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Medical Coding Basics
Diagnosis & Procedural Coding 2015Presenters: Susana Martinez CPC, COC, CPMA, CEMC
and
Kyra Jones, CMIS, RCM Consultant
ICD
1700John
Graunt-London
1837William
Farr- Great Britain
1893Jacques
Bertillion- France
1898U.S.A began
use of Bertillion
Classification of Diseases
1900First
International conference
1938International Classification of Diseases
• John Graunt- one of the first experts in epidemology (disease control)
• William Farr- one of the founders of medical statistics (collection of data for healthcare use)
• Jacques Bertillion- developed Bertillion classifications of Causes of Death
1977WHO- 3 volume set
Today- Condensed into one book either containing two or three
volumes
1978International Classification of
diseases, Ninth Revision, Clinical Modification
ICD-9-CM
CM- Clinical ModificationVolumes 1 and 2• Codes diseases• Illnesses• Injuries• Both outpatient & inpatient
settings
PCS- Procedural Coding SystemVolume 3• Codes surgical• Diagnostic• Therapeutic Procedures• Inpatient Setting
Purpose
Intent- ICD system to provide morbidity statistics for the WHO
Today-medical offices use the coding system Provide information Verify the need for patient care/treatment Provide statistics for analysis of health care costs
ICD coding translates written medical terminology into diagnosis codes
Payers determine if the services are medically necessary and, therefore; reimbursable
Purpose cont’d: “Coding is a language”
• Used by insurance companies
• Used by health care providers
• Vital to care and treatment of patients
• Coder needs to be able to “translate” this language
Medical Coder-Role• Accurate coding essential to healthcare
industry• Review documentation in medical record,
translate into ICD“ If it wasn’t documented… it didn’t happen”
• Service must be reasonable and necessary
• Patient underwent blood glucose testing (procedure) for hyperglycemia (excess glucose)
• Diagnosis codes submitted in claims to payers
Compliance
Coding must meet federal guidelines Basis for studies and research into quality of healthcare Consistency and Accuracy
In the beginning…Simple phrase for
illness or condition or 1-3 digit diagnosis
code
ICD-9Today
5-6 digit diagnosis code
ICD-10October 1, 2015
7 digit diagnosis code
“Clavicle Fracture” 810.02 Clavicle fracture, closed; shaft of
clavicle
S42.022ADisplaced fracture of shaft or left clavicle; initial encounter for
closed fracture
What does ICD-9 mean to patients?
• Each diagnosis to a patient may be given has a code, a numbered designation, that identifies it.
• That code means that every medical professional in the United States and many other parts of the world will understand the diagnosis the same way.
• Documented Dx’s become a permanent part of the patient’s medical record.
• Continuity of Care – Documenting patient care so that others who treat the patient have a source of information on which to base additional care.
What does ICD-9 mean to patients… A Coder’s role
• Be a responsible coder/biller:
– Accuracy (Example: Elevated BP vs. Hypertension and Benign Neoplasms vs. Malignant Neoplasms)
– Information stored in data banks (locally, nation-wide, etc.,.)
– Affordable Care Act – took effect in 2014 (Pre-existing health conditions)
A Coder’s/Biller’s Role (cont’d)
• Cross-lines of “abuse & fraud”:
– Abuse - Actions that are inconsistent w/ accepted standards
– Fraud – Actions that are “intentional”, or knowing it is false
Contents
The introduction to each book provides important information to help coders understand the basic uses of the ICD-10-CM books
Volume understanding Volume I – tabular list
Numerical listing of diseases/injuries 17 chapters grouped by etiology (cause) or anatomical
(body) site.
Volume II – alphabetic index Listing of codes to assist in locating the complete code in
volume I Index to Diseases and Injuries Alphabetic Index to Poisoning and External causes Table of Drugs and Chemicals
Volume III – alphabetic index & tabular index Used by hospitals (procedures and surgeries) Tabular list of procedures by anatomical site Miscellaneous diagnostic and therapeutic procedures
Why are the Volumes of ICD-9 out of sequencing???
