Coding and Charge Capture
From documentation to a billable claim
Coding translates clinical documentation into standardized codes: ICD-10-CM for diagnoses, CPT/HCPCS for procedures and supplies, and revenue codes for facility billing. Charge capture is the process that ensures every service rendered is billed and every billed service was rendered. Candidates must understand the linkage between documentation, code selection, and charge entry, and why the medical record must support the code.
Concepts to master
- Diagnosis coding conventions: sequencing, specificity, laterality, and the distinction between principal and secondary diagnoses.
- E/M level selection based on documented medical decision making or time, per current guidelines.
- Modifiers and their role in preventing bundling edits (e.g., NCCI).
- Charge master maintenance and CPT-to-revenue code mapping.
- Charge reconciliation and late-charge reports.
- Medical necessity linkage between diagnosis and procedure.
Traps in questions
A frequent trap is a coder selecting a code based on a physician's memory rather than the record. Another is assuming a modifier "unbundles" services when the documentation does not support a distinct service. Questions may also test whether a charge should be captured when a service is performed but not documented; the answer is that undocumented services are not billable. Watch for questions conflating coding accuracy with charge capture completeness; they are separate controls.
Rule of thumb
If it is not documented, it is not done; if it is documented but not charged, revenue leaks; if it is charged but not documented, it is a compliance risk.
Worked example
A surgeon performs a lesion excision and a separately identifiable wound repair. The repair is bundled into the excision under NCCI unless a distinct, documented service justifies a modifier. If the operative note does not support distinctness, billing both without justification creates an overpayment exposure.