Medical Coding Decoded

Medical Coding with the Right Information Right Online

Medical coding-the process of translating the information in a patient's charts into a set of coded, billable items-is essentially the first step in the billing process.

Today's standardized coding systems include Diagnosis Codes and Current Procedural Terminology (CPT) for specifying treatment (services rendered).

With the help of these standardized coding systems, found in STAT!Ref Online, medical coding staff are able to describe and distinguish the enormous number and various kinds of medical and surgical procedures, complaints and diagnoses accurately in order to be compensated.

Current Procedural Terminology (CPT codes)
The American Medical Association's Physicians' Current Procedural Terminology (CPT), is maintained with consultation from the AMA CPT Editorial Panel, Advisory Committee, and the AMA CPT Health Care Professionals Advisory Committee. Procedure codes in the CPT are reviewed and revised annually. CPT codes are five-character, all numeric configurations (e.g., 99215). CPT codes are easily found in STAT!Ref by searching or browsing.

Health Care Financing Administration's Common Procedure Coding System (HCPCS) The HCPCS Level II National codes are also available through STAT!Ref Online. The maintenance of these codes is the responsibility of the Health Care Financing Administration and they are reviewed and revised annually. HCPCS codes are five characters with one alpha and four numeric configuration (e.g., A0042).

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization's Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. STAT!Ref offers ICD-9-CM Vols. 1 and 2, geard toward the private practitoner, and ICD-9-CM Vols. 1, 2, and 3, geared toward hospitals and payers since Volume 3 contains procedure codes.

Diagnostic and Statistical Manual IV TR™ (DSM IV TR)
An important alternative to the mental disorders section of the ICD is the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the primary diagnostic system for psychiatric and psychological disorders within the United States and some other countries, and is used as an adjunct diagnostic system in other countries. Since the 1990s, the APA and WHO have worked to bring the DSM and the relevant sections of ICD into concordance, but some differences remain.