- ICD-10-PCS is primarily a billing code used only in inpatient settings.
- CPT and HCPCS are codes used to report procedures and services in outpatient procedures.
- ICD-10-PCS is named in the 2015 Edition certification rules as an optional code set for procedures.
- SNOMED CT U.S. Edition procedure codes can be used to describe treatment in any clinical setting and is not tied to billing but can be cross-mapped to corresponding ICD-10-PCS and CPT/HCPCS codes.
- A Procedure Note records the indications for a non-operative procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
- A Pathology Report Narrative contains a consulting specialist's interpretation of the pathology report.