Medical coding is the process of reviewing health record documentation to translate clinical terminology into alphanumeric codes.  The health record documentation tells the story of the patient, what conditions affect the patient and what procedures or services were performed.  The medical coder translates the documentation into ICD-10-CM, ICD-10-PCS, CPT and/or HCPCS codes.  Coded data is used primarily for healthcare reimbursement, but also many other purposes such as research, public health reporting, patient safety and quality improvement initiatives.

ICD-10-CM: This is the International Classification of Diseases, 10th Revision, Clinical Modification.  ICD-10-CM is a classification system designed to capture patient morbidity in the United States, and was adopted from the version of ICD-10 published by the World Health Organization (WHO).  ICD-10-CM codes represent diagnoses and conditions affecting the patient, and are used in both inpatient and outpatient settings. The  National Center for Health Statistics is responsible for the implementation of ICD-10-CM.  Additional resource: https://www.cdc.gov/nchs/icd/icd-10-cm.htm

ICD-10-PCS: This is the International Classification of Diseases, 10th Revision, Procedure Coding System.  ICD-10-PCS is a classification system designed to capture procedures performed in an acute inpatient hospital setting. The Centers for Medicare and Medicaid Services (CMS) is responsible for the maintenance of ICD-10-PCS.  Additional resource: https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs

CPT: This is the Current Procedural Terminology, Fourth Edition.  CPT is copyrighted and maintained by the American Medical Association (AMA), and represents procedures and services performed by physicians and other qualified healthcare professionals.  CPT codes are used in the outpatient setting, or to capture professional services in the inpatient setting.  Additional resource: https://www.ama-assn.org/practice-management/cpt

HCPCS: This is the Healthcare Common Procedure Coding System. Level I of HCPCS is comprised of CPT codes.  Level II of HCPCS represent codes to capture products, services and supplies not covered by CPT codes.  Examples include ambulance services, durable medical equipment, prosthetics, etc.  HCPCS codes are maintained by Centers for Medicare and Medicaid Services (CMS).  Additional resource: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo