What is generally required for outpatient coding?

For outpatient coding, it is essential to include both diagnosis codes and procedure codes. Diagnosis codes, typically derived from the International Classification of Diseases (ICD), detail the medical conditions or reasons for the patient's visit, which is necessary for justifying the care provided. Procedure codes, generally from the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS), document the specific services or treatments administered during the outpatient visit.

The combination of diagnosis and procedure codes ensures comprehensive documentation that supports billing and medical necessity. This dual approach is critical for health insurance reimbursement, as insurers require justification in the form of both the diagnosis and the services performed to approve payment. Hence, understanding the need for both coding types is fundamental for correct outpatient coding practices.