2 Medical Coding Objectives 16-1 Explain the purpose and format of the ICD volumes that are used by medical offices Describe how to analyze diagnoses and locate correct codes using the ICD Identify the purpose and format of the CPT Name three key factors that determine the level of Evaluation and Management codes that are selected.
3 Medical Coding Objectives Objectives (cont.) 16-5 Identify the two types of codes in the Health Care Common Procedure Coding System (HCPCS) Describe the process used to locate correct procedure codes using CPT Explain how medical coding affects the payment process Define fraud and provide examples of fraudulent billing and coding.
4 Diagnosis Codes: The ICD-9-CM Patient Chief Complaint Physician Medical Diagnosis Insurance Diagnosis Code The diagnosis codes are found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) The use of ICD-9 codes in healthcare is mandated by HIPAA for reporting: Patients Diseases Conditions Signs and Symptoms
5 Alphabetic Index (Volume 2) Diagnoses appear in alphabetical order The index is organized by condition Should be used initially to look up conditions Tabular List (Volume 1) Diagnoses appear in numerical order Listing is organized according to source or body system Diagnosis Codes: The ICD-9-CM (cont.) The Alphabetical Index is never used alone to find a diagnosis code because it does not contain all the necessary information.
6 Diagnosis Codes: The ICD-9-CM (cont.) Code Structure Codes are made up of three, four, and five digits and a description. The four and five digit codes are mandated by payers when they are available. V CodesE Codes Identify encounters for reasons other than illness or injury. Can be used as either a primary code or additional code. Identify external causes of injuries and poisoning. Never used alone as a diagnosis code.
7 Diagnosis Codes: The ICD-9-CM (cont.) ICD-9-CM CONVENTIONS A list of abbreviations, punctuation, symbols, type faces notes that provide guidelines for using the code set. [ ] Brackets are used around synonyms, alternate wording or explanations. ( ) Parentheses are used around alternative wordings.
8 NEC An abbreviation that means not elsewhere classified. This is used when the ICD-9 does not provide a specific code to describe the patients condition. NOS An abbreviation that means not otherwise specified, or unspecified Diagnosis Codes: The ICD-9-CM (cont.)
9 ICD-9-CM CONVENTIONS A list of abbreviations, punctuation, symbols, type faces notes that provide guidelines for using the code set. : Used in the Tabular List after an incomplete term. } Brace encloses a series of terms. Includes This word is followed by the types of conditions.
10 Diagnosis Codes: The ICD-9-CM (cont.) Excludes These notes indicate an entry is not classified as part of the preceding code. Use additional code This note means an additional code should be used if available. Code first underlying disease This means that the code is not to be used as the primary diagnosis.
11 Diagnosis Codes: The ICD-9-CM (cont.) Define these ICD-9-CM CONVENTIONS. } NOS NEC [ ] ( ) : Includes Excludes Use additional code Code first underlying disease
12 Diagnosis Codes: The ICD-9-CM (cont.) Locate statement of diagnosis in patients medical record. Find the diagnosis in the Alphabetic Index. Locate the selected Alphabetic code in the Tabular List. Read all information to find the code that corresponds to the patients condition. Record the code on the claim form.
13 A New Revision: The ICD-10-CM Contains over 2000 disease categories Codes are alphanumeric containing a letter followed by up to five numbers Codes are added to show specific side of the body that is affected by the disease process when applicable Diagnosis Codes: The ICD-9-CM (cont.)
14 Apply Your Knowledge A medical assistant has looked up a medical term in the alphabetic index and next to the term is the wordsee. What does this mean?
15 Answer Apply Your Knowledge - Answer A medical assistant has looked up a medical term in the alphabetic index and next to the term is the wordsee. What does this mean? This means the medical assistant must look up the term that follows the word see because another category should be used or cross-referenced.
16 Procedure Codes: The CPT The Current Procedural Terminology (CPT) book is the most commonly used system for reporting procedures and services provided to the patient. This is the HIPAA required code set. Published annually by the American Medical Association (AMA).
17 Procedure Codes: The CPT Except for the first section, the reference book is arranged in numerical order. Section Range of Codes Evaluation and Management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine
18 Add-On Codes A plus sign (+) is used Modifiers One or more two-digit numbers are added with a hyphen after the five digit number Category II, III, and Unlisted Procedure Codes Category II (tracks healthcare performance measures) Category III (temporary codes) Unlisted Codes (Used when no other code is adequate) Procedure Codes: The CPT (cont.)
19 Evaluation and Management Services Explains how to code different levels of patient services based on: Procedure Codes: The CPT (cont.) The extent of the patient history taken The extent of the examination conducted The complexity of the medical decision made New Patient versus Established Patient New patients have not been seen by physician within the past 3 years. Established patients have been seen within a 3 year period.
20 Surgical Procedures The Surgical Pack is a combination of services needed for surgery such as: Anesthesia Surgery Routine Follow-Up Care Global Period refers to the time period that follow-up is rendered following surgery. Procedure Codes: The CPT (cont.)
21 Laboratory Procedures Panels listed in Pathology and Laboratory sections of the CPT include tests commonly performed. If the panel code is not used and separate codes are used, they will be rebundled. Immunizations Injections require two codes, one for the procedure (injection) and the other for the medication (vaccine or toxoid) Procedure Codes: The CPT (cont.)
22 HCPCS The Health Care Common Procedure Coding System (HCPCS) Developed by the Centers for Medicare and Medicaid Services (CMS) Pronounced hic-picks Contains two levels: Level I codes duplicate CPT codes Level II codes are national codes covering supplies Contains 5 characters, either numbers, letters, or a letter with a number.
23 Avoiding Fraud: Coding Compliance Medical assistants help ensure that maximum appropriate reimbursement for services provided are received. Compliance with federal and state law and payer requirements is mandatory. Code Linkage Diagnostic Procedures This is a process that insurance company representatives use to evaluate the necessity of medical procedures that are reported based on the patients diagnosis. Careful attention to details are needed to prevent errors in coding and incorrect billing.
24 Avoiding Fraud: Coding Compliance (cont.) Investigators look for patterns such as: Reporting services that were not performed. Reporting services at a higher level than was carried out. Performing and billing for procedures that are not related to the patients condition and therefore not medically necessary. Billing separately for services that are bundled in a single procedure code. Reporting the same service twice.
25 Compliance Plans To avoid the risk of fraud, medical offices incorporate a process for finding, correcting and preventing illegal medical practices. A compliance officer and committee will: Audit and monitor compliance Develop written policies and procedures that are consistent with regulations and laws Provide ongoing communication and training to staff Respond to and correct errors Avoiding Fraud: Coding Compliance (cont.)
26 The insurance representative has questioned the codes listed on three patient forms that were submitted last year. When re-checking these forms the office medical assistant should: a.Use the current book to validate accuracy of the codes. b.Use last years book to validate accuracy of the codes. c.Use next years book to validate accuracy of the codes. Apply Your Knowledge
27 The insurance representative has questioned the codes listed on three patient forms that were submitted last year. When re-checking these forms the office medical assistant should: a.Use the current book to validate accuracy of the codes. b.Use last years book to validate accuracy of the codes. c.Use next years book to validate accuracy of the codes. Answer Apply Your Knowledge - Answer