Medical Coding Basics

Diagnosis & Procedural Coding 2015Presenters: Susana Martinez CPC, COC, CPMA, CEMC

and

Kyra Jones, CMIS, RCM Consultant

ICD

1700John

Graunt-London

1837William

Farr- Great Britain

1893Jacques

Bertillion- France

1898U.S.A began

use of Bertillion

Classification of Diseases

1900First

International conference

1938International Classification of Diseases

• John Graunt- one of the first experts in epidemology (disease control)

• William Farr- one of the founders of medical statistics (collection of data for healthcare use)

• Jacques Bertillion- developed Bertillion classifications of Causes of Death

1977WHO- 3 volume set

Today- Condensed into one book either containing two or three

volumes

1978International Classification of

diseases, Ninth Revision, Clinical Modification

ICD-9-CM

CM- Clinical ModificationVolumes 1 and 2• Codes diseases• Illnesses• Injuries• Both outpatient & inpatient

settings

PCS- Procedural Coding SystemVolume 3• Codes surgical• Diagnostic• Therapeutic Procedures• Inpatient Setting

Purpose

Intent- ICD system to provide morbidity statistics for the WHO

Today-medical offices use the coding system Provide information Verify the need for patient care/treatment Provide statistics for analysis of health care costs

ICD coding translates written medical terminology into diagnosis codes

Payers determine if the services are medically necessary and, therefore; reimbursable

Purpose cont’d: “Coding is a language”

• Used by insurance companies

• Used by health care providers

• Vital to care and treatment of patients

• Coder needs to be able to “translate” this language

Medical Coder-Role• Accurate coding essential to healthcare

industry• Review documentation in medical record,

translate into ICD“ If it wasn’t documented… it didn’t happen”

• Service must be reasonable and necessary

• Patient underwent blood glucose testing (procedure) for hyperglycemia (excess glucose)

• Diagnosis codes submitted in claims to payers

Compliance

Coding must meet federal guidelines Basis for studies and research into quality of healthcare Consistency and Accuracy

In the beginning…Simple phrase for

illness or condition or 1-3 digit diagnosis

code

ICD-9Today

5-6 digit diagnosis code

ICD-10October 1, 2015

7 digit diagnosis code

“Clavicle Fracture” 810.02 Clavicle fracture, closed; shaft of

clavicle

S42.022ADisplaced fracture of shaft or left clavicle; initial encounter for

closed fracture

What does ICD-9 mean to patients?

• Each diagnosis to a patient may be given has a code, a numbered designation, that identifies it.

• That code means that every medical professional in the United States and many other parts of the world will understand the diagnosis the same way.

• Documented Dx’s become a permanent part of the patient’s medical record.

• Continuity of Care – Documenting patient care so that others who treat the patient have a source of information on which to base additional care.

What does ICD-9 mean to patients… A Coder’s role

• Be a responsible coder/biller:

– Accuracy (Example: Elevated BP vs. Hypertension and Benign Neoplasms vs. Malignant Neoplasms)

– Information stored in data banks (locally, nation-wide, etc.,.)

– Affordable Care Act – took effect in 2014 (Pre-existing health conditions)

A Coder’s/Biller’s Role (cont’d)

• Cross-lines of “abuse & fraud”:

– Abuse - Actions that are inconsistent w/ accepted standards

– Fraud – Actions that are “intentional”, or knowing it is false

Contents

The introduction to each book provides important information to help coders understand the basic uses of the ICD-10-CM books

Volume understanding Volume I – tabular list

Numerical listing of diseases/injuries 17 chapters grouped by etiology (cause) or anatomical

(body) site.

Volume II – alphabetic index Listing of codes to assist in locating the complete code in

volume I Index to Diseases and Injuries Alphabetic Index to Poisoning and External causes Table of Drugs and Chemicals

Volume III – alphabetic index & tabular index Used by hospitals (procedures and surgeries) Tabular list of procedures by anatomical site Miscellaneous diagnostic and therapeutic procedures

Why are the Volumes of ICD-9 out of sequencing???

