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

The assignment of codes to diagnoses, services, and procedures is fundamentally based on patient record documentation. This documentation includes detailed information provided by healthcare providers about the patient's condition, treatments administered, and any relevant medical history. This data serves as the primary source for coding professionals to accurately denote what has occurred during a patient's visit.

Using documentation ensures that the codes reflect the true nature of the services provided, allowing for proper reimbursement and adherence to healthcare standards. Accurate coding is crucial, particularly for patient records, because it affects patient care continuity, billing, statistical reporting, and research.

While insurance claims, healthcare policies, and medical billing software may play supporting roles in the coding process, they do not provide the foundational details required for coding. The specific information needed to assign the correct codes originates from the clinical notes and records made by healthcare providers during patient encounters.