2 Medical Coding Objectives 16-1 Explain the purpose and format of the ICD volumes that are used by medical.16-2 Describe how to analyze diagnoses and locate correct codes using the ICD.16-3 Identify the purpose and format of the CPT.16-4 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).16-6 Describe the process used to locate correct procedure codes using CPT.16-7 Explain how medical coding affects the payment process.16-8 Define fraud and provide examples of fraudulent billing and coding.
4 Diagnosis Codes: The ICD-9-CM The Diagnosis ProcessPatient ChiefComplaintPhysician MedicalDiagnosisInsuranceDiagnosisCodeThe 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 HIPAAfor reporting: Patient’s Diseases Conditions Signs and Symptoms
5 Diagnosis Codes: The ICD-9-CM (cont.) Alphabetic Index (Volume 2)Diagnoses appear in alphabetical orderThe index is organized by conditionShould be used initially to look up conditionsTabular List (Volume 1)Diagnoses appear in numerical orderListing is organized according to source or body systemUsing the ICD-9The 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 StructureCodes 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 CodesIdentify 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 CONVENTIONSA list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.ConventionsNECAn abbreviation that means “not elsewhere classified”. This is used when the ICD-9 does not provide a specific code to describe the patient’s condition.[ ]Brackets are used around synonyms, alternate wording, or explanations.NOSAn abbreviation that means “not otherwise specified”, or “unspecified”( )Parentheses are used around alternative wordings.
8 Diagnosis Codes: The ICD-9-CM (cont.) ICD-9-CM CONVENTIONSA list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.ConventionsIncludesThis word is followed by the types of conditions.}Brace encloses a series of terms.:Used in the Tabular List after an incomplete term.
9 Diagnosis Codes: The ICD-9-CM (cont.) ICD-9-CM CONVENTIONSA list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.ConventionsUse additional codeThis note means an additional code should be used if available.Code first underlying diseaseThis means that the code is not to be used as the primary diagnosis.ExcludesThese notes indicate an entry is not classified as part of the preceding code.
10 Diagnosis Codes: The ICD-9-CM (cont.) Define these ICD-9-CM CONVENTIONS.NOS}NECIncludes[ ]Excludes( )Use additional code:Code first underlying disease
11 Diagnosis Codes: The ICD-9-CM (cont.) Record the code on the claim form.Steps to Locatingan ICD-9-CMCodeRead all information to find the code that corresponds to the patient’s condition.Locate the selected Alphabetic code in the Tabular List.Find the diagnosis in the Alphabetic Index.Locate statement of diagnosis in patient’s medical record.
12 Diagnosis Codes: The ICD-9-CM (cont.) A New Revision: The ICD-10-CMContains over 2000 disease categoriesCodes are alphanumeric containing a letter followed by up to five numbersCodes are added to show specific side of the body that is affected by the disease process when applicable
13 Apply Your Knowledge - Answer This means the medical assistant must look up the term that follows the word “see” because another category should be used or cross-referenced.- AnswerA medical assistant has looked up a medical term in the alphabetic index, and next to the term is the word “see”. What does this mean?
14 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).
15 Procedure Codes: The CPT Using the CPTExcept for the first section, the reference book isarranged in numerical order.SectionRange of CodesEvaluation and ManagementAnesthesiologySurgeryRadiologyPathology and LaboratoryMedicine
16 Procedure Codes: The CPT (cont.) Add-On CodesA plus sign (+) is usedModifiersOne or more two-digit numbers are added with a hyphen after the five digit numberCategory II, III, and Unlisted Procedure CodesCategory II (tracks healthcare performance measures)Category III (temporary codes)Unlisted Codes (Used when no other code is adequate)
17 Procedure Codes: The CPT (cont.) Evaluation and Management ServicesExplains how to code different levels of patient services based on:The extent of the patient history takenThe extent of the examination conductedThe complexity of the medical decision madeNew Patient versus Established PatientNew patients have not been seen by physician within the past3 years.Established patients have been seen within a 3 year period.
18 Procedure Codes: The CPT (cont.) Surgical ProceduresThe “Surgical Pack” is a combination of services needed for surgery such as:AnesthesiaSurgeryRoutine Follow-Up CareGlobal Period refers to the time period that follow-up is rendered following surgery.
19 Procedure Codes: The CPT (cont.) Laboratory ProceduresPanels 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.ImmunizationsInjections require two codes, one for the procedure (injection) and the other for the medication (vaccine or toxoid)
20 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 codesLevel II codes are national codes covering suppliesContains 5 characters, either numbers, letters, or a letter with a number.
21 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 LinkageThis is a process that insurance company representatives use to evaluate the necessity of medical procedures that are reported based on the patient’s diagnosis.DiagnosticProceduresCareful attention to details are needed to prevent errors in coding and incorrect billing.
22 Avoiding Fraud: Coding Compliance (cont.) Insurance FraudInvestigators 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 patient’s condition and therefore not medically necessary.Billing separately for services that are bundled in a single procedure code.Reporting the same service twice.
23 Avoiding Fraud: Coding Compliance (cont.) Compliance PlansTo 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 complianceDevelop written policies and procedures that are consistent with regulations and lawsProvide ongoing communication and training to staffRespond to and correct errors
24 Apply Your Knowledge - Answer 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:Use the current book to validate accuracy of the codes.Use last year’s book to validate accuracy of the codes.Use next year’s book to validate accuracy of the codes.