ABSTRACT
The topic of coding and documentation is minimally discussed in schools whose aim is to prepare graduate students for work in the behavioral health industry. The term “coding and documentation” is largely seen as a medical, financial, and reimbursement process for how medical records are created, maintained, and used for healthcare purposes. This chapter will explore the background for coding and documentation to further explicate the context and process by which the behavioral health industry has reached the point of necessary regulation and compliance to be true compatriots with the medical industry in the healthcare delivery system. This chapter will also explore the ways in which coding and documentation protocols apply to behavioral healthcare, documentation, diagnosis code assignment, data collection, and reimbursement. In addition, understanding the background of the coding and documentation standards will play a key role when we discuss ICD series compliance later in the book.
