Coding is the assignment of codes to diagnoses, services, and procedures based on what?

Coding is fundamentally based on patient record documentation. This process involves analyzing the medical documents created by healthcare providers to accurately capture the patient's diagnoses, services rendered, and procedures performed. The documentation serves as the primary source of information that coders use to assign the appropriate codes, ensuring that the codes reflect the clinical services received and documented in the patient's health record.

Patient records contain vital information such as clinical findings, treatment plans, and outcome measures that are essential for determining the correct diagnostic and procedural codes. These codes are then used for billing, data collection, and statistical analysis in the healthcare system.

While regulations and requirements from different entities may influence coding practices, the core foundation of coding is rooted in the information documented in the patient's medical record. This makes accurate and thorough documentation crucial for effective coding and subsequent healthcare operations.