Being the Best Coder Requires Having a Handle on the Guidelines

by  Find-A-Code™
Dec 12th, 2023

Medical billing and coding blogs talk an awful lot about code sets. They tend to discuss individual codes and how to apply them in real world scenarios. Codes and code sets are obviously important – they are what medical coding and billing are built on. But there is something else equally important to consider: coding guidelines. To be the best possible coder you can be, you need to have a handle on those guidelines.

Guidelines exist for all the major code sets. Rather than go through all of them here, we will focus on the ICD-10-CM and CPT code sets. Remember that code sets and guidelines are distinct and separate entities. Having a handle on both will help you to be the best coder you can be.

Why the Guidelines Exist

Let us begin by discussing why the guidelines exist in the first place. Medical coding guidelines are essentially a set of detailed instructions and conventions designed to ensure that medical coders consistently code according to standard. They are also designed to help clinicians be more accurate and consistent in their diagnoses and procedural recommendations – at least for billing purposes.

Also note that the guidelines are developed by a number of organizations. They include the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS). Guidelines act as a complement to the official ICD-10 manual by offering additional clarifications and specific rules for applying specific codes.

All of this is necessary because medical coding is both complex and constantly evolving. Coders routinely deal with tens of thousands of codes, most of which can be utilized in numerous ways depending on diagnoses and how, when, where, and why certain procedures are provided.

Four Aspects of Medical Coding

The ICD-10 guidelines deal with four aspects of medical coding. The first is code selection. Coders need to determine which codes most accurately represent the diagnoses they are attempting to capture for billers. When CPT codes are involved, the same things apply, just with procedures rather than diagnoses.

The remaining three aspects are:

• Sequencing – Multiple diagnoses and procedures need to be prioritized for billing purposes. Therefore, medical coders must know how to properly sequence things. They need to put diagnoses and procedures in a certain order to satisfy payers.
• Exclusions – It is not unusual for some conditions to be coded separately rather than being included in other codes normally associated with them. These are known as exclusions. Coders need to know when to code separately and how to go about doing it.
• Conventions – The guidelines include a series of coding conventions that apply to abnormal circumstances. For example, there are conventions for addressing the fact that a patient has seen multiple providers for the same condition.

Guidelines more or less make sense of a code set and manual when things otherwise do not appear clear cut. Yes, the guidelines are lengthy. They can also be complicated themselves. But anyone wishing to be the best medical coder possible needs to at least know their way around the guidelines.

Where the Guidelines Are Found

The only remaining thing to discuss is where medical coders can find the guidelines. Unfortunately, you are not going to find a single set of guidelines you can apply across the board. There are multiple sets published by a variety of organizations. The CDC's guidelines are likely the most authoritative. You can also get published guidelines from the AHA. Even some industry organizations representing certain specialties publish their own guidelines. The guidelines are out there, you just may have to search for them.