CODING INSTRUCTION

by Retha
(SC)

I have questions on trying to learn how to code and was wondering if I am going in the right direction with this. OK when you start out coding you start with the CPT coding first and then write that code down - then you go to ICD-9 codes and get the code from that one write it down. What about trying to learn how to code step by step.


Retha,

I understand how overwhelming it is trying to learn medical coding.

When it comes to coding the doctor must give you all the information about the patient visit. The CPT Code is basically the level of service or treatment the patient has received and you code it from there from the doctors notes - usually given in medical terminology.

The Diagnosis are the ICD-9 codes that are used after the Physician tells you what the patient is diagnosed with. Your CPT Coding Books and ICD-9 Books will help in coding this information. These codes are assigned based on the notation or transcription given by the doctor.

And the insurance payers will reject claims where the CPT treatment codes do not match the ICD diagnosis codes. For example a claim would get rejected for a treatment for a sinus infection when the diagnosis code is for hypertension.

So there is some "common sense" judgments that have to be made when coding from the doctors dictated or transcribed notes. It's also very helpful to know medical nomenclature and terminology in order to locate and assign codes from the code books.

I hope this helps some and answers your question(s).

Thanks,

Gina

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