Describe the service rendered to patient during an encounter


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Some of the coding systems that will be encountered are the International Classification of Diseases, 10th Revision, with Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPT), Healthcare Procedure Coding System (HCPCS).

The ICD-10-CM is a clinical modification system that was created to code medical diagnoses in a health care treatment setting. The diagnostic codes for this coding system always have 3-7 alpha and numeric characters. The first character is always a letter, the second character is a number, and there is always a decimal point after the third character (Pepper, 2020).

CPT codes are used to describe the services rendered to the patient during an encounter (Pepper, 2020). CPT codes consist of modifiers that customize multiple procedures a provider performed such as, the reason service was necessary, the type of visit and how long the visit lasted (Pepper, 2020).

The Centers for Medicare and Medicaid Services CMS and some third-party payers require providers to submit claims with HCPCS codes. This coding system is implemented for non-physician services such as riding in an ambulance, medical equipment's such as wheelchairs, and medication drugs (Pepper, 2020).

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