What does it mean to code a diagnosis to the highest level of specificity supported by the documentation?
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Medical Office Assistant · Medical Economics, Billing, and Coding
Code Assignment Principles and Compliance
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Quick check
5 questions here, of 90 in this lesson’s practice set. Answers stay hidden until you check.
In the United States, ICD-10-CM is the classification system used primarily to report which type of information?
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CPT codes are used to report which type of information on a claim?
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In coding, the saying 'if it is not documented, it did not happen' means that coders should:
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Which organization maintains and publishes the CPT code set?
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Study tools & related lessonsYou’ll learn to · Related
You’ll learn to
- Assign diagnosis and procedure codes to the highest level of specificity supported by the documentation.
- Recognize that every code must be supported by clinician documentation in the health record.
- Apply coding compliance principles, including avoiding upcoding, downcoding, and unbundling.
- Describe how annual code updates affect code selection and office workflow.
- Identify when to query the provider and follow the practice's compliance procedures.
Sources & references
- Centers for Medicare & Medicaid Services — ICD-10
- American Health Information Management Association — AHIMA - Health Information and Coding
- AAPC — Medical Coding and Billing
This lesson was adapted from the open educational references above; their licenses and attributions are preserved. See Copyright & Licensing.
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