 15, 2002,
some professionals prefer to “use electronic instead of the earlier term computer-based because electronic better
describes the medium in which the patient record is managed.”
The electronic medical record (EMR) is created on a computer, using a keyboard, a mouse, an optical
pen device, a voice-recognition system, a scanner, or a touch screen. Records are created using vendor
software, which also assists in provider decision-making (e.g., alerts, reminders, clinical decision support
systems, and links to medical knowledge). Numerous vendors offer EMR software, mostly to physician office
practices that require practice management solutions (e.g., appointment scheduling, claims processing,
clinical notes, patient registration).
Document imaging often supplements the EHR or EMR by converting paper records (e.g., consent to
treatment signed by patients) to an electronic format using laser technology to create the image;
a scanner is used to capture paper record images onto the storage media. The paper record must be
prepared for scanning (e.g., removal of staples) so documents can pass through the scanner properly using a
document feeder that is attached to the scanner; each report is pulled through the scanner so the image is saved.
Each scanned page is indexed, which means it is identified according to a unique identification number (e.g.,
patient record number). A unique feature is that documents for the same patient do not have to be scanned at the
same time. Because each scanned page is indexed, the complete patient record can be retrieved even when a
patient’s reports are scanned at a later time.

Documentation Cloning Is an EMR/EHR Concern

Electronic Health Records Provider Fact Sheet. (Permission to reuse in accordance
with http://www.cms.gov content reuse and linking policy.)

Medicare administrative contractors noted the frequency of electronic medical records (EMRs) and electronic
health records (EHRs) that contain identical documentation across services. This was likely the result
of documentation cloning, which involves using the EMR or EHR to bring information from previous patient
encounters forward to the current encounter without updating that information. Documentation must reflect
patient conditions and treatment for each encounter. Bringing forward previous documentation and simply
changing the date in the EHR or EMR is unacceptable. U.S. Department of Health and Human Services, Office
of Inspector General (HHS-OIG) staff continue to closely monitor EMR and EHR documentation cloning.

Exercise 1.5 – Documentation as Basis for Coding

Instructions: Select the most appropriate response.

1. Continuity of patient care is considered purpose of the patient record.

 1. primary
2. secondary
2. Evaluating quality of patient care is considered apurpose of the patient record.
1. primary
2. secondary
3. Which is an example of patient demographic data?
1. date of birth
2. discharge diagnosis
4. Medical necessity requires providers to document procedures, services, and supplies that are
proper and needed for the
1. convenience of the physician or health care facility.
2. diagnosis or treatment of a patient’s medical condition.
5. Which is the business record for a patient encounter because it documents healthcare services
provided?
1. demographic data collected on admission
2. patient record housed in the facility

1-7Health Data Collection

Health data collection is performed by healthcare facilities and providers for administrative planning,
submitting data and statistics to state and federal government agencies (and other organizations), and reporting
health claims data to third-party payers.
Administrative planning requires health data analysis to determine employee staffing levels, services offered,
and more.
Submitting data and statistics to state and federal government agencies is mandated and includes cancer registry
data, reportable events, reportable diseases, morbidity data, and more.
Reporting health claims data to third-party payers uses data collected from patient records and assigned medical
codes, which helps ensure the financial viability of the healthcare facility or medical practice.

1-7aReporting Hospital Data

Hospitals and other healthcare facilities use automated case abstracting software to collect and report inpatient
and outpatient data for statistical analysis and reimbursement purposes. Data are entered in an abstracting
software program (Figure 1-4), and the facility’s billing department imports it to the UB-04 (or CMS-1450)
claim (Figure 1-5) for submission to third-party payers. The facility’s information technology department
generates reports (Figure 1-6), which are used for statistical analysis. The UB-04 (or CMS-1450) is a standard
claim (uniform bill) submitted by healthcare institutions to payers for inpatient and outpatient services.

Figure 1-4
Sample data entry screen with ICD-10-CM and ICD-10-PCS codes and descriptions
for automated case abstracting software
Permission to reprint granted by QuadraMed.

Figure 1-5
UB-04 outpatient hospital claim with sample patient data in highlighted form locators that also contain ICD-10-
CM and CPT codes
Courtesy of the Centers for Medicare & Medicaid Services, www.cms.gov; claim data created by author.

