Continuity Clinic Objectives Be familiar with ICD-9 and CPT classifications and know the difference between the two Understand how to utilize ICD-9 codes Understand how CPT codes affect the reimbursement of medical services
Continuity Clinic Terminology What is coding? –Numerical representation of diseases and treatment provided –Assignment of codes based on care and services received –Collection, storage and sharing of data and statistics So why code? –The coding system forms the key component of the reimbursement infrastructure (how we get paid!)
Continuity Clinic ICD – 9 International Statistical Classification of Diseases and Related Health Problems ICD-9 is an international disease classification system that groups related disease entities and conditions for the purpose of reporting statistical information Key – It is the problem or condition of the patient. While it is related to how we bill a service, it is not the primary determinate of the cost of the visit.
Continuity Clinic ICD-9 Numeric Codes –0-999 by organ systems –Primary codes ( ie for asthma) V Codes –Primary code for well visit = V20.2 –Secondary code (ie V15.03 = allergy to egg) E Codes –Injuries or adverse events (ie E906.0 = dog bite)
Continuity Clinic CPT Codes The Current Procedural Terminology coding system describes medical and surgical procedures and services performed by physicians and other health providers –Essential to billing for patient care services –System used to develop the Resource Based Relative Value System (RBRVS) to assist in determining the amounts paid to doctors and other medical providers for services –Uniform codes that translate the same for doctors, hospitals, patients, insurance companies, and other parties
Continuity Clinic Don’t Panic Yet!!!
Continuity Clinic Keep it Simple! CPT Codes = what we do –E/M Services Evaluation and Management Services –Procedures Surgery, labs, radiological studies ICD-9 = what the patient has/why they visited the doctor –Establishes medical necessity (insurance does look at this!) –The CPT code is linked to 1 or more diagnosis code(s)
Continuity Clinic For Example A 3 year old patient of your practice visits you for a sore throat. You run a rapid strept test and it is negative and you think she has viral pharyngitis. CPT code: –99213 = the actual visit and doctor time –87880 = the strept test ICD-9 code –462 = pharyngitis; this provides justification for the visit
Continuity Clinic Basic ICD Coding Guidelines 1. Select the diagnosis codes to identify: –Diagnoses –Symptoms –Problems –Complaints –Or reason for encounter
Continuity Clinic Basic ICD Coding Guidelines 2. Code to the highest degree of specificity –Assign the 4 th or 5 th digit whenever available as it will decrease the likelihood that the claim is rejected 3. Diagnoses coded as probable, suspected, or “rule out” should not be coded as if the diagnosis is confirmed
Continuity Clinic Basic ICD Coding Guidelines 4. List the ICD code that is the main reason for the encounter first in the record –List co-existing conditions if those conditions affect the treatment and/or management of the patient 5. A chronic disease treated on an ongoing basis may be coded and reported as many times as is applicable to the patient’s treatment
Continuity Clinic Basic ICD Coding Guidelines 6. Do not code for conditions that were previously treated and no longer exist at the time of the visit –Use V67.9 for follow up examination or V67.59 for follow up after rx 7. E codes are never used as solo codes or as primary codes 8. Use applicable diagnosis codes for surgical procedures
Continuity Clinic Resource Based Relative Value Scale RBRVS determines the fee schedule (what we get paid) for the various services we provide Most CPT codes have a “relative value” Congress determines the Medicare Fee Schedule and most insurance payers use this in their payment schedules
Continuity Clinic RBRVS – Say that again? Services are ranked relative to the cost of the resources used to perform them If service A is harder and takes longer, or uses more resources than service B, then service A will be allotted a proportionately higher value than B What goes into calculation: –Physician work –Practice expense –Malpractice expense