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What to expect when taking your CPC exam for the first time:

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Learning what is diagnostic coding:

When a person goes to see a physician, the physician documents a diagnosis into the patient’s medical record.  When the physician documents the diagnosis, it describes the illness or injuries using medical terminology. When the medical coder gets the medical record they will take the diagnoses and assign the appropriate codes.

If you work for a medical office, you will become familiar with the most common diagnoses of patients seen there. Let’s say you work for a cardiologist’s office, you will be using terms such as cardiac infarction, peripheral artery disease, valvular heart disease, hypertension, etc. You will be using these terms a lot and become familiar with the codes that accompany these diagnoses.

Coding affects the medical billing process. Diagnosis codes give insurance carriers clearly defined diagnoses to help process claims efficiently. An error in coding process gives the insurance carrier the wrong reason a patient received medical services. This causes confusion and can cause a delay in payment or denial of the claim. This is why you need good training when it comes to learning medical coding.

The diagnosis codes are found in the International Classification of Diseases, Ninth Revision, Clinical Modification, referred to as the ICD-9-CM. The ICD-9-CM is a single book or a set of multiple volumes that lists codes according to a system assigned by the World Health Organization of the United Nations. The ICD-9-CM has been revised a number of times and right now they are replacing it with the ICD-10 (effective October 1, 2012).  The ICD-10 contains more than 141,000 codes and accommodates a host of new diagnoses and procedures as the ICD-9-CM contains more than 17,000.

The five steps for analyzing diagnoses and locating the correct ICD-9-CM code are:
(a) Locate the diagnosis in the patient’s medical record.
(b) Find the diagnosis in the ICD-9-CM’s Alphabetic Index.
(c) Locate the code from the Alphabetic Index in the ICD-9-CM’s Tabular List.
(d) Read all information and subclassifications to get the code that corresponds to the patient’s specific disease or condition. Note fourth- or fifth-code requirements and exclusions.
(e) Record the diagnosis code on the health care claim, and proofread the numbers.

Medical coding and billing codes

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