Format of ICD-9 CMDiabetes mellitus
250Diabetes mellitus
without mention of complication
250.0Range (0-9)
Diabetes mellitus without mention of
complication; type II or unspecified type not
stated as uncontrolled250.00
Range (0-3)
4th digit needed: patient’s condition
5th digit needed: higher specificity
Diagnosis Completion
Conventions
Coders need to understand the symbols, abbreviations and other conventions used within the ICD-9-CM
Conventions are found in the introduction of the volume. These are some of them:
Print type Bold face Volume I - All title and codes are printed in bold type Volume II – main term is printed in bold face
Italics• Both volumes to highlight all exclusion notes and
to identify codes that should NOT be used as the primary code
• Instructions for this code are written in italics to code first the underlying disease, such as Diabetes• Diabetes is the primary diagnosis followed by
the Gangrene (manifestation) or secondary diagnosis.
ICD-9 785.4 Gangrene ICD-10 I96 Gangrene, not elsewhere classified
ICD-9 250.70 Diabetes with peripheral circulatory disorders 785.4 Gangrene
ICD-10 E08.52 Diabetes Mellitus due to underlying condition with diabetic gangrene
Volume 1
• Tabular List of Diseases and Injuries• Three major subdivisions:
– Classification of Diseases and Injuries– Supplementary Classifications
(V and E codes)– Appendices
Volume 1 (cont’d)Other ICD-9-CM Elements
V-codes supplemental classification codes for factors that influence a patient’s care Used when a patient sees the doctor without a complaint
or problem (sports exam, etc.) or to describe conditions that could influence patient care (allergies, etc.). There are 3 main categories:
Problems – something that could affect overall health V10.04- Personal History of Malignant Neoplasm
stomach Services – patient seen for a problem/treatment
V70- General Medical Examination Factual findings – description of facts for statistics
V30.01- Single liveborn, born in hospital, delivered by cesarian delivery
Using E Codes
E-codes are optional codes that describe the following Events or circumstances Causes of injury or poisoning Other adverse effects
Should never be used as a primary or stand-alone code
Provide details of an incident or injury and help identify the
following Automobile accident liability Worker compensation situations Third-party insurance liability
Where?Why?How?
Injury coding example
ICD-9• 784.7 Epistaxis (nose bleed)• E917.0 Striking against or
struck accidently by objects or persons in sports
• E007.6 Activities involving other sports and athletics played as a team
• E849.4 Place of occurrence-recreation and sport
ICD-10• R04.0 Hemorrhage from
respiratory passages• W21.89XA Striking
against or struck accidentally by other sports equipment, initial encounter
• Y93.67 Activity basketball• Y92.830 Public park as
the place of occurrence of the external cause
Harold was playing basketball with friends at the park when the ball accidentally hit him in the nose; his nose is bleeding and he goes to see his doctor because the bleeding does not stop.
Volume 2
• Alphabetic list of conditions • Major subdivisions:
– Index to Diseases and Injuries– Table of Drugs and Chemicals– Alphabetic Index to Poisoning and
External Causes (E-codes)
Volume 2 (cont’d): The Key
• Volume 2—Alphabetic Index• Main terms:
– Disease– Sign– Symptom– Condition– Injury
Vol 2 (cont’d):Table of Drugs and Chemicals
• This table contains a classification of drugs and other chemical substances
– Identify poisoning states(poisoning classification range 960-989)
– External causes of adverse effects (external causes code range E850-E982).
Vol 2 (cont’d):Table of Drugs and Chemicals
Volume 3
• Tabular List and Alphabetic Indexof Procedures
• Procedures and surgeries• Organized by location of procedure• Used in facility setting
ICD-9
How to Find ICD-9-CM Code
Have good research habits Basic steps to finding the correct
code:1. Correctly identify the main term/condition (Vol 2)2. Use the index to locate the condition/problem3. Review information given following all instructions4. Locate and confirm the correct code in the tabular list and select
the correct code5. Put codes in correct sequence when using multiple diagnoses
Ex: Patient with peptic ulcer (unspecified as acute or chronic was seen for pharyngitis462- Acute pharyngitis533.9X- Peptic Ulcer unspecified as acute or chronic*0-without mention of obstruction*1-with obstruction
Alphabetic Index to Diseasesand Injuries
• The “key” to locating diagnoses codes
• The index is organized by main terms
DX: “Low Back Pain”• Main term is pain• The coder then asks, what type of
pain…back• Code: 724.2
Code the confirmed diagnosis whenever possible
• If you have confirmed a diagnosis based on the results of the diagnostic test, you should code that diagnosis.
