Bài giảng môn Medical Assisting - Chapter 16: Medical Coding

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.

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16Medical CodingLearning Outcomes16.1 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.2Learning 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.3Introduction Medical codingTranslation of medical terms for diagnoses and procedures into code numbers from standardized code setsTells payers that the services providedWere medically necessaryComplied with payer’s rulesAccurate claims bring maximum appropriate reimbursement for the medical office4Diagnosis Codes: The ICD-9-CMThe Diagnosis ProcessPatient Chief ComplaintPhysician MedicalDiagnosisInsuranceDiagnosisCodeThe 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 symptoms5 The ICD-9-CMAlphabetic Index (Volume 2)Diagnoses appear in alphabetical orderThe index is organized by conditionUse initially to look up conditionsCross-referencesLook up term that follows “see”The Alphabetical Index is never used alone to find a diagnosis code because it does not contain all the necessary information.6The ICD-9-CM (cont.) Tabular List (Volume 1)Diagnoses appear in numerical orderListing is organized according to source or body systemCode 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 codes7The ICD-9-CM (cont.) Supplementary classification of factors influencing health status and contact with health servicesIdentify encounters for reasons other than illness or injuryMay be a primary code or additional code“E” – external Identify external causes of injuries and poisoning resulting from environmental eventsNever used alone as a diagnostic codeV CodesE Codes8A list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set. ConventionsNOSAn abbreviation that means “not otherwise specified” or “unspecified”NECAn 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 wordingICD-9-CM Conventions 9 Conventions:Used in the Tabular List after an incomplete term}Brace encloses a series of termsIncludesRefines content of preceding entry§Indicates that the footnote is applicable to all subdivisions in that codeExcludesIndicates that the entry is not classified as part of the preceding codeICD-9-CM Conventions (cont.) 10 ConventionsExcludesThese notes indicate that an entry is not classified as part of the preceding codeUse additional codeThis note means an additional code should be used if availableCode first underlying diseaseThis means that the code is not to be used for the primary diagnosisICD-9-CM Conventions (cont.) 11Steps to Locating an ICD-9-CM CodeLocate the patient’s diagnosis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The ICD-9-CM Codes (cont.)12The ICD-10-CM/ICD-10-PCSRevisions to ICD-9-CM ICD-10-CM – over 68,000 diagnostic codesICD-10-PCS – 87,000 procedure codesFeatures Combination codesCodes for lateralityExpanded codes capture more detailFlexibility and expandability13Apply Your KnowledgeA 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.Good Answer!14Procedure Codes: The CPTCurrent Procedural Terminology (CPT) book The most commonly used system for reporting procedures and services provided to the patientThis is the HIPAA-required code set Published annually by the American Medical Association (AMA)Updated annuallyUse the appropriate CPT book for the current year15Organization of the CPT ManualExcept for the first section, the CPT book is arranged in numerical orderSectionRange of CodesEvaluation and Management99201–99499Anesthesiology00100–01999Surgery10021–69990Radiology70010–79999Pathology and Laboratory80048–89356Medicine90281–9960216Organization of the CPT Manual (cont.)Add-on codesA plus sign (+) is used to indicate add-on codesAlways used with primary codeModifiersOne or more two-digit numbers (up to three per procedure) assigned to five-digit main numberIndicate that special circumstance applies 17Organization of the CPT Manual (cont.)Category II, III, and Unlisted procedure codesCategory II – tracks health-care performance measuresCategory III – temporary codes for emerging technologies, services, and proceduresUnlisted codes – used when no other code is available18Evaluation and Management (E/M) CodesUsed by all physicians in any medical specialtyKey factors that help determine level of serviceThe extent of the patient history takenThe extent of the examination conductedThe complexity of the medical decision madeNew Patient versus Established Patient New patients – not seen by physician within the past 3 years Established patients – seen within a 3-year period19Surgical Procedure CodesThe surgical packageAll procedures normally a part of an operationAnesthesiaSurgeryRoutine follow-up careGlobal period The time period covered for follow-up careIf past global period, additional services are reported separately20Laboratory ProceduresImmunizationsThe 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 delayed21Apply Your KnowledgeWhich 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!22The 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:Use the current book to validate accuracy of the codesUse last year’s book to validate accuracy of the codesUse next year’s book to validate accuracy of the codesApply Your KnowledgeExcellent!ANSWER:23HCPCS The Health Care Common Procedure Coding SystemDeveloped by the Centers for Medicare and Medicaid Services (CMS)Pronounced “hic-picks”24HCPCS (cont.)Contains two levelsLevel I codes Duplicate CPT codesLevel II codesNational codes for supplies and DME (durable medical equipment)5 characters – numbers, letters, or a combination of bothCan have modifiers 25Using the CPTBecome familiar with guidelines and notes for each sectionFind the procedures and services provided by the office Determine appropriate codes and modifiersEnter codes and modifiers on CMS-1500 form26Locating a CPT CodeLocate services documentedLook up procedure code(s) in the alphabetic index of the CPT manualDetermine appropriate modifiersCarefully record procedure codes on health-care claimMatch procedure with diagnosisUsing the CPT (cont.)27Apply Your KnowledgeWhat 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).Stellar!28Coding ComplianceCompliance with federal and state law and payer requirements is mandatoryCode LinkageDiagnosticProceduresA process used by insurance company representatives to evaluate the necessity of medical procedures reported based on the patient’s diagnosisPrevent errors in coding and incorrect billing by careful attention to details29Insurance FraudInvestigators look for patterns such asReporting services that were not performedReporting services at a higher level Performing and billing for procedures not related to the patient’s condition and therefore not medically necessaryBilling separately for services that are bundled in a single procedure codeReporting the same service twice30Compliance PlansMedical offices establish a process for finding, correcting, and preventing illegal medical practicesGoals of compliance planPrevent fraud and abuseEnsure compliance with applicable lawsHelp defend physicians if investigation occurs31Compliance Plans (cont.)Plan demonstrates to payers honest, ongoing attempts to correct any weak areas of compliancePlan is developed by a compliance officer and committee who also:Audit and monitor complianceDevelop written policies and procedures that are consistent with regulations and lawsProvide ongoing communication and training to staffRespond to and correct errors32Apply Your KnowledgeWhat 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!33In Summary16.1 The purpose of the ICD-9 manual is to find diagnosis codes for patients’ medical conditions. It is formatted with the Alphabetic Index and the Tabular List16.2 To analyze diagnoses, think about the condition and not the body part; then think about the location. This will assist you in finding the correct codes much more easily.16.3 The CPT-4 is used for locating medical procedure codes. It is organized from Evaluation/Management (E/M) to Medicine. 34In Summary (cont.)16.4 The three levels that determine E/M service are extent of patient history taken, extent of exam conducted, and complexity of the medical decision making.16.5 The two types of HCPCS codes are Level I codes (also called CPT codes) and Level II codes, issued by CMS.16.6 In locating a procedure code, you first become familiar with the format and guidelines. For further information on completing this process, see Procedure 16.3.35In Summary (cont.)16.7 Diagnosis and procedure coding must be directly linked when reporting for reimbursement because payers analyze this connection to determine the medical necessity for the charge.16.8 Insurance fraud is an act of deception used to take advantage of another entity. An example of billing and coding fraud is when a physician reports services that were not performed.36Things gained through unjust fraud are never secure. ~ Sophocles End of Chapter 1637
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