Format of ICD-9 CMDiabetes mellitus

250Diabetes mellitus

without mention of complication

250.0Range (0-9)

Diabetes mellitus without mention of

complication; type II or unspecified type not

stated as uncontrolled250.00

Range (0-3)

4th digit needed: patient’s condition

5th digit needed: higher specificity

Diagnosis Completion

Conventions

Coders need to understand the symbols, abbreviations and other conventions used within the ICD-9-CM

Conventions are found in the introduction of the volume. These are some of them:

Print type Bold face Volume I - All title and codes are printed in bold type Volume II – main term is printed in bold face

Italics• Both volumes to highlight all exclusion notes and

to identify codes that should NOT be used as the primary code

• Instructions for this code are written in italics to code first the underlying disease, such as Diabetes• Diabetes is the primary diagnosis followed by

the Gangrene (manifestation) or secondary diagnosis.

ICD-9 785.4 Gangrene ICD-10 I96 Gangrene, not elsewhere classified

ICD-9 250.70 Diabetes with peripheral circulatory disorders 785.4 Gangrene

ICD-10 E08.52 Diabetes Mellitus due to underlying condition with diabetic gangrene

Volume 1

• Tabular List of Diseases and Injuries• Three major subdivisions:

– Classification of Diseases and Injuries– Supplementary Classifications

(V and E codes)– Appendices

Volume 1 (cont’d)Other ICD-9-CM Elements

V-codes supplemental classification codes for factors that influence a patient’s care Used when a patient sees the doctor without a complaint

or problem (sports exam, etc.) or to describe conditions that could influence patient care (allergies, etc.). There are 3 main categories:

Problems – something that could affect overall health V10.04- Personal History of Malignant Neoplasm

stomach Services – patient seen for a problem/treatment

V70- General Medical Examination Factual findings – description of facts for statistics

V30.01- Single liveborn, born in hospital, delivered by cesarian delivery

Using E Codes

E-codes are optional codes that describe the following Events or circumstances Causes of injury or poisoning Other adverse effects

Should never be used as a primary or stand-alone code

Provide details of an incident or injury and help identify the

following Automobile accident liability Worker compensation situations Third-party insurance liability

Where?Why?How?

Injury coding example

ICD-9• 784.7 Epistaxis (nose bleed)• E917.0 Striking against or

struck accidently by objects or persons in sports

• E007.6 Activities involving other sports and athletics played as a team

• E849.4 Place of occurrence-recreation and sport

ICD-10• R04.0 Hemorrhage from

respiratory passages• W21.89XA Striking

against or struck accidentally by other sports equipment, initial encounter

• Y93.67 Activity basketball• Y92.830 Public park as

the place of occurrence of the external cause

Harold was playing basketball with friends at the park when the ball accidentally hit him in the nose; his nose is bleeding and he goes to see his doctor because the bleeding does not stop.

Volume 2

• Alphabetic list of conditions • Major subdivisions:

– Index to Diseases and Injuries– Table of Drugs and Chemicals– Alphabetic Index to Poisoning and

External Causes (E-codes)

Volume 2 (cont’d): The Key

• Volume 2—Alphabetic Index• Main terms:

– Disease– Sign– Symptom– Condition– Injury

Vol 2 (cont’d):Table of Drugs and Chemicals

• This table contains a classification of drugs and other chemical substances

– Identify poisoning states(poisoning classification range 960-989)

– External causes of adverse effects (external causes code range E850-E982).

Vol 2 (cont’d):Table of Drugs and Chemicals

Volume 3

• Tabular List and Alphabetic Indexof Procedures

• Procedures and surgeries• Organized by location of procedure• Used in facility setting

ICD-9

How to Find ICD-9-CM Code

Have good research habits Basic steps to finding the correct

code:1. Correctly identify the main term/condition (Vol 2)2. Use the index to locate the condition/problem3. Review information given following all instructions4. Locate and confirm the correct code in the tabular list and select

the correct code5. Put codes in correct sequence when using multiple diagnoses

Ex: Patient with peptic ulcer (unspecified as acute or chronic was seen for pharyngitis462- Acute pharyngitis533.9X- Peptic Ulcer unspecified as acute or chronic*0-without mention of obstruction*1-with obstruction

Alphabetic Index to Diseasesand Injuries

• The “key” to locating diagnoses codes

• The index is organized by main terms

DX: “Low Back Pain”• Main term is pain• The coder then asks, what type of

pain…back• Code: 724.2

Code the confirmed diagnosis whenever possible

• If you have confirmed a diagnosis based on the results of the diagnostic test, you should code that diagnosis.