• If there’s no confirmed diagnosis or the results are normal, code the signs and symptoms that prompted you to order the test.
For example: • Patient in your office for
chest pain, EKG performed.• The EKG is normal, and the
final diagnosis is chest pain due to suspected gastroesophageal reflux disease (GERD).
• The primary diagnosis code for the EKG should be chest pain, because the EKG was normal and you did not determine a definitive cause for the chest pain
Symptoms and Signs
• Used when definitive diagnosis has not been established
• Not assigned a code if it is part of a disease process with definitive diagnosis
Acute and Chronic Conditions
• Acute – A condition that is of a sudden onset or short duration
• Chronic – A condition that is ongoing, typically permanent, but some can eventually resolve and disappear altogether. More correctly, chronic refers to a time frame of 3-months or
more.
• How to code acute & chronic conditions is addressed in the Official Coding Guidelines. A coder should code both if documented, but select the acute condition first.
Impending or Threatened Conditions
• The coder must ask “Did the condition actually occur?”
• If it did, the diagnosis is confirmed
• If it did not, further research is necessary
ICD-10-CM: Preview
Released by the WHO in 1992
U.S. lagged implementation; effective
October 1, 2015
Volumes 1 and 2 -replaced by ICD-10-
CM
Volume 3 -replaced by ICD-10-PCS
(developed by the Centers for Medicare
and Medicaid Services CMS)
Why ICD-10-CM?
Three objectives of the ICD-10-CM coding system Completeness – unique code for each illness or disease Expandability – new injury or disease can be incorporated
easily into the existing structure Standardization – terminology defined for standardization
with each term being assigned a specific meaning
Comparison
ICD-10-CM
Tabular Alphabetic index Procedures 21 chapters Alpha-numerical code system 6th and 7th digit specificity Limited use of unspecified codes Supplementary class for V and E
codes New chapters for disease of eye and
ear instead of inclusion in nervous system
• Terminology has been modernized and reflects current usage of medical terminology
ICD-9-CM
Tabular Alphabetic index Procedures 17 chapters Numerical code system 4th and 5th digit specificity Category for unspecified codes Supplementary class for V and E
codes Based on outdated technology
and reduces coding effectiveness (left vs. right)
Structure difference
ICD-10… Keeping it Interesting V61.8- Other specified family circumstance
Z63.1- Problems in relationship with the in-laws
E917.4- Striking against or struck accidentally by other stationary object without subsequent fall (lamp post)
W22.02XD- Walking into lamppost, subsequent encounter
T71.231D- Asphyxiation due to being trapped in a (discarded) refrigerator, accidental, subsequent encounter
E844.9- Other specified air transport accidents injuring other person
V97.33XD- Sucked into jet engine, subsequent encounter
W16.221D- Fall into bucket of water causing drowning and submersion, subsequent encounter
E928.4- External constriction caused by hair
W49.01XA- Hair causing external constriction, initial encounter
Getting Ready for the Change
Tips:
Document specific to visit
Choose the diagnosis that fits your documentation
Keep informed of changes
CMS- Recommended Approach
• Step 1- Make a plan
• Step 2- Train your staff
• Step 3- Update your processes (claim forms, superbills and replace ICD-9 diagnosis codes with ICD-10)
• Step 4- Talk to your vendors and health plans (clearinghouses- confirm systems are ready)
• Step 5- Test your systems and processes (verify you can generate claims- test with health plans, clearinghouses and vendors)
• For more information: visit CMS website at cms.gov/ICD10
The fundamentals of ICD-9 will still be important
after the October 1st implementation.
