Chapter 46: Medical Coding

Who created the first comprehensive disease classification system in the United States in 1869?

American Medical Association (AMA)

How often are level I codes updated?

Annually

Who updates and publishes the CPT manual?

AMA

HCPS level II codes include what services that are not in the CPT system and may not be covered by insurance?

Procedures, injections, and durable medical equipment

How often should updated code books be purchased?

Every year

CPT manual contains codes which are usually how many digits long?

5 digits long

What is the first section of Current Procedural Manual?

Evaluation and Management

What is a modifier and how many digits are they?

A two-digit code added to a procedure to indicate unusual circumstances, such as a more extensive procedure or multiple procedures performed in the same session.

What pieces of information may be significant when choosing the correct code for a procedure?

• Location

• Size of lesion or repair

• Method of performing the procedure, test, or surgery

• Number of minutes allotted for a treatment

• Complexity of the procedure or service

What are the two types of CPT codes?

Stand-alone codes and indented codes

If a patient comes in for an exam and has an electrocardiogram done, per the physician’s orders, is this billed under the examination or separately, under its own code?

Separately under its own code

What type of services and providers would find their appropriate codes in the E/M section?

Primary care practitioners and specialists

Define established patient.

A patient who has been seen within the past 3 years

Define new patient.

One who has not had services performed by any provider in the medical office in the previous 3 years

Define inpatient.

A patient who has been admitted to a health care facility for at least one overnight stay

Define outpatient.

One who has not been admitted to a health care facility

What is problem-focused history?

A brief summary addressing the chief complaint and a short history of the illness, used for straightforward issues like a sore throat

What is expanded problem-focused history?

Summarizes the chief complaint, provides a brief history of the current issue, and review relevant systems related to the complaint

What is detailed history?

Summarizes the chief complaint, provides an extended history of the current illness, and review relevant body systems, including those unrelated to the chief complaint.

What is a comprehensive history?

Includes a chief complaint; an extended history of the present illness; a review of all body systems, especially those directly related to the present problem; and a complete family history

What is a panel?

A group of diagnostic tests done simultaneously in one machine.

HCPCS Level II codes are used primarily for items and services that do not have Level I (CPT) codes. What are some examples from your text of what these might be?

Supplies, materials, specific medications, ambulance services, and some procedures

Diagnosis coding was originally developed for what four purposes?

1. To track disease processes

2. To classify the causes of death

3. To collect data for medical research

4. To evaluate hospital service utilization

What organization originally published and still manages the International Classifications of diseases?

The World Health Organization (WHO)

What does the “9” stand for in ICD-9?

9th Revision/Edition

What does the “10” stand for in ICD-10?

10th Revision/Edition

What new features are in the ICD-10, compared to ICD-9?

• More extensive information related to ambulatory care and managed care encounters

• An expansion of injury codes

• New combination diagnosis and symptom codes to decrease the need for two codes

• An added sixth and seventh digit for some conditions

• Increased ability to locate and choose specific codes

In regard to insurance billing, what will happen if the care given does not correspond to the patient's disease?

Many insurance companies will reject a claim

In the Tabular List of the ICD-10-CM manual, the codes are arranged in what way?

In 21 chapters according to classification of the disease or condition or factors influencing health status or contact with health services

What is medical necessity?

Health care that is reasonable and necessary for a patient based on evidence-based clinical standards of care

When coding, the MA has an obligation to do what?

To verify that a procedure code is linked to the correct diagnosis code

What is upcoding?

Using a code to obtain a higher level of reimbursement than is justified by medical procedures performed as documented in the medical record

If an office is found to practice upcoding, what could be their consequence?

It can result in serious fines and penalties

What is downcoding?

Using procedure codes that do not reflect a high enough level of service.

Why is it so important to ensure that what we report on our charges matches the medical record?

An insurance claim may be denied for incomplete information