Medical coding is the numerical representation of diseases and their corresponding treatment. The medical coder reads the medical transcript carefully and finds out the disease and the treatment done on a particular patient. After reading this, he assigns the relevant codes for both the disease and the procedure, and enters these in the claim form. In addition to the CPT procedure/service code, physicians must describe the reasons for their services. It has a major contribution in getting the claim paid. That is why coding is considered as one of the most significant departments in Medical Billing.
The coder should see to it that the codes, which he/she assigns should be accurate and both the DX and the CPT codes must be compatible to each other. If they are not matching with each other, the entire claim becomes unprocessed, and gets denied by the insurance company.
While coding for the disease or the ailment, the coder should look into the transcript carefully and find out exactly the disease or the diagnosis of the patient, and should assign the exact DX code taking from the ICD 9 CM manual (Sample) . While coding for the disease, the coder should always assign the Dx code, which should be of highest level of specificity.
How to choose the correct DX code
For example, if the coder has to code for the disease Acute Bronchospasm, it should be with the code “519.11”. In this the code 519 is for the disease, and 11 after the decimal point is the level of specificity of the disease. Coding DX codes with the highest level of specificity is one of the imperatives in getting the claim paid, and medical documents should be attached wherever necessary.
