© 2009 the mcgraw-hill companies, inc. all rights reserved 16-1 medical coding powerpoint®...

16-1

© 2009 The McGraw-Hill Companies, Inc. All rights reserved

Medical CodingMedical CodingPowerPoint® presentation to accompany:

Medical AssistingThird Edition

Booth, Whicker, Wyman, Pugh, Thompson


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Learning Outcomes

16.1 Explain the purpose and format of the ICD-9-CM volumes that are used by medical offices.

16.2 Describe how to analyze diagnoses and locate correct codes using the ICD-9-CM.

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.


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Learning Outcomes (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.


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Introduction

Medical coding Translation of medical terms for diagnoses and

procedures into code numbers from standardized code sets

Tells payers that the services provided Were medically necessary Complied with payer’s rules

Accurate claims bring maximum appropriate reimbursement for the medical office


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Diagnosis Codes: The ICD-9-CM

Patient Chief Complaint

Physician MedicalDiagnosis

InsuranceDiagnosisCode

The diagnosis codes are found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9)

The use of ICD-9 codes in health care is mandated by HIPAA for reporting:

Patient’s diseases Conditions Signs and symptoms


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Alphabetic Index (Volume 2) Diagnoses appear in alphabetical order The index is organized by condition Use initially to look up conditions Cross-references

Look up term that follows “see”

Diagnosis Codes: The ICD-9-CM (cont.)

The Alphabetical Index is never used alone to find a diagnosis code because it does not contain all the necessary information.


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Tabular List (Volume 1) Diagnoses appear in numerical order Listing is organized according to source or

body system

Code Structure

Codes are made up of three, four, and five digits and a description Three-digit categories are used for diseases, injuries, and

symptoms Categories are further divided into four- and five-digit codes



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Supplementary classification of factors influencing health status and contact with health services

Identify encounters for reasons other than illness or injury

May be a primary code or additional code

“E” – external

Only a supplemental classification of external causes of injuries and poisoning

V Codes

E Codes



16-9

A list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.

Conventions

NOSAn abbreviation that means “not otherwise specified” or “unspecified”

NECAn abbreviation that means “not elsewhere classified”; 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 ( )Parentheses are used around alternative wording

Diagnosis Codes: ICD-9-CM Conventions


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Conventions

: Used in the Tabular List after an incomplete term} Brace encloses a series of terms

Includes Refines content of preceding entry

§ Indicates that the footnote is applicable to all subdivisions in that code

Excludes Indicates that the entry is not classified as part of the preceding code

Diagnosis Codes: ICD-9-CM Conventions (cont.)


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Conventions

ExcludesThese notes indicate that an entry is not classified as part of the preceding code

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 for the primary diagnosis

Diagnosis Codes: ICD-9-CM Conventions (cont.)


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Locate statement of diagnosis in patient’s medical record

Find the diagnosis in the Alphabetic Index

Locate the code from the Alphabetic Index in the Tabular List

Read all information to find the code that corresponds to the patient’s condition

Record the code on the claim form

Diagnosis Codes: The ICD-9-CM Codes (cont.)


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ICD-10-CM: A new revision Major changes

Contains more than 2000 disease categories Codes are alphanumeric, containing a letter

followed by up to five numbers Codes are added to show the specific side of the

body affected by the disease process Expected to be adopted as HIPAA-required

diagnosis code set before 2010

Diagnosis Codes: The ICD-10-CM


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Apply Your Knowledge

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?

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.


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Procedure Codes: The CPT

Current Procedural Terminology (CPT) book 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) Updated annually Use the appropriate CPT book for the current year


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Procedure Codes: Using the CPT

Except for the first section, the CPT book is arranged in numerical order

Section Range of Codes

Evaluation and Management 99201–99499

Anesthesiology 0010–01999Surgery 10021–69990

Radiology 70010–79999

Pathology and Laboratory 80048–89356

Medicine 90281–99602


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Add-on codes A plus sign (+) is used Always used with primary code

Modifiers One or more two-digit numbers (up to three per

procedure) assigned to five-digit main number Indicate that special circumstance applies

Procedure Codes: Using the CPT (cont.)


