Certified Coding Associate (CCA) Practice Exam

Question: 1 / 400

What is defined as an "indication" in medical coding?

A review of medical records

The medical reason for a procedure

An "indication" in medical coding refers specifically to the medical reason for a procedure. This is crucial for coders as it provides the rationale behind why a particular treatment or intervention was necessary for a patient. Understanding the indication allows coders to assign the correct diagnosis codes that reflect the patient's condition and the necessity for the medical service provided.

In medical documentation and coding, the indication helps to justify the procedure to insurers and is pivotal in establishing the medical necessity, which is a key component for reimbursement. By accurately capturing the indication, coders ensure that the services are appropriately linked to the correct clinical diagnosis, which is essential for both compliance and financial aspects of healthcare.

Other options such as reviewing medical records, identifying a coding error, or addressing types of reimbursement do not capture the specific and critical nature of an "indication," which is fundamentally about the reason a procedure was performed.

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A coding error

A type of reimbursement

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