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The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for ...
Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.
Procedure codes are a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The structure of the codes will depend on the classification; for example some use a numerical system, others alphanumeric.
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases (ICD), the Healthcare Common procedural Coding System (HCPCS), and Current Procedural Terminology (CPT) for reporting to the health insurance provider of the recipient of the care.
ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. [30] Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines.
HCPCS Level II codes are alphanumeric medical procedure codes, primarily for non-physician services such as ambulance services and prosthetic devices. [1] They represent items, supplies and non-physician services not covered by CPT-4 codes (Level I). Level II codes are composed of a single letter in the range A to V, followed by 4 digits.