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Category II, III, and Unlisted procedure codes Category II

Tracks health-care performance measures Category III

Temporary codes for emerging technologies, services, and procedures

Unlisted codes Used when no other code is available Require a written explanation

Procedure Codes: Using the CPT (cont.)


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Used by all physicians in any medical specialty Key factors that help determine level of service

Procedure Codes:Evaluation and Management Services

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 – not seen by physician within the past 3 years

Established patients – seen within a 3 year period


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The surgical package All procedures normally a part of an operation

Anesthesia Surgery Routine follow-up care

Global period The time period covered for follow-up care If past global period, additional services are

reported separately

Procedure Codes: Surgical Procedures


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Laboratory Procedures

Immunizations

Procedure Codes: The CPT (cont.)

Injections require two codes One for the procedure (injection) One for the medication (vaccine or toxoid)

Panels – organ or disease-oriented Pathology and Laboratory sections

of the CPT If separate codes are used, they will

be rebundled and payment delayed


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1. Which section of the CPT is not arranged in numerical order and why?

ANSWER: The first section, Evaluation and Management, is not in numerical order because the items in this section are used most often and by all physicians in any medical specialty.

Excellent!


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2. 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:

a. Use the current book to validate accuracy of the codes

b. Use last year’s book to validate accuracy of the codes

c. Use next year’s book to validate accuracy of the codes


Excellent!ANSWER:


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HCPCS

The Health Care Common Procedure Coding System

Developed by the Centers for Medicare and Medicaid Services (CMS)

Pronounced “hic-picks”


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HCPCS (cont.)

Contains two levels Level I codes

Duplicate CPT codes Level II codes

National codes for supplies and DME (durable medical equipment)

5 characters – numbers, letters, or a combination of both

Can have modifiers


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What are HCPCS Level II codes and who issues them?

ANSWER: HCPCS Level II codes are national codes used for supplies, DME, and services not included in the CPT. They are issued by Centers for Medicare and Medicaid Services (CMS).


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Avoiding Fraud: Coding Compliance

Medical assistants help ensure that maximum appropriate reimbursement is received for services provided

Compliance with federal and state law and payer requirements is mandatory

Code Linkage

Diagnostic

Procedures

A process used by insurance company representatives to evaluate the necessity of medical procedures reported based on the patient’s diagnosis

Prevent errors in coding and incorrect billing by careful attention to details


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Avoiding Fraud: Insurance Fraud

Investigators look for patterns such as Reporting services that were not performed

Reporting services at a higher level

Performing and billing for procedures 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


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Medical offices establish a process for finding, correcting, and preventing illegal medical practices

Goals of compliance plan Prevent fraud and abuse Ensure compliance with applicable laws Help defend physicians if investigation occurs

Avoiding Fraud: Compliance Plans


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Avoiding Fraud: Compliance Plans (cont.)

Plan demonstrates to payers honest, ongoing attempts to correct any weak areas of compliance

Plan is developed by a compliance officer and committee who also: 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


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What are the goals of a compliance plan and what does having a plan indicate?

ANSWER: The goals of a compliance plan are to prevent fraud and abuse, ensure compliance with applicable laws, and to help defend physicians if an investigation occurs. Having a plan indicates that the medical office is making honest, ongoing attempts to find and fix weak areas of compliance.

Correct!


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In Summary

ICD-9-CM Diagnostic coding for health-care claims Updated annually Two volumes

Tabular list Alphabetic list

V codes – encounters not related to illness or injury

E codes – injuries related to environmental events


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In Summary (cont.)

CPT Standardized procedure codes for medical,

surgical, and diagnostic services Six sections

Evaluation and Management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine


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In Summary (cont.)

HCPCS is used for coding Medicare services CPT Level II national codes

Claims Link diagnoses and procedures correctly Must comply with applicable regulations and

requirements

Practices should have a compliance plan with a formal process for review of procedures to guard against fraud


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Things gained through unjust fraud are never secure.

~ Sophocles

© 2009 the mcgraw-hill companies, inc. all rights reserved 16-1 medical coding powerpoint®...

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