Ch 25 Procedural and Diagnostic Coding

Coding (Medical)

The conversion of written descriptions of diseases, injuries, procedures, and services into numeric or alphanumeric characters.

Two Primary Coding Systems

Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

HCPCS Level I

Current Procedural Terminology (CPT), which consists of six sections used to report provider services.

HCPCS Level II

Codes used to identify products, supplies, and services not included in the CPT (Level I) codes.

Modifiers

Two-digit suffixes used with CPT and HCPCS codes to indicate something different about how a service or procedure was performed.

CPT Guidelines and Symbols

Tools within the CPT manual that help coders determine correct use, report accurately, or call attention to specific code details.

Evaluation and Management (E/M) codes

Codes used by most outpatient clinic providers to report patient visits; located at the front of the CPT manual despite having the highest numerical range.

Key Components of E/M Services

History, examination, and medical decision making (MDM).

Contributory Factors of E/M Services

Nature of the presenting problem, counseling, coordination of care, and time.

Encounter Form (Superbill)

A paper or electronic document used to record services provided to patients; contains commonly used codes and must be updated annually.

ICD-10-CM

The coding system required on all claims to report patient morbidity (illness) and mortality (death).

Medical Necessity

Services or procedures a prudent physician provides to prevent, diagnose, or treat an illness/injury in accordance with accepted medical standards, not for economic benefit or convenience.

Medical Necessity (Purpose)

Established by the use of ICD-10-CM codes to justify the services and procedures provided to a patient.

ICD-10-CM Manual Sections

The Alphabetic Index and the Tabular List.

Primary Diagnosis

The chief condition or reason the patient is being seen, which must be sequenced first on the insurance claim.

Diagnosis Sequencing Rules

List the primary diagnosis first, followed by additional conditions treated or medically managed during the encounter.

October 1, 2015

The implementation date of ICD-10-CM and ICD-10-PCS in the United States, allowing for greater specificity and system growth.