The learner will: Describe the key characteristics and organization of ICD-10-CM, CPT, and HCPCS coding systems and explain their relationship to healthcare billing. Apply standard coding guidelines to accurately assign codes for typical outpatient and professional services. Evaluate clinical documentation to determine the most accurate diagnosis and procedure codes. Explain how accurate coding influences reimbursement and compliance with payer and federal requirements. Analyze coding discrepancies to identify compliance risks and recommend corrective actions. Develop a coding crosswalk that maps clinical services to appropriate codes, supporting consistency and billing transparency.

Before beginning this unit, learners should have: A working knowledge of healthcare billing processes and terminology. Understanding of clinical documentation workflows and charge capture concepts. Completion of Unit 3.2: Clinical Documentation Improvement (CDI) or equivalent coding exposure.

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This unit is ideal for individuals pursuing careers in medical coding, billing, and revenue integrity who need a strong foundation in code assignment and compliance. It is especially suited for: Medical Coders and Coding Trainees – seeking to develop or strengthen ICD, CPT, and HCPCS coding skills. Billing and Claims Specialists – who need to link clinical services with reimbursement systems. Revenue Integrity and Compliance Analysts – ensuring accurate coding supports legal and financial accountability. Healthcare Students and Entry-Level Professionals – preparing to obtain professional certifications such as CPC, CCS, or CCA. Auditors and Quality Officers – responsible for identifying and correcting documentation and coding discrepancies.