Current Procedure Terminology (CPT) Evaluation and Management (E&M ) and IDC-9/10 coding are daily routines of medical practice if you want to bill third party payers for your clinical services. Practices may have professional coders on staff to assign the E&M, or what was done, and diagnosis ICD9/10, or why, codes from the written note. The ultimate responsibility for the correct billing code lies with the clinician. Coding is a valuable skill set to learn, but it can be cumbersome and confusing. There are now electronic medical record (EMR) programs that allow clinicians to document the patient’s history, physical exam, assessment, and plan: then calculate a suggested E&M code based on what was documented. This feature established the E&M code on the chart documentation so it is very accurate and may eliminate the need for professional coders on staff. The diagnosis ICD- 9/10 codes lists are built in and allow clinicians to agree or override the suggested codes. All EMRs are not the same and many lack this feature. There are government incentives to have all practices convert to EMRs over the next several years, so having a system that calculates the E&M code and provide the correct diagnosis ICD-9/10 codes is critical. ICD-9 Codes are updated annually on October 1st and the switch to ICD-10 is October 2011 to be complete by 2013.
The Web has several free ICD-9/10 and E&M code reference sites for speedy look-ups including:
There are some helpful coding tools you can have on your PDA or Smartphone for quick look-ups. You can download a PDF of the codes you use from the web resources above or several of the reference programs have codes built in. The free Mobile Merck Medicus ( http://www.merckmedicus.com/pp/us/hcp/hcp_mobile_medicus.jsp) has great clinical references , but every disease listed within the Harrison Practice. has an ICD-9 code listed in the resources section. In Epocrates Essentials (http://www.epocrates.com) every disease in the Dx section has IDC-9 code listed in the disease index. In the Lab section there is a list of appropriate diagnosis 1CD-9 codes under the Cost/Billing tab. Dynamed (http://www.ebscohost.com/dynamed/) has ICD-9 and ICD-10 codes in the Description section of all the diseases listed