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Introduction to diagnostic coding

Diagnostic coding is done to promote a practical, clear, and concise flow of information

between all three parties: the health care provider, the patient (who receives the service), and the

third party. In most cases, the third party may be the insurance company involved. In addition,

the government is part of the parties who use coding data to run their research projects and

determine funding in areas of national concern, which helps in the continued development of

health care services.

In diagnostic coding, several key terms are essential to understand, and they include: a)

adverse effects means the unexpected bad reaction to a drug or other treatment methods. b)

Diagnosis means a doctor's definition of a patient's form, disease, or injury. c) Sign is an

indication of an abnormal state that can be measured. d) Symptom is a particular sense or

withdrawal from the normal, related to the patient. e) Medical necessity is a diagnosis to justify

the procedure, service, or treatment provided to the patient by the healthcare provider. f) Risk

factors are the underlying causes of any injury or disease. g) ICD-10 CM stands for International

Classification of Disease-Tenth revision Clinical Modification. h) Coding for coverage a the

process of determining diagnostic concerning what the insurance will pay. i) Up-coding is the

procedure using coding that claims a more service or a more severe condition. j) Double billing

is transferring a claim twice to the same insurance company on the identical procedure or service

delivered to the same patient on the same date. k) Supporting documentation is the paperwork on
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the health claim that represents services performed and why they are provided. l) Unbounding is

coding the separate portions of a specific diagnosis or procedure instead of one grouping that

includes all components. m) Pharmaceuticals are any drugs used for medical purposes. n)

Pathology is the study of the causes and effects of disease or injury. o) Pathophysiology is the

study of abnormal changes in the body’s functions that causes functional changes that lead to

health consequences. p) Organ system refers to a group of organs that work collectively to do a

specific function. q) Etiology is a branch of science that studies the causes of a disease or an

abnormal condition. r) Body areas are the total surface area of the human body. s) Anatomic

position is the position where the body is erect with arms on the side and palms forward. t)

Anatomic site the structure of a human body. u) Anatomic direction is the directions that relate

the locations of structures with other structures in the body. v) Anatomical cavity is any space or

compartment or potential space in the animal body that holds and protects internal organs.

In coding, the most crucial factor to consider is accuracy despite the common belief of timely

coding. There are seven essential steps in coding. They include; first read through the superbill

and the physician's notes to get the entire encounter from the beginning to the end of the

interaction. Secondly, reread the physician’s notes and highlight keywords by identifying and

distinguishing related to diagnoses and procedures relevant to the encounter; this procedure is

also called abstracting physician's notes. Thirdly list and query or confer with the relevant health

care provider who treated the patient on any unclear information. Code only records what was

documented; one should not guess or assume anything. Fourthly, code the diagnosis respectively

to and/or appropriate symptoms describing why the health care provider treated the patient

throughout the meeting, as documented in the notes. This is done based on the best, precise code

accessible based on the documents. The fifth step is to code each procedure as specified within
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the records, recounting the doctor’s service to the patient. The sixth step is to tie every process

code to a minimum of one diagnostic code to validate medical requirement. Finally, verify your

codes, revise the code description of the codes you have assigned then match them with the

records in the books. By following these prescribed steps, it enables quick payment of claims.

In the case study of Haverland Julianna, the correct diagnosis for her condition was made

according to all prescribed steps and ethical conduct. Therefore, it would be fraudulent, illegal,

and unethical to change her code regardless of her being a friend.