Week 9: Medical Coding

International Classification of Diseases (ICD-10-CM)

• maintained by World Health Organization (WHO)

• established to track morbidity (disease) and mortality (death) rates

Translating patient’s diagnosis into codes:

• Three to seven characters

  • First - Alphabetical

  • Second and third - Numeric

  • Fourth to seventh - either alphabetical or numerical

What is needed to code patient:

• Description of Presenting Medical Problem - Chief Complaint

• Review of system - ROS

• Patient exam

• Proper documentation by both physician and MA

ICD-10 Alphabetic Index

starting point for coding

do NOT choose final code from this section

Tabular List - 21 chapters of disease descriptions/codes based on body system or condition

ICD-10 Tabular List

Choose final code from here

ICD-10 - Z Codes

• when a person who may or may not be sick encounters health service for some specific purpose

• when some circumstance or problem is present which influences the person’s health status but is not in itself a current injury or illness

Current Procedural Terminology (CPT) and modifiers

• used to document procedures and services in outpatient settings

• usually 5 digit numerical

• explains what services were provided

Code MUST link with diagnosis

Modifiers help further describe a procedure code without changing its definition

CPT E and M Codes

• Evaluation and management codes

  • referred to as E&M codes

  • use of CPT codes from the range 99202 to 99499

  • represent services provided by a physician or other qualified healthcare professional

Components required to select appropriate level of E/M services:

Examination is based on four types

• Problem Focused - a limited examination of the affected body area or organ system

• Expanded Problem Focused - a limited examination of the affected body area or organ system, and any other symptomatic or related body area(s) or organ system(s)

• Detailed - an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)

• Comprehensive - a general multi-system examination or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s)

Reasons for Diagnosis Codes

• CPT/HCPCS (Healthcare Common Procedure Coding)

  • Level II HCPCS codes are designed to represent non-physician services

  • Ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services

A0427 (HCPCS)

Ambulance service, ALS, emergency transport, Level 1

A0428 (HCPCS)

Ambulance service, BLS non-emergency transport

A0429 (HCPCS)

Ambulance service, BLS, emergency transport

Reasons for Diagnostic Codes

• Facilitation of payment

• Evaluation of care patterns

• Study healthcare costs

• Research

• Prediction of trends

• Planning for future

Superbill

• routing slip.

• ICD-10 codes assigned by provider

• ICD-10 Codes used to justify CPT codes

Downcoding

• reimbursement on a lower code level than submitted

• lack of documentation most common cause

Upcoding

• reimbursement on a higher code level than submitted for a higher fee

• fraudulent

NPI - The National Provider Identifier

• unique identification number for covered health care providers

• must be used when using clearinghouses