• If there’s no confirmed diagnosis or the results are normal, code the signs and symptoms that prompted you to order the test.

For example: • Patient in your office for

chest pain, EKG performed.• The EKG is normal, and the

final diagnosis is chest pain due to suspected gastroesophageal reflux disease (GERD).

• The primary diagnosis code for the EKG should be chest pain, because the EKG was normal and you did not determine a definitive cause for the chest pain

Symptoms and Signs

• Used when definitive diagnosis has not been established

• Not assigned a code if it is part of a disease process with definitive diagnosis

Acute and Chronic Conditions

• Acute – A condition that is of a sudden onset or short duration

• Chronic – A condition that is ongoing, typically permanent, but some can eventually resolve and disappear altogether. More correctly, chronic refers to a time frame of 3-months or

more.

• How to code acute & chronic conditions is addressed in the Official Coding Guidelines. A coder should code both if documented, but select the acute condition first.

Impending or Threatened Conditions

• The coder must ask “Did the condition actually occur?”

• If it did, the diagnosis is confirmed

• If it did not, further research is necessary

ICD-10-CM: Preview

Released by the WHO in 1992

U.S. lagged implementation; effective

October 1, 2015

Volumes 1 and 2 -replaced by ICD-10-

CM

Volume 3 -replaced by ICD-10-PCS

(developed by the Centers for Medicare

and Medicaid Services CMS)

Why ICD-10-CM?

Three objectives of the ICD-10-CM coding system Completeness – unique code for each illness or disease Expandability – new injury or disease can be incorporated

easily into the existing structure Standardization – terminology defined for standardization

with each term being assigned a specific meaning

Comparison

ICD-10-CM

Tabular Alphabetic index Procedures 21 chapters Alpha-numerical code system 6th and 7th digit specificity Limited use of unspecified codes Supplementary class for V and E

codes New chapters for disease of eye and

ear instead of inclusion in nervous system

• Terminology has been modernized and reflects current usage of medical terminology

ICD-9-CM

Tabular Alphabetic index Procedures 17 chapters Numerical code system 4th and 5th digit specificity Category for unspecified codes Supplementary class for V and E

codes Based on outdated technology

and reduces coding effectiveness (left vs. right)

Structure difference

ICD-10… Keeping it Interesting V61.8- Other specified family circumstance

Z63.1- Problems in relationship with the in-laws

E917.4- Striking against or struck accidentally by other stationary object without subsequent fall (lamp post)

W22.02XD- Walking into lamppost, subsequent encounter

T71.231D- Asphyxiation due to being trapped in a (discarded) refrigerator, accidental, subsequent encounter

E844.9- Other specified air transport accidents injuring other person

V97.33XD- Sucked into jet engine, subsequent encounter

W16.221D- Fall into bucket of water causing drowning and submersion, subsequent encounter

E928.4- External constriction caused by hair

W49.01XA- Hair causing external constriction, initial encounter

Getting Ready for the Change

Tips:

Document specific to visit

Choose the diagnosis that fits your documentation

Keep informed of changes

CMS- Recommended Approach

• Step 1- Make a plan

• Step 2- Train your staff

• Step 3- Update your processes (claim forms, superbills and replace ICD-9 diagnosis codes with ICD-10)

• Step 4- Talk to your vendors and health plans (clearinghouses- confirm systems are ready)

• Step 5- Test your systems and processes (verify you can generate claims- test with health plans, clearinghouses and vendors)

• For more information: visit CMS website at cms.gov/ICD10

The fundamentals of ICD-9 will still be important

after the October 1st implementation.