Not all carriers will be ready or even accept the ICD-10 code set. Some
of those carriers are:
Workmen’s Compensation
Auto & Liability Agencies
Current Procedural Terminology
CPT Code Set
CPT is a coding nomenclature (system of names or terms) that allows medical procedures to be transformed to numbers
CPT is based on professional services provided by healthcare providers such as a physician, nurse practitioner or physician assistant
• CPT services include office visits, surgery, laboratory, radiology, pathology, anesthesia and medical procedures
Background
CPT was developed by the American Medical Association and CPT is still currently maintained by the AMA
CPT code sets HCPCS level I
CPT codes maintained by AMA HCPCS level II
HCPCS codes maintained by Federal Government
Background (cont’d)
• 1966: Published by AMA (four-digit codes)
• 1970: Five-digit codes • 1983: Adopted as part of HCPCS
• 1992: Implementation of E&M codes
• Updated yearly (January) and AMA panel reviews codes quarterly (May, August, November & February)
Purpose Reimburse physician services Trending services provided nationally Future coding and reimbursement
planning Benchmarking facilities, costs and
services Measuring quality of care and patient
outcomes nationally
Code Requirements
ALL CPT CODES MUST BE: Commonly performed by physicians
across the nation Consistent with mainstream medical
practice Approved by the AMA CPT Editorial
Board
CPT Code Organization
Each code is followed by a unique code descriptor explaining the service
More than 8,800 unique CPT codes (2015)
CPT codes are 5 digits long CPT manual includes parenthetical
notes
Introduction to CPT
Category I codes are permanent codes 6 Sections of Category I codes-each
with a set of guidelines at the beginning of each Evaluation and Management (E/M) Anesthesia Surgery Radiology Pathology/Laboratory Medicine
CPT Category I Code Number Format
• Five-digit code number and narrative description for each procedure and service
– Stand-alone code – includes complete description of procedure or service
– Indented code – appears below stand-alone code, requiring coder to refer back to common portion of code description located before semicolon
CPT Category I Code Number Format (cont’d)
EXAMPLE:
59514 Cesarean delivery only;
59515 including postpartum care
Category I Codes Evaluation and Management: 99201-99499 Services performed to determine care of patient
Anesthesia: 00100-01999 Routine care: pre-op, intra-op, post-op
Surgery: 10021-69990 (largest section) Divided by body systems: (pre-op, intra-op, post)
Integumentary 10021-19499
Musculoskeletal 20005-20205
Respiratory 31600-31628
Cardiovascular 33010-37799
Hemic and Lymphatic 38100-38999
Mediastinum/Diaphragm 38747-39599
Digestive 40490-49999
Urinary 50010-53899
Male Genital 54000-55899
Female 56405-58999
Maternity Care and Delivery 59000-59899
Endocrine 60000-60699
Nervous 61000-64999
Eye and Ocular Adnexa 65091-68899
Auditory 69000-69990
Category I Codes ContinuedRadiology: 70010-79999 selected based on the body part and number/type of view
Pathology/Laboratory: 80048-89398
Complete procedure includes: Ordering test
Taking/handling the sample
Performing the test
Analyzing/reporting on the test results
Medicine: 90281-99607 include many types of evaluation, therapeutic and diagnostic procedures that physicians and other health care providers perform.
Category II Codes
Used to track physician performance in measuring and monitoring patient care
Are alphanumeric codes, starting with 4 numbers followed by the letter F
Improve quality of care but are not “billable”
Category III Codes
Introduced in 2002 Are alphanumeric codes, starting with 4
numbers followed by the letter T (temporary code)
They are used to report new technology, services or procedures that do not currently have a CPT code assigned
Located directly after the Category II codes Allow researchers to track emerging
technology
CPT Appendices• Appendix A
• Lists/examples of modifiers• Appendix B
• Summary of additions/deletions/revisions• Appendix C
