Chapter 3: The Coding Process

Official guidelines

A listing of rules and regulations instructing how to use a specific code set accurately.

Notations

Alerts and warnings that support more accurate use of codes in a specific code set.

Linking

Confirming medical necessity by pairing at least one diagnosis code to at least one procedure code.

Alphanumeric

Containing both letters and numbers.

Symbols

Marks that provide additional direction to use codes correctly and accurately.

Conventions

Notations and symbols. Located in the Tabular List (ICD-10-CM) and Main Section (CPT).

Alphabetic Index

The section of a code book showing all codes, from A-Z, by the short code descriptions.

Main section

The section of the CPT code book listing all of the codes in numeric order.

Alphanumeric section

The section of the HCPCS Level II code book listing all of the codes in alphanumeric order.

Tabular List

The section of the ICD-10-CM code book listing all of the codes in alphanumeric order.

Tables

The section of the ICD-10-PCS code book listing all of the codes in alphanumeric order, based on the first three characters of the code.

Coding process

The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between health care professional and patient. Abstract the documentation, query if necessary, code the diagnosis or diagnoses, code the procedure(s), confirm medical necessity, and double-check your codes.