medical coding ii – seminar #1 hi255p – 01 deborah a. balentine m.ed., rhia, ccs-p kaplan...
TRANSCRIPT
Agenda Introductions General Class Information Tips and Strategies for Success What is Medical Coding? Basic ICD-9-CM Coding Guidelines Basic CPT Coding Guidelines V-Codes Looking Ahead – Unit 2
IntroductionsWelcome to the Class!
About Your Instructor:15 + years in HIM8 + years as an Instructor
About You:Where were you on New Years Eve?What is the one thing that you would like to
accomplish this year?
General Class InformationAbout the ClassContinuation of Medical Coding IAdvanced Study of Medical Coding Circulatory System Respiratory System Pregnancy and Congenital Anomalies Health Status (V-Codes) Late Effects Reimbursement Topics (POA) Guidelines
General Class InformationCourse Outcomes and Expectations: Accurately locate and report ICD-9-CM and
HCPCS codes following all applicable guidelines.
Use coding software to accurately report ICD-9-CM and HCPCS codes.
Interpret and apply coding and billing guidelines for accurate reimbursement.
Perform data quality reviews to validate code assignment.
General Class Information More Information:Seminars:Sundays, 7:00 – 8:00 pm ESTVirtual Office Hours:Monday – Friday, 9:30 – 10:30 am ESTOther Contact Information:E-mail – [email protected] – (708) 305-7848No texts please
Tips and Strategies for Success Remember that Medical Coding is a language
and it requires a working knowledge of medical terminology, anatomy and physiology.
Always, always look up any unfamiliar terms and phases. Utilize medical dictionaries and your text books.
Attend as many Seminars as you can. It the best way to get you questions answered in “real time”.
Remember that one of your best resources is your instructor. Please feel free to contact me with your questions and concerns.
What is Medical Coding? Translating narrative descriptions into
numbers Generally Accepted Guidelines and
Conventions ICD-9-CM CPT/HCPCS
Other Coding and Classification Systems DSM-IV (Behavioral Sciences) ABC Codes (Alternative Medicine)
What is Medical Coding?Diagnosis vs. Procedure Codes Diagnosis Codes – The “Why”Diagnosis codes identify the disease, problem
or condition that is the reason for the visit. Procedure Codes – The “What”Procedure codes identify the treatment that is
given to the patient for the disease, problem or condition that is the reason for the visit.
When reporting and coding a complete scenario always sequence the “why” before the “what”.
What is Medical Coding?Facility vs. Professional Fee Coding
Facility Fee Coding – The resources expended by the facility when performing a service or procedure.
Professional Fee Coding - The skill, time and effort expended by the practitioner when performing a service or procedure.
What is Medical Coding?When coding for Hospital Inpatient Facility
Services, you use ICD-9-CM diagnosis and procedure codes.
When coding for Hospital Outpatient Facility Services, you use ICD-9-CM for diagnosis and HCPCS/CPT codes for procedures.
When coding for professional (i.e. physician services) you use ICD-9-CM for diagnosis and HCPCS CPT codes for procedures regardless of the clinical setting.
General ICD-9-CM Coding Guidelines
Use both the ICD-9-CM Index to Diseases and the Tabular List of Diseases.
Locate term in the Index to Diseases first, and verify the code in the Tabular List of Diseases.
Assign the highest level of digits available.
Basic ICD-9-CM Coding Guidelines
Principal Diagnosis (Inpatient):
The principal diagnosis is the condition established after study found to be chiefly responsible for the admission of the patient into the hospital for care.
Example #1What is the Principal Diagnosis?A patient is admitted complaining of chest pain,
congestion, and shortness of breath. Diagnostic testing includes a chest x-ray that reveals patchy infiltrates and a sputum culture is consistent with bacterial pneumonia.
Answer:For this scenario, you would only report the
bacterial pneumonia. The signs and symptoms have been linked to the more definitive diagnosis of pneumonia. The diagnostic testing also confirms the presence of the pneumonia.
Basic ICD-9-CM Coding Guidelines
Principal Diagnosis (Outpatient):
In the Outpatient setting you must code to the Highest Level of Certainty. List the ICD-9-CM code for the condition, problem or other reason for the encounter/visit found to be chiefly responsible for the services provided
Example #2What is the “First-Listed” diagnosis?A patient presents for an outpatient MRI due to
a swollen ankle. The MRI is inconclusive for any degenerative changes.
First Listed Dx: Swelling of ankle jointA patient presents for an outpatient MRI due to
a swollen ankle. The MRI reveals bursitis of the ankle joint.
First Listed Dx: Bursitis
Practice ExercisesDetermine the principal diagnosis for each
scenario:1.A female patient is admitted with severe
abdominal pain. An exploratory laparotomy is done which reveals appendicitis and the appendix is removed.
2.A patient who is suffering from chest pain presents to an imaging center for a chest x-ray. The x-ray is inconclusive for any cardiovascular issues.
Answers1. The principal diagnosis is appendicitis. The
abdominal pain is a symptom that has been linked to a more definitive diagnosis.
2. The ‘first-listed’ diagnosis is the chest pain. The results of the chest x-ray was inconclusive, therefore you must code to the highest level of certainty.