• Clinical Examples of E/M Codes• Appendix D
• Summary of CPT Add-on Codes • Appendix E
• Summary of CPT codes exempt from -51• Appendix F
• Summary of CPT codes exempt from -63• Appendix G
• Summary of CPT codes which include conscious sedation• Appendix H
• Alphabetical index of performance measures by clinical condition or topic
CPT Appendices (cont’d)
• Appendix I• Genetic Testing Code Modifiers
• Appendix J• Electro diagnostic Medicine Listing of Sensory, Motor and
Mixed Nerves• Appendix K
• Product Pending FDA Approval• Appendix L
• Vascular Families• Appendix M
• Crosswalk to deleted CPT codes
CPT Appendices (cont’d)
• Appendix N• Re-sequenced codes
• Appendix O• Administrative codes for multi-analyte assays
Punctuation and Symbols; Semicolon
(Divides the common portion of a code descriptor from the unique portion)
● Bullet
(New Code)
▲ Triangle
(Revised code)
+ Plus Symbol
(Add on code)
Modifier 51 Exempt (Circle w/slash)
(Indicates the code cannot be assigned with -51)
Punctuation and Symbols (cont’d)
FDA approval pending
Hollow Circle
(Indicates a reinstated or recycled code)
# Number symbol
(Re-sequenced code)
Bull’s Eye
(That conscious sedation is included in code)
Punctuation and Symbols (cont’d)
►◄ Facing Triangles
(Revised guidelines and note)
Green Arrow
(Refer to CPT Assistant or CPT changes)
Red Arrow
(Refer to Clinical Examples in Radiology for guidance)
CPT/HCPCS Modifiers
Reported as 2-digit numeric & alpha characters added to CPT and HCPCS codes
Used to communicate special circumstances surrounding the assigned code
May increase or decrease the amount of reimbursement
Three types of modifiers CPT Modifiers Facility Modifiers HCPCS Modifiers (CPT and HCPCS book)
CPT Modifiers (continued)
Description of Modifiers 21 prolonged evaluation and management services
22 – unusual (increased) procedural services• Morbidly obese patient with massive adhesions require extra time to
lyse (cut down)
23 – unusual anesthesia
24 – unrelated evaluation and management service by the same physician during a postoperative period• Pt had hysterectomy two weeks ago (90 day period); comes in today for
UTI (totally unrelated to surgical procedure). E/M for today will need 24 for reimbursement
25 – significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service• Pt comes in for routine checkup for hypertension medication refill, In
addition pt has abscess on their back so an ID was performed. Modifier 25 is appended to E/M
Description of Modifiers (cont’d)26 – professional component
27 – multiple outpatient hospital E/M encounters on the same date
32 – mandated services
47 – anesthesia by surgeon
50 – bilateral procedure
51 – multiple procedures
52 – reduced services• CPT 92550 (Use modifier 52 if a test is applied to one ear instead of
two ears) bilateral by CPT guidelines
53 – discounted procedure
54 – surgical care only
Description of Modifiers (cont’d)
55 – postoperative management only• Patient goes to ophthalmologist for cataract surgery, returns for post
operative management for visit(s)
56 – preoperative management only
57 – decision for surgery
58 – staged or related procedure or service by the same physician during the postop period
59 – distinct procedural service
62 – two surgeons
63 – procedure performed on infants less than 4 kg
Description of Modifiers (cont’d)
66 – surgical team
73 - discontinued out-patient hospital/ambulatory surgery center procedure prior to the administration of anesthesia
74 - discontinued out-patient hospital/ambulatory surgery center procedure after administration of anesthesia
76 – repeat procedure by same physician
77 – repeat procedure by another physician
78 – return to the operating room for a related procedure during the postoperative period• Dr. Smith performs a C-section. A week later, the pt returns to OR for a
post-operative infection (complication) and an ID is performed.
79 – unrelated procedure or service by the same physician during the postoperative period• Dr. Jones performs a vasectomy (90 day global). Two weeks later, pt
returns for skin tag removal off back.
