Which document helps ensure that procedures are properly coded for billing?

The Charge Description Master (CDM) serves as a comprehensive listing of all the billable items and services provided by a healthcare facility. It includes codes, descriptions, and prices for each item or service, ensuring that when procedures are performed, they are accurately documented and coded for billing purposes. The CDM provides a standard reference that supports consistent and accurate billing practices, enabling the healthcare organization to capture revenue correctly.

Having an up-to-date and well-maintained CDM is crucial to minimize errors and ensure compliance with billing regulations. It acts as a bridge between clinical documentation and billing, indicating exactly what services were provided to a patient and how they should be coded for insurance claims.

Other documents, while important in their own right, do not primarily focus on the coding and billing process. For example, a patient care plan provides a roadmap for the care to be delivered and is more clinical in nature rather than billing-centric. A claim submission form is utilized after coding is completed to formally request payment from insurers, but it does not ensure correct coding in itself. Documentation standards define the requirements for how clinical information should be recorded, but they do not specifically relate to coding procedures for billing purposes.