What Are Clinical Indicators in Medical Coding? In medical coding, accuracy depends on more than just knowing ICD-10-CM, CPT®, or HCPCS Level II codes. Coders must also evaluate clinical indicators—the documentation in a patient’s health record that supports whether a...
ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System) is the system used in the United States to code inpatient hospital procedures. Unlike ICD-10-CM, which is used for diagnoses, ICD-10-PCS is specific to procedures performed...
Why Knowing Physiology, Anatomy, and Medical Terminology Can Help You in a CPC Course and for AAPC CPC Exam Prep Preparing for the AAPC CPC exam is no small task. While coding guidelines, CPT®, ICD-10-CM, and HCPCS rules form the backbone of the exam, one of the most...
What Is the Table of Drugs & Chemicals? Medical coding the Table of Drugs & Chemicals is an alphabetical list of substances—including prescription medications, over-the-counter drugs, alcohols, gases, industrial chemicals, and other agents—that can cause toxic...
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What is Risk of Mortality (ROM)? Risk of Mortality (ROM) in medical coding is a clinical severity measure used in healthcare coding and reporting that estimates the likelihood a patient will die during a hospital stay. ROM is typically assigned using coding systems...
What is Severity of Illness (SOI)? Severity of Illness (SOI) in medical coding is a classification system used in healthcare reporting that measures the extent of a patient’s illness. It reflects how sick the patient is and how much hospital resources may be required...
Understanding MCC and How It's Used In medical coding, MCC stands for Major Complication or Comorbidity. It is a classification used in the ICD-10-CM and MS-DRG (Medicare Severity Diagnosis-Related Group) systems. MCCs represent conditions that are severe and...
Read the Case Carefully Skim the entire scenario once to understand the big picture (inpatient, outpatient, ED, surgical, etc.). Underline or highlight key clinical details: Primary diagnosis Secondary diagnoses/comorbidities Procedures performed Patient status (new...
Pro fee coding, short for professional fee coding, refers to the process of assigning medical codes to professional services provided by physicians and other qualified healthcare professionals. Pro fee coding focuses on capturing and billing for the provider’s...