Not all carriers will be ready or even accept the ICD-10 code set. Some

of those carriers are:

Workmen’s Compensation

Auto & Liability Agencies

Current Procedural Terminology

CPT Code Set

CPT is a coding nomenclature (system of names or terms) that allows medical procedures to be transformed to numbers

CPT is based on professional services provided by healthcare providers such as a physician, nurse practitioner or physician assistant

• CPT services include office visits, surgery, laboratory, radiology, pathology, anesthesia and medical procedures

Background

CPT was developed by the American Medical Association and CPT is still currently maintained by the AMA

CPT code sets HCPCS level I

CPT codes maintained by AMA HCPCS level II

HCPCS codes maintained by Federal Government

Background (cont’d)

• 1966: Published by AMA (four-digit codes)

• 1970: Five-digit codes • 1983: Adopted as part of HCPCS

• 1992: Implementation of E&M codes

• Updated yearly (January) and AMA panel reviews codes quarterly (May, August, November & February)

Purpose Reimburse physician services Trending services provided nationally Future coding and reimbursement

planning Benchmarking facilities, costs and

services Measuring quality of care and patient

outcomes nationally

Code Requirements

ALL CPT CODES MUST BE: Commonly performed by physicians

across the nation Consistent with mainstream medical

practice Approved by the AMA CPT Editorial

Board

CPT Code Organization

Each code is followed by a unique code descriptor explaining the service

More than 8,800 unique CPT codes (2015)

CPT codes are 5 digits long CPT manual includes parenthetical

notes

Introduction to CPT

Category I codes are permanent codes 6 Sections of Category I codes-each

with a set of guidelines at the beginning of each Evaluation and Management (E/M) Anesthesia Surgery Radiology Pathology/Laboratory Medicine

CPT Category I Code Number Format

• Five-digit code number and narrative description for each procedure and service

– Stand-alone code – includes complete description of procedure or service

– Indented code – appears below stand-alone code, requiring coder to refer back to common portion of code description located before semicolon

CPT Category I Code Number Format (cont’d)

EXAMPLE:

59514 Cesarean delivery only;

59515 including postpartum care

Category I Codes Evaluation and Management: 99201-99499 Services performed to determine care of patient

Anesthesia: 00100-01999 Routine care: pre-op, intra-op, post-op

Surgery: 10021-69990 (largest section) Divided by body systems: (pre-op, intra-op, post)

Integumentary 10021-19499

Musculoskeletal 20005-20205

Respiratory 31600-31628

Cardiovascular 33010-37799

Hemic and Lymphatic 38100-38999

Mediastinum/Diaphragm 38747-39599

Digestive 40490-49999

Urinary 50010-53899

Male Genital 54000-55899

Female 56405-58999

Maternity Care and Delivery 59000-59899

Endocrine 60000-60699

Nervous 61000-64999

Eye and Ocular Adnexa 65091-68899

Auditory 69000-69990

Category I Codes ContinuedRadiology: 70010-79999 selected based on the body part and number/type of view

Pathology/Laboratory: 80048-89398

Complete procedure includes: Ordering test

Taking/handling the sample

Performing the test

Analyzing/reporting on the test results

Medicine: 90281-99607 include many types of evaluation, therapeutic and diagnostic procedures that physicians and other health care providers perform.

Category II Codes

Used to track physician performance in measuring and monitoring patient care

Are alphanumeric codes, starting with 4 numbers followed by the letter F

Improve quality of care but are not “billable”

Category III Codes

Introduced in 2002 Are alphanumeric codes, starting with 4

numbers followed by the letter T (temporary code)

They are used to report new technology, services or procedures that do not currently have a CPT code assigned

Located directly after the Category II codes Allow researchers to track emerging

technology

CPT Appendices• Appendix A

• Lists/examples of modifiers• Appendix B

• Summary of additions/deletions/revisions• Appendix C

• Clinical Examples of E/M Codes• Appendix D

• Summary of CPT Add-on Codes • Appendix E

• Summary of CPT codes exempt from -51• Appendix F

• Summary of CPT codes exempt from -63• Appendix G

• Summary of CPT codes which include conscious sedation• Appendix H

• Alphabetical index of performance measures by clinical condition or topic

CPT Appendices (cont’d)

• Appendix I• Genetic Testing Code Modifiers

• Appendix J• Electro diagnostic Medicine Listing of Sensory, Motor and

Mixed Nerves• Appendix K

• Product Pending FDA Approval• Appendix L

• Vascular Families• Appendix M

• Crosswalk to deleted CPT codes

CPT Appendices (cont’d)

