Sunday, March 4, 2012

Medical and Surgical Coding Introduction

Ok, here is where it gets more challenging (not really, coding is easy once you learn how)... We are entering the wonderful world of coding.


After a patient is seen by the doctor a coder must translate the office visit in to codes. The codes used are called ICD9, CPT and HCPCS. The codes are a different language used to tell a story about the patient’s doctor's office visit. The codes are all maintained by different agencies  and updated periodically. Here is a list of which agency is responsible for which code set.


  • The National Center for Health Statistics (division of the Centers for Disease Control) maintains ICD-9-CM (diagnosis codes), http://www.cdc.gov/nchs/
  • The Centers for Medicare and Medicaid Services maintains HCPCS codes (supply and service codes), www.cms.hhs.gov
  • American Medical Association owns and maintains CPT-4® codes (medical service codes), http://www.ama-assn.org/

(It should be noted that the United States is planning to begin using ICD-10 (10th revision) in 2013. Since we are still using ICD-9 as of the time of this post, I will only discuss ICD-9 at this time. I will talk more on ICD-10 in later posts.)

Before beginning a coding overview, I want to clarify one common misconception about coders (BTW, I am a Certified Coder). This misconception, I find, scares a LOT of people away from coding. So, here is what you need to understand. Coders do not memorize every code. We do not know everything about every disease or procedure in existence. Given, we know a lot of codes. After using them enough, you would too. So, you ask, what makes a coder so special if we do not memorize 25,000+ codes? 

Here is the truth about coders (that some don't want you to know because, in general, we like that you think we are brilliant)... All we coders really know are coding rules, how to use the coding books, where to find the best resources, and anatomy. THAT'S IT! 

In the next few posts, I will share most of this with you in a summary form. It won't be enough to run out and take the CPC or CCS exams, but hopefully, this will remove some of the fears associated with coding. 

So, now we will begin with ICD-9...  

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