What are the steps of diagnostic coding?

What are the steps of diagnostic coding?

What are the 5 main steps for diagnostic coding?

• Step 1: Search the Alphabetical Index for a diagnostic term.
• Step 2: Check the Tabular List.
• Step 3: Read the code’s instructions.
• Step 4: If it is an injury or trauma, add a seventh character.
• Step 5: If glaucoma, you may need to add a seventh character.

What are the 5 main steps for diagnostic coding?

A Five-Step Process

• Step 1: Search the Alphabetical Index for a diagnostic term.
• Step 2: Check the Tabular List.
• Step 3: Read the code’s instructions.
• Step 4: If it is an injury or trauma, add a seventh character.
• Step 5: If glaucoma, you may need to add a seventh character.

What is the first thing a coder must do in the coding process?

diagnosis
The first thing the coder must do in the coding process is locate the diagnosis in the patient’s medical record.

What is the first step in ICD-10-CM diagnosis coding?

How to Use ICD-10-CM. The coding process begins with the analysis and abstraction of a medical report. Using their notes from the report, the coder may go straight to the tabular section or may refer to the alphabetic section to find the correct code, and then confirm it in the tabular.

What is the process of coding?

Coding is a process of identifying a passage in the text or other data items (photograph, image), searching and identifying concepts and finding relations between them. Therefore, coding is not just labeling; it is linking from the data to the idea and back to other data..

What are the 8 steps to accurate coding?

Terms in this set (8)

• Identify the main term(s) in the diaagnostic statement.
• Locate the main term(s) in the Alphabetic Index.
• Review any sub terms under the main term in the Index.
• Follow any cross-reference instructions, such as “see.”
• Verify the code(s) selected from the Index in the Tabular List.

What are the basic steps for procedural coding?

The correct process for assigning accurate procedure codes has six steps: (1) review complete medical documentation; (2) abstract the medical procedures from the visit documentation; (3) identify the main term for each procedure; (4) locate the main terms in the CPT Index; (5) Verify the code in the CPT main text; and …

What is initial coding?

Initial coding, also known as “open coding,” is the first step of the coding process, particularly in qualitative methods such as grounded theory. Codes in the initial coding step can range from being descriptive, to conceptual, to theoretical.

What are the steps in coding a diagnosis?

Basic Steps of Coding. 1. Review the health record. 2. Identify the diagnoses and procedures to be coded. 3. Identify the principal diagnosis and the principal procedure. 4. Identify main term (s) in the Alphabetic Index.

What is the purpose of ICD diagnostic coding?

Diagnosis coding accurately portrays the medical condition that a patient is experiencing. Like all medical codes, ICD diagnostic codes are intended to convey an exact aspect of medical information. ICD diagnostic coding accurately reflects a healthcare providers findings.

What should I do with my medical coding certification?

You have to make sure your coding education, including your medical coding certification, goes to good use. When you’re presented with a transcription of a complex procedure, or procedures, start by determining the diagnosis. Sometimes, there’s only one relevant diagnosis, so this is the only one that you have to worry about.

How are procedure codes reported in ICD-9 CM?

For procedure codes included in Volume III of ICD-9-CM and in the International Classification of Diseases-10th Edition- Procedure Coding System (ICD-10-PCS), the procedure performed must be supported by the available documentation in the patient’s medical record. Diagnostic codes are usually reported in conjunction with procedure codes.