• Appendix N• Re-sequenced codes

• Appendix O• Administrative codes for multi-analyte assays

Punctuation and Symbols; Semicolon

(Divides the common portion of a code descriptor from the unique portion)

● Bullet

(New Code)

▲ Triangle

(Revised code)

+ Plus Symbol

(Add on code)

Modifier 51 Exempt (Circle w/slash)

(Indicates the code cannot be assigned with -51)

Punctuation and Symbols (cont’d)

FDA approval pending

Hollow Circle

(Indicates a reinstated or recycled code)

# Number symbol

(Re-sequenced code)

Bull’s Eye

(That conscious sedation is included in code)

Punctuation and Symbols (cont’d)

►◄ Facing Triangles

(Revised guidelines and note)

Green Arrow

(Refer to CPT Assistant or CPT changes)

Red Arrow

(Refer to Clinical Examples in Radiology for guidance)

CPT/HCPCS Modifiers

Reported as 2-digit numeric & alpha characters added to CPT and HCPCS codes

Used to communicate special circumstances surrounding the assigned code

May increase or decrease the amount of reimbursement

Three types of modifiers CPT Modifiers Facility Modifiers HCPCS Modifiers (CPT and HCPCS book)

CPT Modifiers (continued)

Description of Modifiers 21 prolonged evaluation and management services

22 – unusual (increased) procedural services• Morbidly obese patient with massive adhesions require extra time to

lyse (cut down)

23 – unusual anesthesia

24 – unrelated evaluation and management service by the same physician during a postoperative period• Pt had hysterectomy two weeks ago (90 day period); comes in today for

UTI (totally unrelated to surgical procedure). E/M for today will need 24 for reimbursement

25 – significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service• Pt comes in for routine checkup for hypertension medication refill, In

addition pt has abscess on their back so an ID was performed. Modifier 25 is appended to E/M

Description of Modifiers (cont’d)26 – professional component

27 – multiple outpatient hospital E/M encounters on the same date

32 – mandated services

47 – anesthesia by surgeon

50 – bilateral procedure

51 – multiple procedures

52 – reduced services• CPT 92550 (Use modifier 52 if a test is applied to one ear instead of

two ears) bilateral by CPT guidelines

53 – discounted procedure

54 – surgical care only

Description of Modifiers (cont’d)

55 – postoperative management only• Patient goes to ophthalmologist for cataract surgery, returns for post

operative management for visit(s)

56 – preoperative management only

57 – decision for surgery

58 – staged or related procedure or service by the same physician during the postop period

59 – distinct procedural service

62 – two surgeons

63 – procedure performed on infants less than 4 kg

Description of Modifiers (cont’d)

66 – surgical team

73 - discontinued out-patient hospital/ambulatory surgery center procedure prior to the administration of anesthesia

74 - discontinued out-patient hospital/ambulatory surgery center procedure after administration of anesthesia

76 – repeat procedure by same physician

77 – repeat procedure by another physician

78 – return to the operating room for a related procedure during the postoperative period• Dr. Smith performs a C-section. A week later, the pt returns to OR for a

post-operative infection (complication) and an ID is performed.

79 – unrelated procedure or service by the same physician during the postoperative period• Dr. Jones performs a vasectomy (90 day global). Two weeks later, pt

returns for skin tag removal off back.

Description of Modifiers (cont’d)

80 – assistant surgeon

81 – minimum assistant surgeon

82 assistant surgeon (when qualified resident surgeon not available)

90 – reference (outside) laboratory

Description of Modifiers (cont’d)

91 – repeat clinical diagnostic laboratory test

99 – multiple modifiers

Description of Modifiers (cont’d)“Eyelids, Fingers & Toes”

EYELIDS: FINGERS: TOES:E1- upper left eyelid FA-left hand thumb TA- left foot great toeE2- lower left eyelid F1- left hand second digit T1- left foot second digitE3- upper right eyelid F2- left hand third digit T2- left foot third digitE4- lower right eyelid F3- left hand fourth digit T3- left foot fourth digit

F4- left hand fifth digit T4- left foot fifth digit F5- right hand thumb T5- right foot great toeF6- right hand second digit T6- right foot second digitF7- right hand third digit T7- right foot third digitF8- right hand fourth digit T8- right foot fourth digitF9- right hand fifth digit T9- right foot fifth digit