Figure 1-6
Sample procedure data report containing ICD-10-PCS codes
Courtesy of the Centers for Medicare & Medicaid Services, www.cms.gov.
Example
Procedure data reports, profit and loss statements, and patient satisfaction surveys are used by healthcare
planning and forecasting committees to determine the types of procedures performed at their facilities
and the costs associated with providing such services. As a result of the report analysis, procedures that
contribute to a facility’s profits and losses can be determined; in addition, some services may be expanded while
others are eliminated.

1-7bReporting Physician Office

Data
Computerized physicians’ offices use medical practice management software to enter claims data and either
electronically submit CMS-1500 claims data to third-party payers or print paper-based CMS-1500 claims
that are mailed or faxed to clearinghouses or payers for processing.
The CMS-1500 is a standard claim submitted by physicians’ offices to third-party payers. Medical practice
management software (e.g., e-Medsys, MediSoft) is a combination of medical practice management and
medical billing software that automates the daily workflow and procedures of a physician’s office or clinic:
 Appointment scheduling (e.g., initial and follow-up appointments) (Figure 1-7)
 Claims processing (e.g., CMS-1500 claims processing) (Figure 1-8)
 Patient invoicing (e.g., automated billing) (Figure 1-9)
 Patient management (e.g., patient registration) (Figure 1-10)
 Report generation (e.g., accounts receivable aging report) (Figure 1-11)
Figure 1-7
Appointment schedule screens in e-Medsys®

e-Medsys ®
Suite – Practice Management/EHR/Mobile
Figure 1-8
Claims processing screen

Figure 1-9

Billing screen
Figure 1-10

Patient registration screen in e-Medsys®

e-Medsys ®
Suite – Practice Management/EHR/Mobile
Figure 1-11
Accounts receivable aging report
Medical assistants and insurance specialists use medical practice management software to collect
physician office data for reimbursement purposes by locating patient information, inputting ICD-10-CM, CPT,
and HCPCS Level II codes for diagnoses and procedures/services and generating and processing CMS-1500
claims. Medical practice management software generates claims for a variety of medical specialties, and
claims can be printed and mailed to clearinghouses, TPAs, or third-party payers for processing. The
software also allows for submission of HIPAA-compliant electronic claims to clearinghouses, TPAs, or
third-party payers.
When records are reviewed to select ICD-10-CM, CPT, and HCPCS Level II codes for reporting to third-party
payers, documentation in the physician's office patient record serves as the basis for coding.
Coders are responsible for reviewing patient records to select the appropriate diagnoses and procedures/services
to which codes are assigned. Information in the record must support the codes submitted on claims for third-
party payer reimbursement processing. The patient’s diagnosis must justify diagnostic or therapeutic procedures
or services provided (medical necessity), and the provider must document services or supplies that:
are proper and needed for the diagnosis or treatment of a medical condition;
are provided for the diagnosis, direct care, and treatment of a medical condition;
meet the standards of good medical practice in the local area; and
are not mainly for the convenience of the physician or health care facility.
Claims can be denied if the medical necessity of procedures or services is not established. Each procedure or
service reported on the CMS-1500 claim must be linked to a condition that justifies the necessity for performing
that procedure or providing that service. If the procedures or services delivered are determined to be
unreasonable and unnecessary, the claim is denied. On the UB-04 claim, procedures or services are not linked;
however, payers often request copies of patient records to review documentation to verify diagnoses,
procedures, and services reported on the claim.

Exercise 1.6 – Health Data Collection

Instructions: Complete each statement.

1. Appointment scheduling and claims processing are processes associated with medical software.
2. Hospital coders and abstractors use automated case abstracting software to collect and report
inpatient and outpatient data for statistical analysis and reimbursement purposes.
3. Physicians’ offices submit data to third-party payers on the CMS 1500 claim.
4. Hospitals submit data to third-party payers on the UB-04 (or CMS-1450) claim.
5. Claims are denied if MEDICAL necessity of procedures or services is not established.

Chapter Review
1-8aSummary
A coder is expected to master the use of coding systems, coding principles and rules, government
regulations, and third-party payer requirements to ensure that all diagnoses, services, and
procedures documented in patient records are accurately coded for reimbursement, research, and
statistical purposes. To prepare for entry into the profession, students are encouraged to join a
professional association. Students usually pay a reduced membership fee and receive most of the
same benefits as active members. The benefits of joining a professional association include eligibility
for scholarships and grants, the opportunity to network with members, free publications, reduced
certification exam fees, and website access for members only.

