Introduction Not all words written in the health record translate into ICD-CM/PCS or HCPCS coded data. Coders must determine when documented conditions meet reportable claims data requirements. As the role of coded data expands beyond statistical reporting and diagnosis-related groups to accurate depictions of clinical scenarios, it is becoming increasingly difficult to determine when a condition reaches a reportable threshold. Both government and commercial insurers rely on administrative data in the form of codes to measure the quality of care provided to their beneficiaries. Coded data is also used to validate the medical necessity of rendered services. Medical necessity has always been a CMS and private payer.

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