One of the ways to achieve data consistency and effective communication is
through standardization. Classification standards and terminologies help ensure accurate,
secure, and successful interoperability and reliable communication of medical
information. Basically, it allows everyone to speak the same “language” and improve data
quality. Accurately coding medical records for claims submissions is important to avoid
claim rejections and to obtain the maximum reimbursement amount. Using standardized
coding such as ICD-10, CPT, and HCPCS eliminates ambiguity and improves efficiency
by ensuring codes are accurate and consistent. Standardization also makes it easier to
track trends or patterns.
Inpatient coding utilizes standardized coding with ICD-10-CM and ICD-10-PCS
codes. These codes are for services and treatments that occur over an extended period of
time while a patient is admitted to a medical facility (i.e.: hospital, nursing home, rehab
facility). Outpatient coding is typically for one visit of direct care and utilizes
standardized codes ICD-10-CM, CPT, and HCPCS Level II for services and supplies.
Reference
Giannangelo, K., (2019).Healthcare Code Sets, Clinical Terminologies, and
Classification Systems, Fourth Edition. American Health Information Management
Association (AHIMA).
