Computer-Assisted Coding

Sources and review notes

These links support definition-level research and do not establish the regulatory status, safety, or suitability of any product.

CDC publishes official, date-specific ICD-10-CM files and guidance, while CMS describes the national coding systems used for diagnoses, procedures, services, supplies, and claims and states that a code's existence does not itself determine Medicare coverage or payment. CMS's Documentation Matters resources keep responsibility for complete, accurate, and timely records with providers. These sources provide the baseline against which computer-assisted coding suggestions must be checked; they do not validate a CAC product or authorize automatic code submission. Organizations must verify the applicable code-set version, setting, payer policy, source documentation, medical necessity, edit history, confidence handling, coder review, clinician query, and final claim controls.

• Source 1: www.cdc.gov/nchs/icd/icd-10-cm/files.html
• Source 2: www.cms.gov/cms-guide-medical-technology-companies-and-other-interested-parties/coding/overview-coding-classification-systems
• Source 3: www.cms.gov/medicare/medicaid-coordination/states/dcoumentation-matters-toolkit