When using ICD-10-CM codes, what should always be verified before coding?

The specificity of the diagnostic statement should always be verified before coding with ICD-10-CM codes because the accuracy and completeness of the code selection directly impact the quality of the medical record and the reimbursement process. ICD-10-CM requires a higher level of detail compared to its predecessor, ICD-9-CM, including specific diagnoses, laterality, and associated conditions. Ensuring that the diagnostic statement is clear and precise helps coders select the most appropriate code, which is essential for capturing the patient's health condition accurately and ensuring appropriate billing.

Verification of the diagnostic statement minimizes the risk of coding errors, which can lead to claim denials, incorrect reimbursement, or even compliance issues. A thorough understanding of the clinical details and the correct coding guidelines will ensure that the codes assigned reflect the services provided and align with the medical necessity for those services. This practice supports both proper administrative processes and high-quality patient care.