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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-2
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-3
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-5
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
Diagnosis Codes: The ICD-9-CM (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
Diagnosis Codes: The ICD-9-CM (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-14
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-15
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-16
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-22
Apply Your Knowledge
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!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
Apply Your Knowledge
Excellent!ANSWER:
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-26
Apply Your Knowledge
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).
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
16-27
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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Apply Your Knowledge
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!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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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