decoding healthcare codes: icd-10, drg, cpt, hcpcs

Decoding Health Care Codes: ICD-10, DRG, CPT, HCPCS

Chicago Technology for Value-based Healthcare

Scope of this presentationWhat’s included:

For each code, this presentation will answer:

● Who created it● Who maintains it● Where is it found● What does it look like

Please speak up if you have questions or experience with coding you can share

What’s not included but worth noting important:

● Limitations within the codes● In depth information about how codes relate,

translate, encode and decode meaning● How coding impact payer and provider

financing

Where does information from this presentation come from?

● Wikipedia● CMS● AMA

Why do we code?● There is a massive amount of

data created for each episode of care:

● Very specific information

○ Example DRG code: Intracranial hemorrhage or

cerebral infarction with CC or tPA in 24 hours

● Uniform documentation between medical facilities

○ Interoperability ● To get paid properly

○ UB-40 form

Image Source: http://www.outsourcestrategies.com/medical-billing-outsourc ing.htm

http://www.outsourcestrategies.com/medical-billing-outsourc

Decoding Health Care Codes

International Statistical Classification of Diseases and Related Health Problems (ICD-10)

Diagnostic Related Groups (DRG)

Current Procedural Terminology (CPT)

Healthcare Common Procedure Coding System (HCPCS)

International Statistical Classification of Diseases and Related Health Problems (ICD)● Who created it? Who maintains it?

○ World Health Organization, countries have their own versions. In the US, CMS has ICD-10-CM and ICD-10-PCS. CMS contracted with 3M to develop ICD-10-PCS

● Who uses it? What is it for?○ UK, Sweden and Brazil all adopted ICD-10 before

2000○ US adopted it in Oct. 2015○ Used for classifying:

■ disease states■ signs and symptoms■ abnormalities■ procedures Image source:

https://www.aapc.com/medical-coding-books/2016/2016-icd-10-pcs-book.aspx



International Statistical Classification of Diseases and Related Health Problems (ICD)

● Where is it found?○ EMR systems, billing

■ Codes for reasons for visits in all American health care settings

● What do ICD10 codes look like?○ 7 digit, mix of letters and

numbers○ The position of the digit has

significance (e.g. Indicate a part of the body)

○ Don’t always expect a decimal point

Image Source: http://www.mtuitive.com/synoptic-reporting-can-solve-icd-10-woes/

http://www.mtuitive.com/synoptic-reporting-can-solve-icd-10-woes/

Technologies

● IT systems using ICD: ○ EDW and Business

intelligence○ Clinical documentation○ Electronic data interchange○ Computer assisted coding○ Revenue cycle management

● Example solutions:○ Aqua.io: code conversion API○ Computer assisted coding

Image source: http://hitconsultant.net/2015/02/17/computer-assisted-coding-market-expected-to-reach-3-5b-by-2019/

http://hitconsultant.net/2015/02/17/computer-assisted-coding-market-expected-to-reach-3-5b-by-2019/

Diagnostic Related Groups (DRG)● What is it for?

○ statistical system of classifying any inpatient stay into groups for the purposes of payment

○ intended to identify the products that a hospital provides

● Who uses it? ○ Medicare uses it for

reimbursements○ Countries develop their own

DRG version (i.e. SwissDRG)● Who created it?

○ Professors from Yale

Image Source: http://www.slideshare.net/stefanst/introduction-to-swissdrg-english

http://www.slideshare.net/stefanst/introduction-to-swissdrg-english

Diagnostic Related Groups (DRG)● Where is it found?

○ Medical billing ○ Many versions:

■ Medicare DRG (CMS-DRG & MS-DRG)

■ Refined DRGs (R-DRG)■ All Patient DRGs (AP-DRG)■ Severity DRGs (S-DRG)■ etc.

● What do the codes look like?○ 3 numeric digits○ High level code, MDC codes offer

more granularity○ Examples: CMS Index○ ICD-10 codes fall into a DRG

https://www.cms.gov/ICD10Manual/version33-fullcode-cms/fullcode_cms/P0002.html

Current Procedural Terminology (CPT)● Who created it? Who maintains it?

○ Maintained by AMA○ Copyrighted, you need to license it from AMA

■ Pay AMA a fee● Who uses it? What is it for?

○ the code set used to bill outpatient and office procedures

○ Similar to ICD10○ It identifies the services rendered rather than

the diagnosis on the claim

“the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS) and HIPAA, and the data for the code sets appears in the Federal Register.”

Current Procedural Terminology (CPT)● Where is it found?

○ Insurance claims● What do ICD10 codes look like?

○ Category 1: Numeric, 5-digits○ Category 2: Alphanumeric, 4-digits,

5th is a character (i.e. F)■ clinical components usually

included in evaluation and management or clinical services and are not associated with any relative value

○ Category 3: Alphanumeric, 4-digits, 5th is a character (i.e. T)

■ Emerging technology

Image source: https://www.mtnmedical.com/physician/cpt-codes-mri.php

https://www.mtnmedical.com/physician/cpt-codes-mri.php


● Who created it? Who maintains it?○ Developed by the CMS○ Maintained by the AMA

● Who uses it? What is it for?○ Covers services, procedures, and equipment not covered by CPT codes

■ durable medical equipment■ prosthetics■ ambulance rides■ certain drugs and medicines

○ Superset of CPT codes


● Where is it found?○ official code set for

outpatient hospital care, chemotherapy drugs, Medicaid, and Medicare, among other services

○ HIPAA mandated● What do HCPCS codes look

like?○ Level 1: CPT codes○ Level 2: 5-digits,

alphanumeric

Image Source: http://heartlandtrc.org/2013-telehealth-codes/

http://heartlandtrc.org/2013-telehealth-codes/

Questions?

Thanks for joining us tonight!

Chicago Technology for Value-based Healthcare

decoding healthcare codes: icd-10, drg, cpt, hcpcs

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