Medical Billing and Coding Specialist how-to
How to Assign an ICD-10-CM Diagnosis Code
Correct diagnosis coding supports medical necessity and accurate payment.
Correct diagnosis coding supports medical necessity and accurate payment. In short: read; look; follow, then complete the remaining steps below.
Step by step
Read the entire encounter note and identify the condition(s) the provider documented as the reason for the visit.
Look up the main term in the ICD-10-CM Alphabetic Index.
Follow any subterms, notes and cross-references to a tentative code.
Verify the code in the Tabular List. Never code from the index alone.
Check instructional notes such as Excludes1, Excludes2, “code first” and “use additional code.”
Assign the code to the highest level of specificity (all required characters, including any seventh character).
Sequence the first-listed diagnosis correctly and query the provider if documentation is unclear.
Safety reminders for medical billing and coding specialists
- Protect patient information under HIPAA: access only what you need for your job
- Never upcode or bill for services not documented; this can constitute fraud
- Lock your screen and secure your home workspace if remote
- Report suspected compliance problems through proper channels
Key terms
ICD-10-CM · CPT · HCPCS Level II · Modifier · CMS-1500 · UB-04: see the full medical billing and coding specialist glossary.