JAYDILYNE D.

CABALTERA

BSOA 3C

OAC 115 MEDICAL OFFICE PROCEDURE

ACTIVITY

How Records Are Coded

There are three different types of medical coding procedure that the
medical office administration assistant will use in day-to-day tasks. They
include ICD-10, CPT, and HCPCS.

ICD-10 Coding – The use of ICD-10 helps standardize medical coding

internationally. The International Classification of Diseases (ICD) is used to
record diagnoses by physicians and other medical professionals. ICD
consists of alphanumeric codes that follow an international standard,
making sure that diagnoses are interpreted the same way by every health
care professional who treats patients.

CPT Coding – Current Procedural Terminology (CPT) coding is a U.S.

standard for coding medical procedures maintained by the American
Medical Association (AMA). CPT identifies the services provided and helps
determine how much physicians will be paid for their services by insurance
companies.
HCPCS – Healthcare Common Procedure Coding System (HCPCS) is a set
of health care procedure codes based on the AMA’s CPT system. HCPCS is
a medical billing process used by the Centers for Medicare and Medicaid
Services (CMS).

The HCPCS coding procedure was created to standardize the coding of

specific items and services provided by health care professionals and billed
to Medicare and Medicaid. The HIPPA Act of 1996 made the use of HCPCS
coding mandatory for processing insurance claims through Medicare and
Medicaid.

Medical Record Keeping Steps

With these steps, you can start to learn more about the process of medical
record keeping. Of course, like most skills, medical record keeping requires
time and practice to get it right. Remember to follow your facility’s rules and
ask for help whenever necessary.

Here are some of the general guidelines that healthcare professionals

should follow when performing medical record-keeping tasks:

1. Check to ensure that the organization only allows authorized

staff access to patient medical records.
2. Consider medical considerations to help you decide how long
to keep a patient’s records. For instance, if another physician sees
a patient for the first time, they may want to review immunization
records or significant health events.
3. Ensure medical records are available:
  Whenever requested by the patient or their
authorized representative

 To the physician or succeeding physician if the

physician discontinues their practice

 As required by law

4. Do not refuse to transfer medical records that are requested by

the patient or their authorized representative.
5. Charge a fair fee (if required) to transfer the record.
6. Store medical records that have not been transferred to the
patient’s current physician.
7. Inform the patient on how they can access their stored records,
the amount of time they will be available, etc.
8. Verify that discarded medical records are appropriately
destroyed to protect the patient’s confidentiality.