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Medical Coding

Understanding Medical Coding 2nd ed, Chapter 1-4
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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