powerpoint® presentation to accompany: medical assistingptcmot120.wikispaces.com/file/view/chapter...

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

16-1

Medical Coding

PowerPoint® presentation to accompany:

Medical AssistingThird Edition

Booth, Whicker, Wyman, Pugh, Thompson


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.


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.


16-4

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


16-5

Diagnosis Codes: The ICD-9-CM

Patient

Chief

Complaint

Physician

Medical

Diagnosis

Insurance

Diagnosis

Code

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”

NEC

An 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 termsIncludes 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.)


16-12

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.)


16-13

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


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.


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


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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 0010–01999

Surgery 10021–69990

Radiology 70010–79999

Pathology and Laboratory 80048–89356

Medicine 90281–99602


16-17

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.)


16-18

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.)


16-19

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


16-22


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:


16-24

HCPCS

The Health Care Common Procedure Coding System

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

Pronounced “hic-picks”


16-25

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


16-26


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).


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


16-28

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


16-29

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


16-30

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


16-31


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!


16-32

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


16-33

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


16-34

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


16-35

Things gained through unjust fraud are never secure.

~ Sophocles

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