Description of Modifiers (cont’d)
80 – assistant surgeon
81 – minimum assistant surgeon
82 assistant surgeon (when qualified resident surgeon not available)
90 – reference (outside) laboratory
Description of Modifiers (cont’d)
91 – repeat clinical diagnostic laboratory test
99 – multiple modifiers
Description of Modifiers (cont’d)“Eyelids, Fingers & Toes”
EYELIDS: FINGERS: TOES:E1- upper left eyelid FA-left hand thumb TA- left foot great toeE2- lower left eyelid F1- left hand second digit T1- left foot second digitE3- upper right eyelid F2- left hand third digit T2- left foot third digitE4- lower right eyelid F3- left hand fourth digit T3- left foot fourth digit
F4- left hand fifth digit T4- left foot fifth digit F5- right hand thumb T5- right foot great toeF6- right hand second digit T6- right foot second digitF7- right hand third digit T7- right foot third digitF8- right hand fourth digit T8- right foot fourth digitF9- right hand fifth digit T9- right foot fifth digit
CPT Physical Status Modifiers
-P1 normal healthy patient
-P2 patient with mild systemic disease
-P3 patient with moderate systemic disease
-P4 patient with severe systemic disease that is constant threat to life
-P5 moribund patient who is not expected to survive without operation
-P6 declared brain-dead patient whose organs are being removed for donor purposes
HCPCS Level II Anesthesia Modifiers
-AA anesthesia services performed personally by anesthesiologist
-AD medically supervised by a physician for more than four concurrent procedures
-G8 monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
-G9 MAC for patient who has a history of severe cardiopulmonary condition
HCPCS Level II Anesthesia Modifiers (cont’d)
-QK medical direction of two, three, or four concurrent anesthetic procedures involving qualified individuals
-QS monitored anesthesia care service
-QX CRNA service, with medical direction by physician
-QY medical direction of one CRNA by an anesthesiologist
-QZ CRNA service, without medical direction by physician
HOW TO ASSIGN CPT CODES AND MODIFIERS
Step 1: Read the introduction in the CPT manual.
Step 2: Review the complete medical documentation
Step 3: Abstract the medical procedures that should be coded• Code what is documented in source document• Obtain clarification from provider if necessary
Step 4: Identify the main terms and related terms in the CPT Index‒ Main terms can be located by referring to:
• Procedure or service documented• Organ or anatomic site• Condition documented in the record• Substance being tested• Synonym• Eponym• Abbreviation
HOW TO ASSIGN CPT CODES AND MODIFIERS (cont’d)
Step 5: Locate sub-terms and follow cross referencing
Step 6: Review the description of codes and section notes in the appropriate CPT section
Step 7: Verify the code against the documentation
Step 8: Assign codes for all significant services, applicable add on codes and modifiers
Step 9: Cross check your NCCI edits
CPT UPDATES
New, deleted and changed CPT codes are updated yearly, in October by the AMA and go into effect January 1st of the following year.
Category III codes are updated twice a year, July 1 and January 1.
CPT
Unlisted Procedures/Services
• Assigned for procedure or service for which there is no CPT code
• Special report (e.g., copy of procedure report) is attached to claim to describe:– Nature– Extent– Need for procedure or service– Time, effort, and equipment necessary
CPT Index
• Organized by alphabetical main terms
• Main terms represent:– Procedures or services– Organs or anatomic sites– Conditions– Synonyms, eponyms, and abbreviations
CPT Index – Single Codes and Code Ranges
• Index code numbers are represented by:– Single code number– Range of codes, separated by:
• Dash• Series of codes separated by commas• Combination of single codes and ranges of
codes
Evaluation and Management Section
• Located at beginning of CPT because these codes describe services most frequently provided by physicians
• Accurate assignment is essential to success of physician practice because most revenue is generated by these services
Professional vs. Technical Component
• Professional component – covers supervision of procedure and interpretation/documentation of report describing examination and findings
• Technical component – covers use of equipment, supplies provided, and employment of radiologic technicians
Professional vs. Technical Component (cont’d)
• When two separate billings are required:‒ CPT modifier -26 (professional component) is
added to CPT Radiology code number by physician
‒ HCPCS level II modifier -TC (technical component) is added to CPT Radiology code by hospital
• Exception to this rule:‒ When code description restricts use of code to
“supervision and interpretation”
Surgery Section
• Organized by body system
• Subsections are subdivided into categories by specific organ or anatomic site
• To code surgeries properly, ask the following questions:
1.What body system was involved?2.What anatomic site was involved?3.What type of procedure was performed?
Surgical Package
• Global period – number of days associated with surgical package; designated as 0, 10, or 90 days
HELPFUL CODING RESOURCES
Medical Dictionary Anatomy & Physiology Text Current ICD-9-CM, CPT, and HCPCS
codebooks Physician’s Desk Reference Contractor’s Provider Manual Subscription to AMA Coding Assistant www.cms.hhs.gov/NationalCorrectCodInitEd www.cms.hhs.gov/center/coverage.asp http://www.icd10data.com/Convert
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