02 — Capability · BC-1840.20
Medical Coding
Turn each encounter's documentation into accurate, complete diagnosis and procedure codes, supported by the record, so claims, quality data and risk scores reflect the care given. Maintaining the code sets themselves is clinical terminology.
- Clinical Coding
- Health Information Coding
- HIM Coding
In scope
- Inpatient coding and grouping to diagnosis-related groups
- Outpatient, professional and procedure coding
- Clinical documentation improvement queries
- Coding quality audits and risk adjustment coding
Out of scope
- Code set and terminology content (see BC-1880.40)
- Writing the clinical documentation itself (see BC-1820.10)
- Population risk stratification for care management (see BC-1860.10)
- HCC recapture programs (see BC-1860.30) and risk adjustment data submission by a health plan (see BC-1870.70)
Realized by · 1
- Oracle Health · Health Information Management and Acute Case Managementstrong via BC-1840.20.10
Used in · 1
Build it · 1
Governed by · 1
Decomposes into · 5
- BC-1840.20.10Inpatient CodingCode each inpatient stay's diagnoses and procedures from the full record and assign the diagnosis-related group that drives payment.
- BC-1840.20.20Outpatient & Professional CodingCode outpatient, emergency and clinic visits, procedures and professional services, and apply modifiers and edits correctly.
- BC-1840.20.30Clinical Documentation ImprovementReview records during and after the stay and ask clinicians compliant questions where documentation is unclear or incomplete, so the codes reflect the patient's true condition.
- BC-1840.20.40Coding Quality AuditAudit samples of coded encounters for accuracy, educate coders and clinicians on what is found, and track accuracy by coder and service.
- BC-1840.20.50Risk Adjustment CodingCode every chronic condition documented in an encounter to the level the record supports, so risk-adjusted payments are accurate.