Comprehensive Health Insurance Billing, Coding, and Reimbursement

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Comprehensive Health Insurance Billing, Coding, and Reimbursement. Chapter 4 ICD-9-CM Medical Coding. Definition of Diagnosis Coding. Describes services and procedures diagnoses ICD-9-CM: Volumes are now used for coding the appropriate medical conditions. Coding History. - PowerPoint PPT Presentation

Text of Comprehensive Health Insurance Billing, Coding, and Reimbursement

  • COMPREHENSIVE HEALTH INSURANCEBILLING, CODING, AND REIMBURSEMENT

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    DEFINITION OF DIAGNOSIS CODINGDescribes services and procedures diagnosesICD-9-CM:Volumes are now used for coding the appropriate medical conditions

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    CODING HISTORYBills of mortality 1665: some of the earliest uses of codingWarnings of plague epidemicsDiagnoses were often wrong or vague18th century: Cause of death was noted

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    PURPOSE OF THE ICD-9-CMEstablishes medical necessityTranslates written terminology into common languageProvides data for statistical analysis

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    THE YEARLY ADDENDAIncludes the addition of new codesDeletes old codesIncludes descriptor revisions

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    THE THREE VOLUMES OF THE ICD-9-CMVolume 1: Tabular/numerical list of diseasesVolume 2: Alphabetic index of diseaseVolume 3: Tabular and alphabetic index of procedures

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    ICD-10-CMReplaces volumes 1 and 2 of the ICD-9-CMUses alphanumeric codesIs much more detailed than ICD-9-CMIncludes ambulatory and managed care encountersContains injury codes

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    ICD-10-CMCombines many codes to give a more detailed description of the injury or illnessNo implementation date has been set yet for the ICD-10-CM. Implementation will be based on the process for adoption of standards under HIPAA.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    COMMON TERMINOLOGYEncounter: Refers to all healthcare settingsProvider: Physician or qualified healthcare providerDiagnostic statement: The main reason for encounterPrimary diagnosis: The main reason for visit or encounter

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    COMMON TERMINOLOGYPrincipal diagnosis: The final diagnosisManifestation: The sign or symptom of a diseaseNEC: Not elsewhere classifiedNOS: Not otherwise specified

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    SYMBOLS AND TYPEFACE AND TERMSBoldface: Main termSubterms: Indented two spaces to the rightSupplementary term: Assists coder in finding correct term( ): Parentheses enclose supplementary words

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    SYMBOLS AND TYPEFACE AND TERMSColon (:) is used after incomplete phrase or term requiring indented term(s)[ ]: used to enclose synonyms, alternate wordings, or explanatory phrasesInstructional terms: Assists coder in finding most specific term

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    VOLUME 2, THE ALPHABETICAL INDEXUse this volume first to search for the correct code or condition.After you find the code, use Volume 1 (tabular list) to research the specific code.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    VOLUME 1, THE TABULAR LISTUsed to research the specific codePunctuation has various meanings.A colon : is used after an incomplete phrase or when a modifier is needed.Square brackets, [ ], are used to enclose synonyms, alternate wordings, or explanations.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    VOLUME 1, THE TABULAR LISTPunctuation has various meanings.Parentheses () are used to enclose supplementary words that may be present or absent in a statement of disease without affecting the code assignment

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    THREE STEPS FOR ACCURATE CODINGDetermine the reason for the encounter.Locate the term in alphabetic index Volume 2.Verify the code in the tabular list (Volume 1).

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    KEY CODING GUIDELINESCode the primary diagnosis first, followed by current coexisting conditions.Code to the highest level of certainty.Code to the highest level of specificity.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    CODE TO THE HIGHEST LEVEL OF CERTAINTYCode condition of encounter.Sign: ObjectiveSymptom: SubjectiveSigns, symptoms, ill-defined conditionsUse Volume 2, alphabetic index, for sign or symptomUse Volume 1, Chapter 16, to verify

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    CODE TO HIGHEST DEGREE OF SPECIFICITYAssign three-digit codes if there are no four-digit codes in the category.Assign four-digit codes if there are no five-digit codes in the category.Claims submitted with three- or four-digit codes will be returned if four- to five-digit codes are available.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    PROPER ORDER FOR CODINGMain reason for encounterAny current coexisting conditionDo not code conditions that were previously treated and no longer exist.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    SUBSEQUENT CODINGSurgical coding: Diagnosis for which surgery is performedLate effects/residual effects: Condition that remains after an acute illness or injuryAcute and chronic conditionsCombination codes

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    SUBSEQUENT CODINGV codes: Supplemental code that describes problems, services, or factsE codes: Supplemental classifications of external causes of injuries and poisonings

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    NINE STEPS OF ACCURATE ICD-9-CM CODINGLocate main term in the diagnostic statement.Locate the main term in Volume 2, the alphabetic index.Refer to all notes under the main term. Use instructions in any notes appearing in a box after the main term.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    NINE STEPS OF ACCURATE ICD-9-CM CODINGExamine any modifiers.Note any subterms that provide greater specificity.

    Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

    NINE STEPS OF ACCURATE ICD-9-CM CODINGFollow any cross-reference instructions.Confirm the code selection in the tabular list (Volume 1).Follow the instructional terms in Volume 1.Assign the correct code number.

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