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Medical Assisting Chapter 16

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1 Medical Assisting Chapter 16
PowerPoint® to accompany Medical Assisting Chapter 16 Second Edition Ramutkowski • Booth • Pugh • Thompson • Whicker Chapter 16 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

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 Process 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:  Patient’s Diseases  Conditions  Signs and Symptoms

5 Diagnosis Codes: The ICD-9-CM (cont.)
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 Using the ICD-9 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 Codes E 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, typefaces, and notes that provide guidelines for using the code set. Conventions NEC An 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. NOS An 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 CONVENTIONS A list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set. Conventions Includes This 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 CONVENTIONS A list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set. Conventions 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. Excludes These 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 } NEC Includes [ ] 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 Locating an ICD-9-CM Code Read 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-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

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. - Answer A 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 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

16 Procedure Codes: The CPT (cont.)
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)

17 Procedure Codes: The CPT (cont.)
Evaluation and Management Services Explains how to code different levels of patient services based on: 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.

18 Procedure Codes: The CPT (cont.)
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.

19 Procedure Codes: The CPT (cont.)
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)

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 codes Level II codes are national codes covering supplies Contains 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 Linkage This is a process that insurance company representatives use to evaluate the necessity of medical procedures that are reported based on the patient’s diagnosis. Diagnostic Procedures Careful attention to details are needed to prevent errors in coding and incorrect billing.

22 Avoiding Fraud: Coding Compliance (cont.)
Insurance Fraud 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 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 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

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.

25 End of Chapter End of Chapter

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