Coding Architecture
How Diagnosis, Procedure, Equipment, and Payment Codes Work Together
A clean claim is a connected story: the diagnosis explains the patient condition, the service or item is coded accurately, modifiers report supported facts, documentation proves the clinical and operational requirements, and payer policy determines adjudication.
Diagnoses and reasons for care
ICD-10-CM
Use the code set effective for the date of service and code to the supported level of specificity.
Open ICD-10-CM centerProfessional and outpatient services
CPT
Use a current AMA-licensed code source for complete descriptors, instructions, and updates.
Open CPT centerEquipment, supplies, drugs, and other items
HCPCS Level II
Connect the exact product or service to current coding, policy, documentation, and payment rules.
Open HCPCS Level II centerThe reimbursement chain
- 1. Clinical facts
Document the condition, function, tests, treatment, and reason for the item or service.
- 2. Code selection
Select codes from current official or licensed sources based on what the record supports.
- 3. Policy and documentation
Apply benefit, coverage, authorization, order, delivery, frequency, and modifier rules.
- 4. Claim and adjudication
Submit internally consistent claim data, then read the remittance and payer decision.