🧾 Top 10 Common Medical Coding Terms Explained
1. ICD-10 (International Classification of Diseases – 10th Revision)
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Use: To represent diagnoses and medical conditions.
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Example: E11.9 – Type 2 diabetes mellitus without complications.
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Why It Matters: Essential for documenting why a patient received care.#MedicalCoding
2. CPT (Current Procedural Terminology)
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Use: To describe procedures and medical services performed by healthcare providers.
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Example: 99213 – Office visit for an established patient.
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Why It Matters: It explains what service was provided.
3. HCPCS (Healthcare Common Procedure Coding System)
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Use: Codes for non-physician services, supplies, and equipment (like ambulances, crutches, etc.).
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Example: E0114 – Crutches, underarm.
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Why It Matters: Used mostly for Medicare/Medicaid and billing DME (Durable Medical Equipment).
4. E/M (Evaluation and Management)
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Use: Codes for office visits, consultations, and hospital visits.
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Example: 99203 – New patient office visit (moderate complexity).
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Why It Matters: A key part of provider reimbursement; shows the complexity and time of the visit.
5. Modifier
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Use: Two-digit codes added to CPT/HCPCS to provide additional info about a service.
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Example: Modifier -25 – Significant, separately identifiable E/M service on the same day.
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Why It Matters: Clarifies special circumstances without changing the core code.
6. DRG (Diagnosis-Related Group)
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Use: For inpatient hospital billing. Groups similar diagnoses and procedures into fixed payments.
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Example: DRG 291 – Heart failure and shock with major complications.
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Why It Matters: Used for Medicare payments to hospitals.
7. Upcoding
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Definition: Using a higher-level code than appropriate to get increased payment.
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Why It Matters: It’s considered fraud and can lead to penalties.
8. Downcoding
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Definition: Using a lower-level code than supported by documentation.
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Why It Matters: Can lead to loss of revenue and compliance issues.
9. Superbill
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Use: A detailed document created by providers listing all services rendered.
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Why It Matters: Helps coders and billers submit accurate claims.
10. Medical Necessity
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Definition: Justification that a procedure/service was clinically required.
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Why It Matters: Insurers won’t pay for services deemed not medically necessary.
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