Final answer:
In a hospital, diagnosis codes on UB-04 claim forms are reported using the ICD coding system, and procedures are reported using CPT or HCPCS codes. ICD codes are found in medical records and laboratory test orders.
Step-by-step explanation:
A hospital submitting an outpatient claim would use a UB-04 claim form and rely on specific coding systems to report diagnosis and procedure information. For diagnosis codes, the hospital uses the International Classification of Diseases (ICD) coding system. Procedures are reported using the Current Procedural Terminology (CPT) for most outpatient services or the Healthcare Common Procedure Coding System (HCPCS) for services not covered by CPT.
When a patient seeks treatment, for instance, for a viral infection, medical professionals use the ICD code to order specific tests and prescribe treatment. This same code guides medical laboratories in identifying necessary tests to confirm the diagnosis. The ICD code ensures that the healthcare management system verifies the appropriateness of all treatments. Additionally, medical coders use these codes to assign accurate procedures codes, which medical billers then use to process insurance claims for reimbursement. These codes are also vital for vital-records keepers and epidemiologists for statistical purposes.
Two locations where you would likely find an ICD code include the patient's medical records at healthcare facilities and on medical laboratory test orders.