_______ codes are supported by the history obtained from the patient and exam findings?

_______ codes are supported by the history obtained from the patient and exam findings?

• A. Diagnosis
• B. Procedure
• C. Medication
• D. Billing

Answer: (A)

In medical coding, the codes that describe what the patient actually has or is diagnosed with come from the clinician’s assessment based on the history and the physical examination. The history the patient provides and what is found on exam create the clinical basis for identifying a condition, and the diagnosis code (ICD-10-CM) is then assigned to reflect that diagnosed problem. Procedure codes, by contrast, describe what was done during the visit (tests, procedures, services), not the patient’s underlying condition. Medication codes relate to drugs prescribed or dispensed, and billing involves charging for services using the appropriate diagnosis and procedure codes. So the diagnosis codes are the ones directly supported by the history and exam findings.

In medical coding, the codes that describe what the patient actually has or is diagnosed with come from the clinician’s assessment based on the history and the physical examination. The history the patient provides and what is found on exam create the clinical basis for identifying a condition, and the diagnosis code (ICD-10-CM) is then assigned to reflect that diagnosed problem. Procedure codes, by contrast, describe what was done during the visit (tests, procedures, services), not the patient’s underlying condition. Medication codes relate to drugs prescribed or dispensed, and billing involves charging for services using the appropriate diagnosis and procedure codes. So the diagnosis codes are the ones directly supported by the history and exam findings.