Medical coders turn clinical documentation into the standardised codes that drive billing, quality measurement and research. This course covers the code sets and their conventions, evaluation and management coding, procedural coding across common specialties, modifiers, compliance, productivity and the path into a coding career. Every lesson includes a worked example to practise the logic. It is independent study material and does not issue any credential or guarantee any exam outcome.
Modules
Coding Foundations
Lessons
Diagnosis Coding with ICD-10-CM
Lessons
Evaluation and Management Coding
Lessons
Procedural Coding
Lessons
Compliance and Quality
Lessons
Tools and Career
Lessons
Other Lessons
Module 4 Review
Module review: key terms, activity and quiz.
Lesson 1.1: Why Medical Coding Exists and the Three Code Sets
Medical coding translates the free-text clinical story in a medical record, what the patient reported, what the provider found, and what the provider did, into standardized alphanumeric codes that payers, researchers, an
Lesson 5.1: Modifier -25 and Modifier -59
Modifier -25 is appended to an E/M code to indicate a significant, separately identifiable evaluation and management service was performed by the same physician on the same day as a procedure or other service. It is used
Lesson 1.2: Reading the Medical Record for Coding
Before assigning any code, a coder reads the relevant documentation to identify what was actually documented, not what was likely intended or typically done. Key documentation types include the chief complaint and histor
Lesson 5.2: Laterality, Anatomic, and Other Common Modifiers
Modifiers -LT (left side) and -RT (right side) are used on procedures performed on paired anatomic structures (such as a knee, shoulder, or eye) to identify which side was treated, which matters both for payment accuracy
Lesson 1.3: Coding Compliance and Staying Current
Coding compliance means coding consistently and accurately according to official guidelines rather than to maximize reimbursement, and it protects both the coder and the practice from fraud and abuse exposure. Upcoding (
Lesson 5.3: NCCI Edits: PTP Edits and MUEs
The National Correct Coding Initiative (NCCI), maintained by CMS, publishes two main types of edits that automatically check claims for correct code pairing and quantity. Procedure-to-Procedure (PTP) edits identify pairs
Module 1 Review
Module review: key terms, activity and quiz.
Module 5 Review
Module review: key terms, activity and quiz.
Lesson 2.1: ICD-10-CM Structure and Format
ICD-10-CM codes are alphanumeric, ranging from 3 to 7 characters. The first character is always a letter, the second character is always a number, and characters three through seven can be either letters or numbers. A de
Lesson 6.1: A Complete Office Visit Coding Scenario
Consider a documented office visit: an established patient with well-controlled type 2 diabetes mellitus returns for a routine follow-up, and during the visit the provider also addresses a new complaint of a painful ingr
Lesson 2.2: Using the Alphabetic Index and Tabular List Together
Correct ICD-10-CM coding always uses two parts of the code set together: the Alphabetic Index, organized by main term (usually the condition, not the body part), and the Tabular List, organized numerically by code, which
Lesson 6.2: A Complete Injection and Drug Coding Scenario
Consider a second scenario: a patient with an acute musculoskeletal strain receives a therapeutic intramuscular injection of an anti-inflammatory medication during an office visit that is entirely dedicated to this probl
Lesson 2.3: Combination Codes, Laterality, and Sequencing
ICD-10-CM uses combination codes in many chapters, meaning a single code can capture two diagnoses, or a diagnosis with an associated manifestation or complication, when the classification provides for it. For example, E
Lesson 6.3: Coding Audits and Professional Credentials
Coding audits are periodic reviews of a sample of coded encounters, comparing the codes billed against the actual documentation, performed either internally by the practice’s compliance program or externally by a payer o
Module 2 Review
Module review: key terms, activity and quiz.
Module 6 Review
Module review: key terms, activity and quiz.
Lesson 3.1: CPT Structure and Evaluation and Management (E/M) Coding
CPT codes are five-character codes, generally numeric (Category I codes) though Category II codes end in ‘F’ and Category III codes end in ‘T’. Category I codes are organized into sections including Evaluation and Manage
Lesson 3.2: Surgical Package Concepts and the Global Period
CPT surgical codes generally include a ‘surgical package’: the procedure itself along with certain related services performed around it, such as local anesthesia, a related E/M service on the same day as a minor procedur
Lesson 3.3: CPT Category II and Category III Codes
Category II codes are supplemental tracking codes, ending in the letter ‘F,’ used to report performance measures such as whether a specific screening was performed, a specific counseling service was provided, or a specif
Module 3 Review
Module review: key terms, activity and quiz.
Lesson 4.1: HCPCS Level II Structure and Common Categories
HCPCS Level II codes consist of one letter followed by four numbers (for example, J1885 or E0143), and are maintained by CMS to cover items and services that CPT does not describe in enough detail or does not describe at
Lesson 4.2: HCPCS Modifiers and Coding Drugs Correctly
HCPCS Level II modifiers are two-character codes (letters, or a letter and a number) appended to either a CPT or a HCPCS Level II code to provide additional information without changing the code’s basic definition. Commo
Lesson 4.3: Coordinating CPT and HCPCS Level II on the Same Claim
Many outpatient encounters require both a CPT code and one or more HCPCS Level II codes on the same claim to fully and accurately describe what was done. For example, a patient receiving a therapeutic injection in the of