Medical Coding Examples: What Does Medical Records Coding Look Like?

Key Insights:

• Medical coding is in high demand and serves an important purpose for the healthcare field. Check out a few medical coding examples to help you determine if this is a good career path for you.
• Medical coders use three universal coding systems: ICD, CPT, and HCPCS. Each contains different code sets, and medical coders must understand how to select and apply these codes correctly.
• If you want to pursue a career in medical coding, Ultimate Medical Academy (UMA) offers two program options, each of which includes certification prep.

As the population increases, grows older, and faces chronic diseases, medical coding is in high demand.¹ A medical billing and coding program can help you prepare to pursue this healthcare role. But is it a good career path for you?

Seeing a few medical coding examples may help you decide. First, let’s clarify why this position — and coding accuracy — is so important in the healthcare field.

Learn more: What Is Medical Coding?

Why is Medical Records Coding Important?

Patient information has been documented for roughly 3,000 years and, in the 1960s, people began using electronic health records (EHRs) to help improve the ability to store, retrieve, and manage health data.² EHRs contain patients’ medical records and health histories, including their diagnoses, procedures performed, and medical services provided. This is where medical coding comes into play.

Medical coders transform patient information into alphanumeric codes using standard coding systems. This involves pulling the information from the documentation supplied and assigning it the proper codes, explains the American Academy of Professional Coders (AAPC).³ Accuracy is important for medical coders because wrong codes can lead to dire consequences.

3 Medical Coding Examples

When determining which codes to assign, medical coders use three standardized coding systems:

• International Classification of Diseases (ICD)
• Current Procedural Coding (CPT)
• Healthcare Common Procedure Coding System (HCPCS)

Here’s what medical coding might look like using an example of each.

1. #1: ICD code example

   ICD codes are used for public health purposes and help us better understand injuries, diseases, and causes of death.⁵ This data can be used to identify health risks some segments of the population might face more frequently, for instance, or to learn the factors that may contribute to an early death.

   In this ICD code example, imagine that a patient with type 2 diabetes dies as a result of a diabetic coma. The medical coder would assign a mortality code of 5A11/5A23 — 5A11 is the code for type 2 diabetes mellitus (the underlying condition or cause of death), and 5A23 is the code for diabetic coma (the terminal cause of death).⁶

   Since ICD codes are used to inform public health, researchers may search for this code in patient record databases to learn how many people with type 2 diabetes die from a diabetic coma. This could help them better understand the risk of coma-related death for people with this blood sugar condition, reinforcing why it’s so important for medical coders to enter the correct ICD codes.

2. #2: CPT code example

   CPT codes are used to report medical procedures and services performed. Healthcare organizations typically utilize this information for administrative purposes, such as to develop medical care guidelines or process insurance claims.⁷

   Applying accurate CPT codes can help providers get reimbursed on time and enhance patient care while reducing the risk of errors (and audits) and ensuring regulatory compliance.⁸ Let’s look at an example of medical coding with CPT codes.

   Imagine that a doctor saw a new patient for evaluation. The appointment took around 25 minutes and involved straightforward medical decision-making. The CPT code for this is 99202.⁹ If the encounter lasted longer and/or required a higher level of decision making, the medical coder would select a different code to signify this.

3. #3: HCPCS code example

   HCPCS codes are used for medical equipment and supplies, or to report outpatient services not included in the CPT coding system.¹⁰ An example of the latter is ambulance or medical transportation services.

   For this medical coding example, let’s imagine that a wheelchair van is used for the non-emergency transportation of a patient to a doctor’s visit. The HCPCS code for this service is A0130.¹¹

   This code can change based on several factors. If the transport was by ambulance or emergency transport, or if advanced life support was required, a different code would apply. As a medical coder, it’s your responsibility to know which code to select based on the exact services rendered.

Build Your Medical Coding Skills at UMA

If coding for medical billing is a career interest for you, Ultimate Medical Academy (UMA) can help prepare you for this role. UMA offers two online medical billing and coding programs:

1. A Medical Billing and Coding Diploma program

   , which can be completed in 11 months or more,¹² and includes preparation to sit for the CBCS certification exam, if eligible.¹³

2. A Medical Billing and Coding Associate of Science/Associate of Applied Science Degree program

   , which includes general education and elective courses for a rounded education, and can be completed in 18 months or more,¹² and includes preparation to sit for the CBCS certification exam.¹³

Contact our Online Admissions team to learn more about these medical billing and coding programs, or for help to decide which one may be right for you. At UMA, we feel strongly about supporting our learners, which includes helping you find a program to prepare you for a career path that aligns with your interests and professional goals.

FAQs

• What is medical coding?

  It involves transforming patient information such as diagnoses, procedures, and treatments into alphanumeric codes that can be used for both billing and research purposes. Check out this short video to learn more: What is Medical Billing and Coding?

• What are the types of medical coding?

  Three standardized coding systems used by medical coders are the International Classification of Diseases (ICD), Current Procedural Coding (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes. Each is used for different aspects of healthcare, such as medical services versus equipment, making it important for medical coders to be familiar with all three.

• What are the skills needed for coding?

  Because coding accuracy is so important, medical coders benefit from a keen attention to detail. Computer skills, an understanding of medical terminology, and records management are also important skills for medical coding professionals — and all these topics are covered in UMA’s Medical Billing and Coding programs.