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Module 3: Coding and Coding
Guidelines
Correct medical coding is integral to the financial success of any organization. Medical Coding: process of abstracting diagnosis, procedures, and services from the medical record and converting them to numeric and/or alphanumeric codes for claims submission. Accurate coding begins with verifying the clinical documentation in the patient’s medical record. Medical record: documents health care services provided to a patient medical record. Clinical diagnoses, procedures, services, and supplies are reported to payers for reimbursement using current ICD- 10-CM and CPT. ICD-10-CM: International Classification of Diseases- th Revision-Clinical Modification. Codes for diseases, injuries, and statuses. CPT: Current Procedural Terminology. Codes for services and procedures. Medicare uses HCPCS services code in addition to CPT codes for certain encounters. Medical and financial record reviews are performed to ensure correct coding and reporting,
>>Abstracting Health Information
Providers document the patient’s encounter in Electronic Health record (EHR). Electronic Health Record (EHR): a digital version of a patient’s chart that includes information documented by
multiple providers at different facilities regarding one patient. Documentation for each encounter includes the reason for the encounter, history, physical exam, diagnostic, or laboratory tests, and a treatment plan to support each CPT, ICD-10-CM, or HCPCS code reported on the claim. The provider is expected to complete the documentation in a timely manner and the documentation should validate the appropriateness of the medical services or treatment, aka Medical Necessity. Medical Necessity: process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable diagnosis codes to service/procedure codes with the billing software, which is referred to as linkage/linking.
Medical Necessity Example
Patient record Chief Complaint: fall with scraped skin on elbow and hip pain. HPI: Patient presented to the office for an abrasion on the left upper arm from fall 2 days ago in the driveway. Patient also reports left hip pain that began yesterday. The patient describes the hip pain as throbbing and is an 8 out of 10. Assessment and Plan— 1.Abrasion left upper arm: keep area clean and cover with clean dressing daily. 2.Left hip pain: Ibuprofen q 4 hr as needed, left hip x-ray to rule out fracture. The organization of documentation throughout the medical record varies by EHR vendor and type of health care organization, but the information needed to assign
Clinical documentation: information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider. The key information for coding is the clinical documentation which includes services and procedures performed such as the patient encounters, pathology, and laboratory testing, or diagnostic studies and EKGs. Some of the typical types of documentation used to validate or to assign codes include: 1.History and Physical (H&P): information pertaining to the patients’ health history and current condition. 2.Progress Notes: documentation of a patient encounter which includes a history, exam, and medical decision making. 3.Consultation Report: this type of report includes physical examination and test results, along with the consultant’s expert’s opinion about the patient’s condition. 4.Orders: request made by the provider to receive services, labs, diagnostic tests, therapies, or medication. The order includes a diagnostic statement to indicate why the order is needed. Without an order these services cannot be performed. 5.Operative Report: surgeon dictated report containing details about the procedure performed, why it was necessary, operative findings, and the condition of the patient at the end of the procedure. 6.Radiology/Nuclear Medicine Reports: a report written by the radiologist which describes the findings and assessment of radiology films or nuclear medicine. 7.Discharge Summary: a summary of an inpatient or surgical encounter which includes the last face-to-face encounter, a physical exam, review of medications,
and any discharge orders for home health or physical therapy and any other instructions for the patient. This summary report is often used by the PCP.
QUESTION
Which of the following reports contains documentation for coding an appendectomy? A. Consultation B. Progress C. Operative D. Radiology
>>Documentation and Coding Concepts
Clinical concepts are inherent to medical codes used for billing and reporting. Recognizing these concepts is important because coding is typically completed using a software application. Code assignments are often made by using the search feature, which relies on the assumptions that the most relevant key terms were used.
>>Examples of Clinical Concepts in Coding
Acuity Anatomy Complicated by Contributing factors Episode External causes History of Laterality Localization
DEF: Diabetic hyperosmolarity: Extremely high levels of glucose in the blood with ketones. E11.00 Type 2 diabetes mellitus with hyperosmolarity without non-ketotic hyperglycemic-hyperosmolarity come (NKHHC). E11.1 Type 2 diabetes mellitus with hyperosmolarity.
>>CPT Example of an Additional Add-On
Symbol and Parenthetical Note
11000: debridement of extensive eczematous or infected skin; up to 10% of the body surface. (For abdominal wall or genitalia debridement for necrotizing soft tissue infection, see 11004-11006) +11001: each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure). (Use 1101 in conjunction with 11000) One of the driving forces behind creating medical codes was to standardize the language used in medical records. These terminology standards are used for all types of data, tests, imaging reports, and drugs. The standard code sets used for billing (CPT, ICD-10, HCPCS) are terminology standards. Another standard is SNOMED-CT, used for clinical documentation. Other examples include: o Logical Observation Identifiers Names and Codes (LOINC)-used for laboratory tests, measurements, and observations. o National Drug Code (NDC)-used for drugs.
o Centers for Disease Control and Prevention (CDC) Vaccines Administered (CVX)-used for vaccines. Terminology standardization concepts also include the use of abbreviations and acronyms. The Joint Commission maintains a list that is NOT recommended for use because of the potential of causing medical errors: DO NOT USE POTENTIAL PROBLEM USE INSTEAD U, u (unit) Mistaken for “ 0 ” (zero) The number “ 4 ” (four) or “cc” Write “unit.” IU (international unit) Mistaken for IV (intravenous) or the number 10 (ten) Write International Unit Q.D., q.d., qd (daily), Q.O.D,, QOD, q.o.d., qod, (every other day Mistaken for each other. Period after Q mistaken for “i” and the “O” for “l” Write “daily” Write “every other day” Trailing Zero (X. mg) Lack of leading zero (.X mg) Decimal point missing Write X mg. Write X mg MS MS04 and MgS Can mean Morphine Sulfate, or Magnesium Sulfate Confused for one another Write Morphine Sulfate Write Magnesium Sulfate
>>Code Sets and Their Uses
ICD-10-CM codes remain important to the revenue cycle, regardless of the payment model because they establish medical necessity for services rendered. Another code set is used is Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), which is used in EHR systems.
QUESTION
A. NDC
B. ICD-10-CM
C. ICD-10-PCS
D. SNOMED-CT
E.CPT
_____Sets of clinical phrases grouped together by like terms. _____Identify individual drug products. _____Identify products, supplies, and services. _____Report professional services and procedures. _____Reporting of inpatient procedures classification of conditions, illness, and injuries.
>>CPT Codes
CPT is published by the American Medical Association (AMA) annually. This code set is used by providers of all specialties to report professional medical, surgical, therapeutic, and diagnostic procedures, and services.
>>CPT Code Updates
HIPAA Mandate: new, revised, and deleted CPT codes must be updated annually for use beginning January 1 st .
>>CPT Code Format
CPT code set is divided into 3 categories:
- Category I a) The largest and most used group of codes is separated into 6 sections.
- Category II a) Are supplemental tracking codes used to collect data for reporting performance measurement. b) Are an exception to the concept of valuation because they do not have reimbursement value attached to individual codes.
- Category III a) Are temporary cades used to report emerging technology and experimental medical procedures and services. b) Offer the opportunity to specify services that are not involved in Category I.
>>CPT Manual at a Glance
Category Six Sections Section Numeric Series Section Title #1 99202-99499 E/M #2 00100-01999 Anesthesia #3 1-6 Systems: 10004-19499 Integumentary 20100-29999 Musculoskeletal 30000-32999 Respiratory 33016-39599 Cardiovascular
QUESTION
Which of the following is the number od sections in the CPT manual? A. 3 B. 6 C. 5 D. 2
>>CPT Conventions
Are rules that guide the user to a code, and in the case the multiple codes are required, the correct sequencing of the codes. Found at the beginning of each main section and through category I section of codes. Symbols are found throughout the Tabular List and are located before a code to provide additional information about the code. A symbol key is provided on the inside front cover of the manual with short descriptions of the meanings of each symbol.
>>CPT Code Symbol
New Code
Revised Code
Add On Code
Modifier -
FDA Approval Pending
Contains new or revised text.
Resequensed Code
Telemedicine
Duplicate PLA (Proprietary Laboratory
Analysis) test.
>>CPT Coding Manual Conventions:
Parenthetical
Parenthetical notes contain information about deleted cades, cross reference, specific coding instructions, or examples within a code description.
anatomic site, procedure, condition, or other relevant descriptor. Each code contains 5 numeric or alphanumeric characters which are followed by a detailed description of the service or procedure. The format of the terminology refers to standalone and indented codes. Standalone code (parent) will contain the complete description, and the indented (children) codes will include only each code’s unique specifications.
>>Format of the Terminology Example:
25100 Arthrotomy, wrist joint; with biopsy 25105 with synovectomy The complete CPT code description for 25105 would read: Arthrotomy, wrist joint; with synovectomy. Using the CPT manual; coders must reference the stand- alone portion of the code description listed before the semicolon for a full description of the indented code.
>> Medical Terminology Applied to CPT
Medical terminology is a standardized vocabulary used by medical professionals to improve communication and encourage accurate reporting for billing and coding. A comprehensive understanding of medical terminology is required to identify the procedure or service documented in the pattern’s medical record and assign
the CPT code that captures the work performed by the provider. Many CPT category codes share characteristics, then are divided based on clinical concepts. Analyzing medical terms (word roots, prefixes, suffixes, and combining vowels) for the relevant concepts supports coding specificity and accuracy.
QUESTION
Which of the following medical terms describes the surgical removal of ovaries? A. Oophorotomy B. Hysterectomy C. Oophorectomy D. Hysterotomy
>>E/M Codes
Are used by providers of all specialties in a variety of settings. Organized according to the place and type of service provided to the patient and further categorized by the patient status. Examples: Place of Service: office or other outpatient services, hospital observation services, nursing facility services. Type of Service: Consultations, non-face-to-face services, newborn care services.
examination performed (if any) is determined by the provider for each encounter. Medical decision making (MDM): the provider uses the history and exam components to determine a diagnosis or assess the patient’s current clinical status of a known diagnosis. The elements of MDM are: o Problems addressed during the encounter. o Tests or other data ordered, reviewed, or analyzed during the encounter. o The associated risk of the patient’s management decisions made during the encounter. While the amount of history and examination performed as well as the complexity of medical decisions making by the physician, determines the level of code for most E/M codes, some subsections include time-based codes, or codes that can be either component or time-based with the determination made by the service provider.
>>Examples of E/M subsection
requirements
Time-Based Component-Based Time- or Component Based Critical Care Services Hospital Observation Care Office or Other Outpatient Service
>>ICD-10-CM Codes
The International Classification of Diseases was developed by the World Health Organization (WHO) in 1948 as a global classification system. This system is divided into 2 code sets for diagnosis and procedures: 1.The International Classification of Diseases, 10 th Revision, Clinical Modification (ICD-10-CM). 2.The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS).
>>ICD-10-PCS Codes
Maintained by the Centers for Medicare and Medicaid Services (CMS). These codes are updated annually for use beginning October 1 st each year. Are used by hospitals to report inpatient procedures, including devices and reflecting various technologies used.
>>ICD-10-CM Codes
The National Center for Health Statistics (quality) collaborates with the WHO to maintain the ICD-10-CM code set. These codes (like ICD-10-PCS) are updated annually for use beginning Oct. 1 st each year.