Coding systems and medical nomenclatures are used by healthcare facilities, healthcare providers,
and third-party payers to collect, store, and process data for a variety of purposes. A coding system
organizes a medical nomenclature according to similar conditions, diseases, procedures, and
services; it contains codes for each. A medical nomenclature includes clinical terminologies and
clinical vocabularies that are used by health care providers to document patient care.

Clinical terminologies include designations, expressions, symbols, and terms used in the field of
medicine, and

Clinical vocabularies include clinical phrases or words along with their meanings.

Codes include numeric and alphanumeric characters that are reported to health plans for health care
reimbursement and to external agencies for data collection and internally for education and research.
Coding is the assignment of codes to diseases, injuries, reasons for an encounter, services, and
procedures based on patient record documentation.

Encoder software automates the medical coding process, allowing coders to use a search function to
locate and verify codes.

Computer-assisted coding (CAC) software analyzes EHR or EMR documentation to generate codes
for terms and phrases, and coders use data analytic skills to review and determine which CAC-
generated codes are to be reported.

Healthcare providers are responsible for documenting and authenticating legible, complete, and
timely patient records in accordance with federal regulations and accrediting agency standards. The
provider is also responsible for correcting or editing errors in patient record documentation.
Health data collection is performed by health care facilities to do administrative planning, to submit
statistics to state and federal government agencies, and to report health claims data to third-party
payers for reimbursement purposes.

Chapter Review
1-8bInternet Links

 Alternate Billing Codes (ABC codes): www.abccodes.com

 AHA Coding Clinic Advisor: codingclinicadvisor.com
 AAPC:www.aapc.com
 American Association of Medical Assistants (AAMA): www.aama-ntl.org
 American Health Information Management Association
(AHIMA): www.ahima.org
 American Medical Technologists (AMT): www.americanmedtech.org
 Clinical Care Classification System: careclassification.org
 Current Dental Terminology (CDT): Go to www.ada.org, scroll over
Publications, and click on CDT coding.
 Diagnostic and Statistical Manual of Mental Disorders
(DSM): https://dsm.psychiatryonline.org
 ICD-10-CM and ICD-10-PCS encoder (subscription-
based): www.encoderpro.com (free trial available)
 Health Insurance Prospective Payment System (HIPPS) Rate Codes: Go
to www.cms.gov, click on the Medicare link, scroll to the Medicare Fee-for-Service
Payment heading, click on the Prospective Payment Systems - General Information
link, and click on the HIPPS Codes link.
 International Classification of Diseases for Oncology (ICD-O-3): Go
to https://training.seer.cancer.gov, click on Resources, click on Links to Reference
Materials, and scroll down and click on the ICD-O-3 Training module link. The
international version of the ICD-O-3 coding manual is available by going
to www.iacr.com.fr, scrolling over Support for Registries, and clicking on
International Classification of Diseases for Oncology (ICD-O).
 National Drug Codes (NDC): Go to www.fda.gov, and use the Search feature to
enter National Drug Code Directory to navigate to the online NDC Directory.
 National Cancer Institute’s Surveillance, Epidemiology, and End Results
(SEER) Training Modules: Go to https://training.seer.cancer.gov, click on the
Cancer Registration & Surveillance Modules link, and click on the Coding Primary
Site & Tumor Morphology link.
 RxNorm: Go to https://uts.nlm.nih.gov, and click on the RxNorm link.
 SNOMED CT: Go to https://uts.nlm.nih.gov, and click on the SNOMED CT link.
 Unified Medical Language Systems (UMLS): Go to https://uts.nlm.nih.gov, and
click on the Unified Medical Language System (UMLS) link.

Chapter Review
1-8cReview
Multiple Choice
Instructions: Select the most appropriate response.

1. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires two types of code
sets, large code sets and small code sets, to be adopted for the purpose ofdata elements.
1. decrypting
 2. encoding
3. interpreting
4. translating
2. Which is considered to be a small code set according to HIPAA?
1. Actions taken to prevent, diagnose, treat, and manage diseases and injuries
2. Causes of injury, disease, impairment, or other health-related problems
3. Diseases, injuries, impairments, and other health-related problems
4. Race, ethnicity, type of facility, and type of unit
3. Which is a code set adopted by HIPAA for use by clearinghouses, health plans, and providers?
1. CDT
2. CMIT
3. ICD-9
4. SNOMED CT
4. The purpose of adopting standard code sets was to
1. establish a medical nomenclature to standardize HIPAA data submissions.
2. improve data quality and simplify claims submission for providers.
3. increase costs associated with processing health insurance claims.
4. regulate health care clearinghouses and third-party administrators.
5. According to HIPAA, health plans that do not accept standard code sets are required to modify their
systems to accept all valid codes or to contract with a(n)
1. electronic data interchange.
2. health care clearinghouse.
3. insurance company.
4. third-party administrator.
6. Which type of clinical terminologies and clinical vocabularies are used by health care providers to
document patient care?
1. Classification system
2. Demographic data
3. Medical nomenclature
4. Patient record
7. The requirement that patient diagnoses justify diagnostic and/or therapeutic procedures or services
provided is called:
1. continuity of care.
2. facilities planning.
3. medical necessity.
4. policy making.
8. Which is the business record for a patient encounter (inpatient or outpatient) that documents health care
services provided to a patient?
1. Demographic data
2. Financial record
3. Health care statistics
4. Medical record
9. The primary purpose of the patient record is, which involves documenting patient care services so that
others who treat the patient have a source of information on which to base additional care and treatment.
1. continuity of care
2. medical necessity
3. medicolegal
4. quality of care
10. Which is a secondary purpose of the medical record that does not relate directly to patient care?
1. Clinical research
2. Continuity of care
3. Discharge note
 4. Hybrid record
11. Which type of medical record format stores documentation in labeled sections?
1. Integrated record
2. Problem-oriented record
3. Source-oriented record
4. SOAP notes
12. A progress note contains diagnoses of muscle strain and weakness. This statement would be located in
theportion of the POR progress note.
1. Assessment
2. Objective
3. Plan
4. Subjective
13. A progress note contains documentation that the patient is to be followed up with in the physician’s
office two weeks after discharge from the hospital. This statement would be located in theportion of the
POR progress note.
1. Assessment
2. Objective
3. Plan
4. Subjective
14. A progress note contains documentation that the EKG showed elevated T-wave changes. This statement
would be located in theportion of the POR progress note.
1. Assessment
2. Objective
3. Plan
4. Subjective
15. Which is documented in the progress notes section of the POR to summarize the patient’s care,
treatment, response to care, and condition on release from the facility?
1. Demographic data
2. Discharge note
3. Medical necessity
4. Transfer note
16. Which is used to capture paper record images onto storage media?
1. EHR
2. EMR
3. Documentation cloning
4. Scanner
17. To provide the maximum benefit to students, internships are typicallywork experiences that are arranged
by academic program faculty.
1. elective
2. nonpaid
3. optional
4. voluntary
18. To whom does the student report at the professional practice experience (or internship) site?
1. Human resources
2. PPE or internship supervisor
3. Program faculty
4. Volunteer department
19. Which is a benefit of joining a professional association?
1. Free certification examination fees
2. Opportunities to network with other members
3. Reduced benefits as compared with nonmembers
4. Website-only access to professional journals
20. Which processes health care claims and performs related business functions for a health plan?
1. Health care clearinghouse
2. Health care provider
3. Third-party administrator
4. Third-party payer
21. Which classifies outpatient hospital and physician office procedures and services?
1. CDT
2. CPT
3. ICD-10-CM
4. ICD-10-PCS
22. Which is a standard classification of mental disorders used by mental health professionals in the United
States?
1. ABC
2. CCC
3. DSM
4. ICF
23. Which is an electronic database and universal standard used for clinical care and management?
1. LOINC®
2. SNOMED CT
3. READ
4. UMLS
24. Hospitals and other health care facilities use automated case abstracting software to
1. collect and report data for statistical analysis and reimbursement purposes.
2. generate claims data for electronic submission to health care providers.
3. justify diagnostic or therapeutic procedures or services provided to patients.
4. submit standard claims to providers for inpatient and outpatient services.
25. Which is the standard claim submitted by physicians’ offices to third-party payers?
1. CMS-1450
2. CMS-1500
3. UB-04
4. UB-92