Physicians and other practitioners are required to justify the amount of money they charge for an patient interactions they bill as services. Medical billing coding is one way that this is monitored. Following a visit, the provider must document the extent of the medical attention needed. They will record the review of the patients history, the list of problems that the patient presents with, their physical findings, medical necessity and acuity or difficulty level of visit. Through an evaluation of these items a provider will then assign a CPT codes to the visit. Each and every service or procedure that is provided will be assigned a code.

In addition to the CPT codes, a provider will assign another code to the visit. This additional code will also help support medical billing coding. At some point in the visit, the provider will attach a diagnosis , or multiple diagnoses, to the visit. This is the actual reason for the visit, like hypertension, diabetes or hyperlipidemia. Each diagnosis has its own ICD – 9 code. So, the diagnosis is then translated in to its ICD – 9 code for billing purposes. Then, through a billing office, these codes along with necessary supporting office notes will be sent to the patients insurance company for reimbursement.