HIM 215 5-3 Journal
Southern New Hampshire University
The differences between ICD-10-CM, CPT codes, and HCPCS II codes can be determined by the
nature of the information within the documentation. If the terminology is referring to a diagnosis,
then the appropriate code selection would be ICD-10-CM. If the reference is to a service or
procedure performed within the patient’s chart, then the correct code selection would be CPT.
HCPCS II codes would be determined by any products, supplies or services, such as ambulance
services or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).
From an initial review of the chart, the main terms identified include alcoholism,
cirrhosis, x-ray of left wrist and chest, complete blood count differential (CBC), urinalysis, blood
chemistry, and intramuscular injection of thiamine. A concern is understanding when a HCPCS II
code is applicable for a medication, i.e. if they are only included for injectable medications?
There is also uncertainty with coding medications in general – my understanding is that there
must be a separate coding process for medications since there are no results that appear in
SelectCoder when searching things like Tylenol or Valium. Otherwise, I feel confident in my
ability to select the appropriate ICD-10-CM and CPT codes.