Basic CPT Coding GuidelinesCPT Notes and Guidelines
Location Provides information on:
Alternate Codes Deleted Codes Add-on Codes Other information
Basic CPT Coding GuidelinesCPT Coding Guidelines: At the beginning of a chapter
Evaluation and Management Guidelines (pg.1) At the beginning of a section heading
Surgery, Removal of Skin Tags (pg.47) Within parentheses before or after a code
CPT code 23660 (pg.81) At the end of a code range.
CPT code 43101 (pg.159)
Basic CPT Coding Guidelines
The Steps to Basic CPT Coding (cont.) Step One: Read the source document and
code only from the information listed. Step Two: Identify the main term and
modifying terms (if applicable) for the procedure to be coded.
Step Three: Locate the main term in the CPT index.
Step Four: Look for sub terms indented below the main terms in the index.
Basic CPT Coding Guidelines
The Steps to Basic CPT Coding Step Five: Jot down the tentative code or
range of codes for each procedure. Step Six: Locate each tentative code in the
appropriate section of the code book. Step Seven: Read any instructional notes, and
watch for diagnoses or specific procedures within code descriptions.
Basic CPT Coding GuidelinesThe Steps to Basic CPT Coding
Step Eight: Verify that the code matches the procedure statement provided in the record.
Step Nine: Assign a modifier to the code if necessary.
Step Ten: Assign the code.
ExampleBill for the surgeon’s procedural services
onlyA patient who was recently diagnosed with a
carcinoma of the left kidney presents today for a partial nephrectomy.
Step One – Read the source documentStep Two – Identify the main term and any
modifying termsMain Term - “Nephrectomy”Modifying Term – “Partial”
ExampleBill for the surgeon’s procedural services onlyA patient who was recently diagnosed with a
carcinoma of the left kidney presents today for a partial nephrectomy.
Step Three: Locate the main term in the CPT indexCPT Alpha Index pg. 576 Step Four: Look for sub terms indented below the
main terms in the index.NephrectomyPartial………………50240
Laparoscopic……50543
ExampleBill for the surgeon’s procedural services onlyA patient who was recently diagnosed with a carcinoma of
the left kidney presents today for a partial nephrectomy. Step Five: Jot down the tentative code or range of
codes for each procedure.Nephrectomy, partial………….50240 Step Six: Locate each tentative code in the appropriate
section of the code book.Surgery Section pg. 183 Step Seven: Read any instructional notes, and watch
for diagnoses or specific procedures within code descriptions.
Instructional Note: For laparoscopic partial nephrectomy, use 50543…
ExampleBill for the surgeon’s procedural services onlyA patient who was recently diagnosed with a
carcinoma of the left kidney presents today for a partial nephrectomy.
Step Eight: Verify that the code matches the procedure statement provided in the record.
Step Nine: Assign a modifier to the code if necessary.
In the procedural statement, the nephrectomy is being performed on the left kidney, therefore modifier (-LT) may be used.
Step Ten: Assign the code.The correct code to report would be - 50240-LT
Practice Exercise
Code the following procedural statement. Code for the surgeon’s services only:
Repair of forearm extensor tendon sheath with free graft
AnswerMain term:Repair/Tendon SheathModifying terms:Tendon sheath, extensor, forearm, free graftCPT Code Range:25275Modifiers:None Code(s) to Report:
25275
V - CodesClassification of Factors Influencing Health
Status and Contact with Health ServiceCode Range: V01 – V89V-codes are used for the following situations: When a patient who is currently not sick uses
the health services for some reason. Aftercare Services Encounters for the sole purpose of receiving
special therapeutic Services (i.e. chemotherapy)
V-codes To indicate that a person has a history, health
status or other problem that is not a current illness but may influence patient care.
To indicate the outcome of delivery for obstetric patients.
To indicate the birth status of newborns.
V-codesLocating V-codes Main terms for V-codes are located within the
Alphabetical Index of Diseases (Volume 2) The Tabular listing for V-codes is located within the
Tabular Listing of Diseases (Volume 1) Main terms for V-codes describe situations as
opposed to conditions, diseases, or disorders. Some main terms used for locating V-codes include
the following: Status Management Procedure Encounter/Admission (for) Aftercare Screening
V-Codes
V-Code Guidelines V-codes may be used as principal or
secondary diagnoses An extensive listing of V-code
guidelines is located in your ICD-9-CM coding book.
V-codesExamples:Aftercare for a healing traumatic fracture of the
tibiaV54.16Admission for HPV vaccinationV04.89Status post breast reconstructionV43.82Outcome of delivery – liveborn twinsV27.2Encounter for ChemotherapyV58.11
V-CodesCoding Practice – Code the diagnostic portion
only of the following scenarios:1.A patient with a humerus fracture is seen for
the removal of an internal fixation device.2.A patient presents to the doctor’s office for a
refill of their birth control pills.3.A patient presents for a screening colonoscopy
due to a family history of colon cancer.4.Single liveborn infant born in hospital via C-
section5.29 y/o Egg Donor
Answers1. V54.01 – Main terms include “Removal” and
“Aftercare”2. V25.41 – Main term is “Contraception”.3. V76.51 and V16.0 – Main terms are
“Screening” and “History”.4. V30.01 – Main term is “Newborn”5. V59.71 – Main term is “Donor”