Medical Coding

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Understanding Medical Coding 2nd ed, Chapter 1-4

Centers for Medicare & Medicaid Services (CMS)

An administrative agency within the Department of Health and Human Services (DHHS) that oversees Medicare, Medicaid, and other government programs. Formerly known as the Health Care Financing Administration (HCFA)

American Academy of Professional Coders (AAPC)

The professional association for medical coders providing ongoing education, certification, networking and recognition, with certifications for coders in physicians' offices and hospital outpatient facilities

American Health Information Management Association (AHIMA)

One of the four co-operationg parties for ICD-9-CM. Professional association for over 38,000 Health Information Management Professionals throughout the country

Board of Advanced Medical Coding (BAMC)

An organization of coders, clinicians, and compliance professionals dedicated to the evaluation, recognition, and career advancement of professional medical coders within physician practices, facility and post-acute settings

Board of Advanced Medical Coding (BMAC)

provides specialty certification for::
Anesthesia/Pain Management, Cardiology, Dermatology,
Facility Outpatient/ Ambulatory Surgical Center, Family Practice/Pediatrics, Gastroenterology, General Surgery, Obstetrics/Gynecology, Ophthalmology, Orthopedics, Radiology, Urology

Health Insurance Portability and Accountability Act (HIPAA)

Mandates regulations that govern privacy, security, and electronic transactions standards for health care information

insurance fraud

intentional, deliberate misrepresentation of information for profit or to gain some unfair or dishonest advantage

Health Insurance Association of America (HIAA)

An agency providing statistics and resources for public health information which includes diseases, pregnancies, aging, and mortality.

insurance abuse

inconsistent activities considered unacceptable business practice

Omnibus Budget Reconciliation Act (OBRA)

A federal law outlining numerous areas of healthcare, establishing guidelines and penalties

tools of the trade for coders

current: ICD-9-CM manual issued every October, CPT manual issued every January, HCPCS manual issued every January, medical dictionary w/ supplement for medical abbreviations and acronyms, carrier bulletins, newsletters, and websites

Healthcare Common Procedure Coding System (HCPCS)

coding system that consists of CPT and national codes (level II), used to identify procedures, supplies, medications (except vaccines), and equipment. pronounced hick picks.

Healthcare Common Procedure Coding (HCPCS)

a three-level coding system:
Level I - CPT,
Level II - National Codes,
Level III- Local codes deleted 12/31/03

HCPCS codes

Codes are required when reporting services and procedures provided to medicare and Medicaid beneficiaries

Physicians' Current Procedure Terminology (CPT)

numeric codes and descriptors for services and procedures performed by providers, published by American Medical Association

CPT

provides uniformity in accurately describing medical , surgical, and diagnostic services for effective communication among physicians, patients, and third-party payers.

CPT

introduced in 1966, greatest change was 1992 when Evaluation and Management services were created

CPT Evaluation and Management

CPT section requires practitioners to make decisions as to level of service for offices, hospitals, nursing home services

CPT Appendix B

summarizes the changes since the previous edition, including additions and deletions essential for updating computer programs and or encounter forms used in the facilty

CPT Level I Modifers

Appendix A, is a two -digit code added to the main CPT code indicating the procedure has been altered by a specific circumstance. Ex.: 19100-50

CPT Level II National Codes (HCPCS)

alphanumeric "national codes" supplied by the federal government, these codes supplement CPT codes enabling providers to report non physician services such as durable medical equipment, ambulance services, supplies and medications, particularly injectable drugs

Level II HCPCS Modifers

are either alphanumeric or letters that can be used with all levels of HCPCS codes. Ex. -LT used to identify procedures performed ton the left side of the body

CPT Level III

called local codes, deleted 12/31/03 under HIPAA regulations, many local code concepts were moved to Level II

International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9-CM)

coding system used to report diagnoses, diseases, and symptoms and reasons for encounters for insurance claims

ICD-9-CM

created by the World Health Organization (WHO) based in Geneva, Switzerland

ICD-9-CM

provides a diagnostic coding system for the compilation and reporting of morbidity and mortality statistics for reimbursement purposed in the US

ICD-9-CM

allows for the reporting of conditions, injuries, and traumas along with complications and circumstances occurring with the illness or injury, also provides the reason for patient care

ICD-9-CM

contains three volumes

ICD-9-CM Volume 1

Tabular List of Diseases, used by all health care facilities , used to report diagnoses

ICD-9-CM Volume 2

Alphabetic Index to Diseases, used by all health care facilities, used to report diagnoses

ICD-9-CM Volume 3

Used by by hospitals, used to report inpatient procedures (CPT is used to report procedures performed in physician offices, ambulatory care centers, and hospital outpatient departments)

ICD-9-CM three major functions for insurance purposes

1. justifies procedures and services rendered by the physician.
2. It assists in establishing medical necessity for services and procedures performed by the physician.
3. It serves as an indicator in measuring the quality of health care delivered by the physician provider.

