Medical coding turns what the doctor wrote in the file into standard codes that insurers and claims systems understand. Abu Dhabi uses code sets defined by the Department of Health, the best known being diagnosis codes and procedure codes.
Diagnosis codes (ICD-10-CM)
They describe the patient's condition: the disease, injury or symptom. The more precise the code, such as side, type and stage, the stronger the claim.
Procedure codes (CPT)
They describe what the doctor provided: the consultation, test or procedure. Every procedure code must be linked to a diagnosis that justifies it.
Three rules a doctor needs
- The coder can only code what the doctor wrote; incomplete documentation means an incomplete code.
- The code must match what actually happened in the visit, no more and no less.
- The diagnosis and the procedure must make medical sense together.
This article is a general introduction. The binding reference is the current coding manuals and instructions of the Department of Health – Abu Dhabi.