CPT Physical Status Modifiers

-P1 normal healthy patient

-P2 patient with mild systemic disease

-P3 patient with moderate systemic disease

-P4 patient with severe systemic disease that is constant threat to life

-P5 moribund patient who is not expected to survive without operation

-P6 declared brain-dead patient whose organs are being removed for donor purposes

HCPCS Level II Anesthesia Modifiers

-AA anesthesia services performed personally by anesthesiologist

-AD medically supervised by a physician for more than four concurrent procedures

-G8 monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure

-G9 MAC for patient who has a history of severe cardiopulmonary condition

HCPCS Level II Anesthesia Modifiers (cont’d)

-QK medical direction of two, three, or four concurrent anesthetic procedures involving qualified individuals

-QS monitored anesthesia care service

-QX CRNA service, with medical direction by physician

-QY medical direction of one CRNA by an anesthesiologist

-QZ CRNA service, without medical direction by physician

HOW TO ASSIGN CPT CODES AND MODIFIERS

Step 1: Read the introduction in the CPT manual.

Step 2: Review the complete medical documentation

Step 3: Abstract the medical procedures that should be coded• Code what is documented in source document• Obtain clarification from provider if necessary

Step 4: Identify the main terms and related terms in the CPT Index‒ Main terms can be located by referring to:

• Procedure or service documented• Organ or anatomic site• Condition documented in the record• Substance being tested• Synonym• Eponym• Abbreviation

HOW TO ASSIGN CPT CODES AND MODIFIERS (cont’d)

Step 5: Locate sub-terms and follow cross referencing

Step 6: Review the description of codes and section notes in the appropriate CPT section

Step 7: Verify the code against the documentation

Step 8: Assign codes for all significant services, applicable add on codes and modifiers

Step 9: Cross check your NCCI edits

CPT UPDATES

New, deleted and changed CPT codes are updated yearly, in October by the AMA and go into effect January 1st of the following year.

Category III codes are updated twice a year, July 1 and January 1.

CPT

Unlisted Procedures/Services

• Assigned for procedure or service for which there is no CPT code

• Special report (e.g., copy of procedure report) is attached to claim to describe:– Nature– Extent– Need for procedure or service– Time, effort, and equipment necessary

CPT Index

• Organized by alphabetical main terms

• Main terms represent:– Procedures or services– Organs or anatomic sites– Conditions– Synonyms, eponyms, and abbreviations

CPT Index – Single Codes and Code Ranges

• Index code numbers are represented by:– Single code number– Range of codes, separated by:

• Dash• Series of codes separated by commas• Combination of single codes and ranges of

codes

Evaluation and Management Section

• Located at beginning of CPT because these codes describe services most frequently provided by physicians

• Accurate assignment is essential to success of physician practice because most revenue is generated by these services

Professional vs. Technical Component

• Professional component – covers supervision of procedure and interpretation/documentation of report describing examination and findings

• Technical component – covers use of equipment, supplies provided, and employment of radiologic technicians

Professional vs. Technical Component (cont’d)

• When two separate billings are required:‒ CPT modifier -26 (professional component) is

added to CPT Radiology code number by physician

‒ HCPCS level II modifier -TC (technical component) is added to CPT Radiology code by hospital

• Exception to this rule:‒ When code description restricts use of code to

“supervision and interpretation”

Surgery Section

• Organized by body system

• Subsections are subdivided into categories by specific organ or anatomic site

• To code surgeries properly, ask the following questions:

1.What body system was involved?2.What anatomic site was involved?3.What type of procedure was performed?

Surgical Package

• Global period – number of days associated with surgical package; designated as 0, 10, or 90 days

HELPFUL CODING RESOURCES

Medical Dictionary Anatomy & Physiology Text Current ICD-9-CM, CPT, and HCPCS

codebooks Physician’s Desk Reference Contractor’s Provider Manual Subscription to AMA Coding Assistant www.cms.hhs.gov/NationalCorrectCodInitEd www.cms.hhs.gov/center/coverage.asp http://www.icd10data.com/Convert

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