ICD-10-CM

replacement for ICD-9-CM

ICD-10-CM

anatomy is the foundation, criteria to select and assign a diagnostic code will be based on etiology, site, or morphology

ICD-10-CM

three volumes
Volume 1 - Tabular List
Volume 2 - Instruction Manual
Volume 3 - Alphabetic List

ICD-9-CM

is used for coding and classifying diagnoses and procedures by numerical system

DRG

Diagnosis Related Groups, method of prospective payment used by Medicare and other third party payers for hospital inpatients

ICD-9-CM

is updated every year with changes every October 1

four agencies that are responsible for maintaining and updating ICD-9-CM

American Hospital Association (AHA)
National Center for Health Statistics (NCHS)
Centers for Medicare and Medicaid Services (CMS)
American Health Information Management Association (AHIMA)

cooperating agencies

four agencies who share responsibility for maintaining and updating ICD-9-CM

ICD-9-CM Coordination and Maintenance Committee

various federal ICD-9-CM users, serve as an advisory committee to the cooperating parties

The Coding Clinic for ICD-9-CM

a quarterly publication published by the AHA. Considered to be the official publication for the ICD-9-CM coding guidelines and advice from the four cooperating parties

The Coding Clinic for ICD-9-CM

advice given is to be followed by coders in all settings, including physician office, clinic, outpatient, and hospital inpatient coding

sequencing

arranging codes in the proper order according to the definitions of principal or primary diagnosis

NCHS

maintains and updates the diagnosis portion of ICD-9-CM

CMS

maintains and updates the procedure portion (Volume 3)

AHA

maintains the Central Office on ICD-9-CM to answer questions from coders and produces the Coding Clinic for ICD-9-CM, the official guidelines for ICD-9-CM usage

AHIMA

provides training and certification for coding professionals

principal diagnosis

the reason, after study, which caused the patient to be admitted to the hospital, inpatient

first-listed diagnosis

in the outpatient setting, the primary diagnosis is the main reason for the visit. it is usually the diagnosis taking the majority of resources for the visit

How to look up a ICD-9-CM term

Step 1- locate the main term
Step 2- identify subterms

ICD-9-CM Step 1 locating the main term

look in the alphabetic index of Volume Two under the main term.

main term

the patients illness or disease, in the ICD-9-CM the main term is the primary way to locate the disease in the alphabetic index. are printed in boldface, even with the left margin on each page

main terms examples

fracture, pneumonia, disease, injury, and enlarged

not main terms examples

anatomic terms : kidney, shoulder

alphabetic index

Volume 2 of the ICD-9-CM, the alphabetic listing of diagnoses

alphabetic index

cross-refrenced extremely well to allow the coder to locate the correct code using several different terms. Ex. "congestive heart failure" can be found under the main term " failure" and/or "congestive"

ICD-9-CM three alphanumeric classifications

V codes, E codes, M codes

V codes (ICD-9-CM)

used to describe the main reason for the patient's visit in cases where the patient is not sick. used as a secondary diagnosis to provide further information about the patient's medical condition.

E codes (ICD-9-CM)

are external causes of injury and poisoning. are optional by some carriers, many state statues require the assignment of an E code to a claim form. E codes are secondary diagnosis to show the cause of injury, such as a fall or automobile accident, if it is known.

M codes, Morphology Codes (ICD-9-CM)

located in the alphabetic index, used to further identify the behavior and cell type of a neoplasm and are used in conjunction with neoplasm codes from the main classification

M codes (ICD-9-CM)

used primarily by cancer registries and are not assigned when submitting a claim to a carrier by the physician office

category

categories are three-digit representations of a single disease or group of similar conditions, such as category 250, Diabetes Mellitus. Many categories are divided further into subcategories and classifications.

subcateory

four-digit subcategories are subdivisions of categories to provide greater specificity regarding etiology, site, or manifestations.

subcassification

fifth-digit sub-classifications are subdivisions of subcategories to provide even greater specificity regarding etiology, site, or manifestation of the illness or disease.

