Government Guidelines for Medical Coding

Medical coding is the designation of numerical or alphanumerical codes to a patient̵7;s conditions and treatments. The government sets forth specific coding guidelines for uniformity of reimbursement, tracking and research.

Highest Coding Level

• Coders must code to the highest level of specificity. If a fifth digit explanation is available for a code, a fourth digit level cannot be assigned.

Signs and Symptoms

• Signs or symptoms can only be reported if cause is undetermined. A patient with chest pain symptoms diagnosed later as heart attack is coded as heart attack.

Multiple Code Assignment

• Generally, two codes are not used when one will suffice. Exceptions apply for conditions like infections, where an additional code identifies bacterial cause.

Acute and Chronic Conditions

• If a condition is documented as acute and chronic, then assign both codes for the condition.

Combination Codes

• On occasion, one combination code covers multiple conditions. In order to assign a combination code, the patient must meet all requirements in the code description.

Late Effects

• Late effects are conditions that arise from a previous illness or injury. They are generally reported by two codes, with the ̶0;nature of the late effect̶1; first, followed by the late effect code. For example, abnormal gait due to an old hip fracture would code to gait first followed by hip fracture.