Medical billing and coding is one of today’s high paying careers. The definition for Medical – code is descriptions that physicians and the heath care providers, and facilities use to describe healthcare procedures and diagnosis into numeric or alphanumeric designations. Coding is the descriptions of diseases, injuries and procedures into numeric or alphanumeric codes, there are three basic steps in locating codes.
First we locate the term in the Alphabetic Index, then verify the code number in the Tabular list, finally assign the code when it has been verified by the physician and the coder. We must locate the term in the Alphabetic Index. In coding the correct codes and to be paid by the insurance company the coder must code accurately and precisely so the first step in coding it to locate the main tern in the Alphabetic Index of the coding book. If a main term cannot be located, then try searching for sub terms, notes, or cross- reference. A coder can refer to any notes in the Alphabetic Index. When the code is located it must be verify in the Tabular list coder then will review the title of the chapter, section, and category to make sure that the correct code has been identified. The coder will read and follow instructional notes and refer to any other codes as instructed if the coder is unsure it is then discuss with the physician.
Once the main term is verified the coder then will assign the code to be used for several different reasons: reporting medical necessity for services performed, identifying conditions to alert the healthcare provider, and to supply date for clinical care, research and education purposes. “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without documentation accurate coding cannot be achieved.”