Tabular List of ICD-9-CM

set up in categories, subcategories, and fifth-digit subclassifications

residual subcategories (ICD-9-CM)

when the coder has limited amount of information, a residual category may be used. these include "other" and "unspecified" categories

fifth-digit sub-classification

if available must be used. the coder must always code to the greatest level of specificity

Braces { } (ICD-9-CM)

used in the tabular list to reduce repetitive wording by connecting a series of terms on the left with a statement on the right.

brackets [ ] (ICD-9-CM)

used in the tabular list to enclose synonyms, alternative wordings, and explanatory phrases. Ex. 460 Acute Nasopharyngitis [ common cold ]

slanted square brackets (ICD-9-CM)

used only in the alphabetic index to enclose a second code number that must be used with the first, and is always sequenced second. the first code (the one not in italicized brackets) represent the underlying condition. the second code represents the manifestation or what resulted from the underlying condition.

brackets (ICD-9-CM)

brackets in the alphabetic index can never be sequenced as principal diagnosis. they neeed to sequenced in the order as they appear in the Alphabetic Index

section marks §

indicate a footnote that normally means that a fifth digit is needed in that category (some books might use a different symbol)

cross-referenced terms (ICD-9-CM)

see
also see
includes notes
excludes notes
code also

"see" (ICD-9-CM)

requires the coder to look up a different term

"see also" (ICD-9-CM)

directs the coder to look under another main term if there is not enough information under the first term to identify the proper code.

includes notes (ICD-9-CM)

provide further examples or defines the category

excludes notes (ICD-9-CM)

printed in italics and in a box. it means the condition must be coded elsewhere or needs further codes to complete the description

notes (ICD-9-CM)

appear in both the tabular list and alphabetic index to provide further instructions or give directions

code also

means the coder must use a second code to fully describe the condition

multiple coding (ICD-9-CM)

is required for certain conditions not subject to the rules for combination codes.
Alphabetic index: codes for both etiology and manifestation of disease appear following the sub-entry term, with the second code italicized and in slanted brackets. assign both codes in the same sequence in which they appear in the alphabetic index

multiple coding (ICD-9-CM)

tabular list: instructional terms such as "code also" "use additional code for any" and "note" indicate when to use more than one code.

multiple coding "code also" (ICD-9-CM)

underlying disease assign the codes for both the manifestation and the underlying cause. the codes for manifestations that are printed in italics cannot be used (designated) as principal diagnosis

multiple coding "use additional code, if desired, to identify manifestations as...." (ICD-9-CM)

assign also codes that identifies the manifestation, such as but not limited to the examples listed. the codes for manifestations that appear in italicized print cannot be used (designated) as principal diagnosis

Not Elsewhere Classified (NEC) (ICD-9-CM)

means that a more specific category is not available in the ICD-9-CM.

Not Otherwise specified (NOS) (ICD-9-CM)

interpreted as unspecified and is used when the coder has no further information available in the medical record to fully define the conditon

ICD-9-CM Volume 3 procedural coding

includes the alphabetic index and tabular list for procedures. procedures are grouped by system and use numerical codes only.

procedure coding (ICD-9-CM)

the same as coding for diagnosis, locate main term in the alphabetic index and verify it in the tabular list. main term for procedure is in the procedure itself.

Volume 3 (ICD-9-CM)

not used in physician's office/clinic setting

subterms procedural coding (ICD-9-CM)

classify the procedure as to site and /or surgical technique .

canceled proceure

code as far as it proceeded. there are V codes available to code the diagnosis of surgery cancelled

"code also" coding procedure (ICD-9-CM)

used in the tabular list for procedures to mean code also if another procedure was performed

"omit code" coding procedure (ICD-9-CM)

a procedure may be done solely as an approach to be able to perform another procedure. it is at this time that the coder may see the instructional term "omit code" which means that the coder does not code this separately if it was performed as an operative approach

code operative report

first read through the entire report and make notes of any possible diagnoses or abnormalities noted and any procedures performed. sometimes a coder may find other diagnosis and procedures t hat the physician failed to list at the top. then review the physicians list of diagnosis to see if they match. problems should be brought to physicians attention

"sign" (ICD-9-CM)

is visible evidence that the physician can determing objectively

"symptom" (ICD-9-CM)

is subjective , descriptive term, usually in the patient's own words

conditions that are an integral part of a disease process

should not be assigned as additional codes. Ex. chest congestion is sign of pneumonia. code only pneumonia

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