Diagnosis (ICD) versus Service (CPT)Diagnosis (ICD) versus Service (CPT)
ICD codes are diagnosis codesICD codes are diagnosis codes–Describe new and established Describe new and established
diagnoses diagnoses –Also include symptom codesAlso include symptom codes–headache (symptom code), vs headache (symptom code), vs
migraine (diagnosis code)migraine (diagnosis code)
Diagnosis (ICD) versus Service (CPT)Diagnosis (ICD) versus Service (CPT)
CPT codes are service codesCPT codes are service codes–Describe performed services, both Describe performed services, both
procedures and procedures and evaluation/management (E/M)evaluation/management (E/M)
–Service codes must be based on Service codes must be based on necessity determined by necessity determined by diagnosis/ICD-9 codesdiagnosis/ICD-9 codes
ICD or Diagnosis/Disease ICD or Diagnosis/Disease CodesCodes
IInternational nternational CClassification of lassification of DDiseasesiseasesDeveloped by the WHODeveloped by the WHOFacilitates classification of morbidity and Facilitates classification of morbidity and mortality data and international disease mortality data and international disease standardizationstandardizationRevised periodicallyRevised periodically
ICD-9 CM ICD-9 CM
ICD-9 CM: International Classification of ICD-9 CM: International Classification of Diseases, 9Diseases, 9thth Revision, Clinical Revision, Clinical ModificationModification
System modified from ICD, includes more System modified from ICD, includes more specificity for clinical and billing purposes specificity for clinical and billing purposes
Revised annuallyRevised annually
ICD-10 CM has an in use deadline of ICD-10 CM has an in use deadline of
1 OCT 151 OCT 15
ICD-9 CM Cont…ICD-9 CM Cont…
ICD-9 CM diagnosis codes range from general to ICD-9 CM diagnosis codes range from general to specificspecificMore specific codes may better support billing i.e. justify More specific codes may better support billing i.e. justify why higher level of service was deemed necessarywhy higher level of service was deemed necessary
ICD-9 CMICD-9 CM DiagnosisDiagnosis
427.9427.9 Arrhythmia, NOSArrhythmia, NOS
427.31427.31 Atrial fibrillationAtrial fibrillation
250.01250.01 Diabetes type IDiabetes type I
250.03250.03 Diabetes Type I, UncontrolledDiabetes Type I, Uncontrolled
595.0595.0 UTI -cystitisUTI -cystitis
590.10590.10 UTI – pyelonephritis, acuteUTI – pyelonephritis, acute
428.1428.1 CHF, leftCHF, left
428.30428.30 CHF, diastolic unspecifiedCHF, diastolic unspecified
V Codes (sub set of ICD-9 CM codes)V Codes (sub set of ICD-9 CM codes)
Code for preventative careCode for preventative care
Usually not reimbursable themselves, but…Usually not reimbursable themselves, but…
May allow for reimbursement of other May allow for reimbursement of other services not otherwise authorizedservices not otherwise authorized– HIV, asymptomatic (v08) allows for payment of HIV, asymptomatic (v08) allows for payment of
vaccines not otherwise reimbursedvaccines not otherwise reimbursed– Family history, breast cancer (v16.3) allows for Family history, breast cancer (v16.3) allows for
reimbursement of early screening or genetic reimbursement of early screening or genetic testingtesting
CPT Codes/Service CodesCPT Codes/Service Codes
CCurrent urrent PProcedural rocedural TTerminologyerminologyDescribe performed services, both procedures and Evaluation and Management (E/M)Describe performed services, both procedures and Evaluation and Management (E/M)Service codes must be based on necessity determined by diagnosis/ICD-9 codesService codes must be based on necessity determined by diagnosis/ICD-9 codes
CPT Codes Cont…CPT Codes Cont…
Currently the national standard for almost all Currently the national standard for almost all health insurers (Medicare, Medicaid and health insurers (Medicare, Medicaid and private insurers)private insurers)
1960’s 1970’s 1983
Developed by AMA to standardize
billing/coding for Surgical Specialties
Expanded to include medical procedures and
services
Adopted and standardized by
federal government to include all
subspecialties
CPT Codes Cont…CPT Codes Cont…
5 digit codes5 digit codes
Cover all billable services and proceduresCover all billable services and procedures– Anesthesia 00100-01999Anesthesia 00100-01999– Surgery 10040-69999Surgery 10040-69999– Radiology 70010-79999Radiology 70010-79999– Pathology and Laboratory 80001-89399Pathology and Laboratory 80001-89399– Medications (ie meds administered) 90700-99199Medications (ie meds administered) 90700-99199– Evaluation and Management (E/M) 99201-99499Evaluation and Management (E/M) 99201-99499
CPT Codes – an exampleCPT Codes – an example
An 65 yo man visits his PCP for his annual checkup and An 65 yo man visits his PCP for his annual checkup and incidentally complains of 2 days of knee pain. On exam incidentally complains of 2 days of knee pain. On exam his knee is erythematous, warm, tender and swollen. his knee is erythematous, warm, tender and swollen. You perform a joint aspiration, and he also receives a You perform a joint aspiration, and he also receives a Pneumovax as part of his routine preventative care.Pneumovax as part of his routine preventative care.
3 codes apply (and can all be used for the single visit)3 codes apply (and can all be used for the single visit)– Evaluation and management codeEvaluation and management code– Medication code (for vaccine)Medication code (for vaccine)– Surgery code (for joint aspiration)Surgery code (for joint aspiration)
Medical Necessity RuleMedical Necessity Rule
There must be a connection between the There must be a connection between the diagnosis and the corresponding service diagnosis and the corresponding service CPT codeCPT code
MD must decide what is medically MD must decide what is medically necessary care for the given diagnosis, necessary care for the given diagnosis, and bill accordinglyand bill accordingly
Even if documentation is extensive, only Even if documentation is extensive, only bill for medically necessary carebill for medically necessary care
Medical Necessity Rule: CMS (centers for Medical Necessity Rule: CMS (centers for Medicaid and Medicare Services) official statementMedicaid and Medicare Services) official statement
““Medical necessity is determined based on Medical necessity is determined based on the diagnosis submitted for that service or the diagnosis submitted for that service or supply. Specificity and accuracy of supply. Specificity and accuracy of diagnosis code and linkage on the claim diagnosis code and linkage on the claim form determine payment.”form determine payment.”