Medical Coding, Essay Example

Medical coding and billing is a distinctive process for assigning the correct evaluation code with the appropriate medical diagnosis code as determined through the CPT and ICD-9 coding methods. Medical physician office visits, hospital visits, procedures, injections, and surgeries are all included in the reporting through these codes. Specific steps are required for accurate recording of an evaluation and management (E/M) code.

The components for selecting the appropriate E/M code include several steps. The first step is the history of the patient and the subjective problems they present with. Step 2 deals with the examination of the patient, which is the subjective component. The next step is the assessment and plan which is comprised of the medical decision making by the practitioner. These three steps are the essential factors to consider when selecting E/M service codes (HRSA, 2009).

The final steps are the key contributing components. Step 4 reflects the extent of counseling done by the practitioner. Step 5 is the coordination of care with other medical or psychological providers. Step 6 is the nature of the presenting problem such as outpatient or inpatient. The final step is the time of the visit and is the controlling factor to qualify for a particular level of E/M service (AACAP, 2009).

There are code categories also which distinguish types of code.  Category I signify procedure codes and contain all of the E/M codes and are five digits in length. Category II are optional codes and are quality measures and are also five digits in length but the last digit is always noted as an ‘F’ to discern the difference. Category III are temporary codes used for new and cutting-edge technology not yet formalized. These codes have the fifth digit signifying the difference with a “T” ending the code.

References

AACAP. American Academy of Child and Adolescent Psychiatry. CPT Code Training Module. Web. Retrieved March 3, 2010 form http://www.aacap.org/galleries/PracticeInformation/CPT%20Module%20October%202009.pdf

HRSA. Health Resources and Services Administration. 2009. Web. Retrieved March 3, 2010 from http://74.125.47.132/search?q=cache:m24INRbRTfQJ:ftp://ftp.hrsa.gov/TPR/EM-coding.pdf+eight+steps+to+CPT+coding&cd=1&hl=en&ct=clnk&gl=us