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Coding Study Guide

The Medical Coding Study Guide covers essential coding guidelines for ICD-10-CM, CPT, and HCPCS Level II, emphasizing accurate code selection and adherence to official guidelines. It highlights the importance of medical terminology and anatomy in understanding documentation and coding processes. The guide outlines a systematic approach to coding from medical records, including steps for identifying diagnoses and assigning appropriate codes.

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Neida Caro-Boone
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152 views3 pages

Coding Study Guide

The Medical Coding Study Guide covers essential coding guidelines for ICD-10-CM, CPT, and HCPCS Level II, emphasizing accurate code selection and adherence to official guidelines. It highlights the importance of medical terminology and anatomy in understanding documentation and coding processes. The guide outlines a systematic approach to coding from medical records, including steps for identifying diagnoses and assigning appropriate codes.

Uploaded by

Neida Caro-Boone
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

🧠 Medical Coding Study Guide

📘 Understanding Coding Guidelines and Conventions

➤ ICD-10-CM (Diagnosis Coding)

● Governed by: Official Guidelines for Coding and Reporting

● Key Concepts:

○ Code sequencing rules

○ Selection of the principal diagnosis

○ Use of additional codes to fully describe the patient’s condition

○ Coding must reflect clinical documentation accurately

➤ CPT (Procedure Coding)

● Managed by: American Medical Association (AMA)

● Key Guidelines:

○ Proper code selection for procedures

○ Use of modifiers to provide additional details

○ Coding of multiple procedures

➤ HCPCS Level II (Supplies/Services Not in CPT)

● Managed by: Centers for Medicare & Medicaid Services (CMS)

● Purpose:

○ Codes for medical supplies, DME, drugs, and non-physician services

○ Used when services/supplies are not included in CPT

○ Ensures reimbursement accuracy


📚 Medical Terminology and Anatomy

➤ Why It Matters:

● Medical terminology helps decode complex terms in documentation

● Anatomy knowledge helps pinpoint body systems, organs, and procedures

➤ Focus Areas:

● Prefixes (e.g., "hyper-", "brady-")

● Suffixes (e.g., "-itis", "-ectomy")

● Root words (e.g., "cardi-", "neuro-")

● Structure and function of:

○ Cardiovascular system

○ Musculoskeletal system

○ Digestive system, etc.

📄 Coding from Medical Records

➤ Essential Steps:

1. Read the complete medical record

○ Understand the patient's condition and treatment

2. Identify the principal diagnosis

○ Main reason for the encounter → First listed

3. Identify secondary diagnoses

○ Additional conditions treated or affecting care → Listed next in order of


significance

4. Assign procedure codes

○ Use CPT guidelines and modifiers when needed


5. Assign HCPCS Level II codes

○ For supplies, equipment, or other services not captured in CPT

6. Review and verify

○ Ensure code selections are accurate, complete, and follow official guidelines

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