Coding, Billing, and Claims Review
From documentation to claim
Coding translates clinical documentation into standardized codes: ICD-10-CM for diagnoses, ICD-10-PCS and CPT for procedures, and HCPCS Level II for supplies and drugs. A candidate must understand the coding conventions: specificity, laterality, sequencing, and the difference between principal and secondary diagnoses. Know the role of modifiers (e.g., -25, -59, -26, -TC) and how they affect payment and bundling.
Concepts to master
Understand the National Correct Coding Initiative edits, including bundling and the appropriate use of modifiers to override them. Know the difference between global surgical packages and separately billable services. Familiarize yourself with claim forms (CMS-1500 for professional, UB-04 for institutional) and the data elements each requires. Understand the concept of medical necessity linkage: the diagnosis must support the procedure billed.
Traps in questions
Common distractors include using a modifier to unbundle services that are never separately payable, billing a diagnosis that does not support the procedure, or confusing professional and technical components. Watch for questions that assume a code is correct simply because it exists; the code must match the documentation and the payer's rules.
Rule of thumb
Code what is documented, not what you expect to be paid. Worked example: a physician performs and interprets an EKG in the office. The professional component (-26) may be billed; if the practice owns the equipment and performs the tracing, the technical component may also apply. Billing both without documentation of both components is improper.