Coding and Charge Capture
Translating care into billable data
Coding and charge capture convert clinical documentation into codes that support reimbursement and compliance. Know the code sets: ICD-10-CM (diagnoses), ICD-10-PCS (inpatient procedures), CPT (outpatient procedures/services), HCPCS Level II (supplies, drugs, DME), and revenue codes for facility billing. Understand Evaluation and Management (E/M) leveling, modifiers (e.g., -25 for significant, separately identifiable E/M; -59/X modifiers for distinct services), and medical necessity linking diagnosis to service.
Charge capture must be complete, accurate, and timely. Concepts: charge master maintenance, charge lag, late charges, and the link between documentation and code selection. Coding compliance requires that codes reflect documented services - upcoding and unbundling are compliance risks.
Traps in questions
- Assuming the highest-paying code is correct; code selection follows documentation, not revenue targets.
- Confusing ICD-10-CM (diagnosis) with CPT (procedure).
- Misusing modifier -59 to bypass edits when services are truly bundled - this is unbundling.
- Ignoring medical necessity: a correctly coded service can still be denied if the diagnosis doesn't support it.
Rule of thumb
"If it isn't documented, it isn't coded." Match every charge to documentation and to a supporting diagnosis.
Worked example
A visit includes a problem-focused E/M plus a separately identifiable procedure. If documentation supports both and the E/M is significant and separate, append modifier -25 to the E/M; if the E/M is part of the procedure's usual work, do not.