1 Medical Assisting Chapter 16 PowerPoint ® to accompany Second Edition Ramutkowski Booth Pugh...

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Medical Assisting Chapter 16

PowerPoint® to accompany

Second Edition

Ramutkowski • Booth • Pugh • Thompson • Whicker

Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

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Medical CodingObjectives16-1 Explain the purpose and format of the ICD

volumes that are used by medical.16-2 Describe how to analyze diagnoses and locate

correct codes using the ICD.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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Medical Coding Objectives

Objectives (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.

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Diagnosis Codes: The ICD-9-CM

Patient Chief Complaint

Physician MedicalDiagnosis

InsuranceDiagnosisCode

The diagnosis codes are found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9)

The use of ICD-9 codes in healthcare is mandated by HIPAA for reporting:

Patient’s Diseases Conditions Signs and Symptoms

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Alphabetic Index (Volume 2) Diagnoses appear in alphabetical order The index is organized by condition Should be used initially to look up conditions

Tabular List (Volume 1) Diagnoses appear in numerical order Listing is organized according to source or body system

Diagnosis Codes: The ICD-9-CM(cont.)

The Alphabetical Index is never used alone to find a diagnosis code because it does not contain all the necessary information.

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Diagnosis Codes: The ICD-9-CM(cont.)

Code Structure

• Codes are made up of three, four, and five digits and a description.• The four and five digit codes are mandated by payers when they

are available.

V Codes E Codes

Identify encounters for reasons other than illness or injury.

Can be used as either a primary code or additional code.

Identify external causes of injuries and poisoning .

Never used alone as a diagnosis code.

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Diagnosis Codes: The ICD-9-CM(cont.)

ICD-9-CM CONVENTIONSA list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.

Conventions

NOSAn abbreviation that means “not otherwise specified”, or “unspecified”

NEC

An abbreviation that means “not elsewhere classified”. This is 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 wordings.

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Diagnosis Codes: The ICD-9-CM(cont.)

ICD-9-CM CONVENTIONSA list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.

Conventions

: Used in the Tabular List after an incomplete term.} Brace encloses a series of terms.Includes This word is followed by the

types of conditions.

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Diagnosis Codes: The ICD-9-CM(cont.)

ICD-9-CM CONVENTIONSA list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.

Conventions

ExcludesThese notes indicate an entry is not classified as part of the preceding code.

Use additional

code

This note means an additional code should be used if available.

Code first underlying

disease

This means that the code is not to be used as the primary diagnosis.

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Diagnosis Codes: The ICD-9-CM(cont.)

Define these ICD-9-CM CONVENTIONS.

}NOS

NEC

[ ]

( )

:

Includes

Excludes

Use additional code

Code first underlying disease

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Diagnosis Codes: The ICD-9-CM(cont.)

Locate statement of diagnosis in patient’s medical record.

Find the diagnosis in the Alphabetic Index.

Locate the selected Alphabetic code 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.

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A New Revision: The ICD-10-CM Contains over 2000 disease categories Codes are alphanumeric containing a

letter followed by up to five numbers Codes are added to show specific side of

the body that is affected by the disease process when applicable

Diagnosis Codes: The ICD-9-CM (cont.)

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Apply Your Knowledge

A 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?

This means the medical assistant must look up the term that follows the word “see” because another category should be used or cross-referenced.

- AnswerAnswer

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Procedure Codes: The CPT The Current Procedural Terminology (CPT)

book is the most commonly used system for reporting procedures and services provided to the patient.

This is the HIPAA required code set. Published annually by the American Medical

Association (AMA).

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Procedure Codes: The CPT

Except for the first section, the reference book is arranged in numerical order.

Section Range of Codes

Evaluation and Management 99201-99499

Anesthesiology 0010-01999

Surgery 10021-69990

Radiology 70010-79999

Pathology and Laboratory 80048-89356

Medicine 90281-99602

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Add-On Codes A plus sign (+) is used

Modifiers One or more two-digit numbers are added with a

hyphen after the five digit number Category II, III, and Unlisted Procedure Codes

Category II (tracks healthcare performance measures) Category III (temporary codes) Unlisted Codes (Used when no other code is adequate)

Procedure Codes: The CPT (cont.)

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Evaluation and Management Services Explains how to code different levels of patient

services based on:

Procedure Codes: The CPT (cont.)

The extent of the patient history takenThe extent of the examination conducted

The complexity of the medical decision made

New Patient versus Established Patient

New patients have not been seen by physician within the past 3 years. Established patients have been seen within a 3 year period.

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Surgical Procedures The “Surgical Pack” is a combination of

services needed for surgery such as: Anesthesia Surgery Routine Follow-Up Care

Global Period refers to the time period that follow-up is rendered following surgery.

Procedure Codes: The CPT (cont.)

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Laboratory Procedures

• Panels listed in Pathology and Laboratory sections of the CPT include tests commonly performed.

• If the panel code is not used and separate codes are used, they will be rebundled.

Immunizations

• Injections require two codes, one for the procedure (injection) and the other for the medication (vaccine or toxoid)

Procedure Codes: The CPT (cont.)

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HCPCS The Health Care Common Procedure

Coding System (HCPCS) Developed by the Centers for Medicare and

Medicaid Services (CMS) Pronounced “hic-picks” Contains two levels:

Level I codes duplicate CPT codes Level II codes are national codes covering supplies

Contains 5 characters, either numbers, letters, or a letter with a number.

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Avoiding Fraud: Coding Compliance Medical assistants help ensure that maximum appropriate

reimbursement for services provided are received. Compliance with federal and state law and payer

requirements is mandatory.

Code Linkage

Diagnostic

Procedures

This is a process that insurance company representatives use to evaluate the necessity of medical procedures that are reported based on the patient’s diagnosis.

Careful attention to details are needed to prevent errors in coding and incorrect billing.

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Avoiding Fraud: Coding Compliance(cont.)

Investigators look for patterns such as:

Reporting services that were not performed. Reporting services at a higher level than was carried out. Performing and billing for procedures that are not related

to the patient’s condition and therefore not medically necessary.

Billing separately for services that are bundled in a single procedure code.

Reporting the same service twice.

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Compliance Plans To avoid the risk of fraud, medical offices

incorporate a process for finding, correcting, and preventing illegal medical practices.

A compliance officer and committee will: Audit and monitor compliance Develop written policies and procedures that are

consistent with regulations and laws Provide ongoing communication and training to staff Respond to and correct errors

Avoiding Fraud: Coding Compliance(cont.)

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The 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:

a. Use the current book to validate accuracy of the codes.

b. Use last year’s book to validate accuracy of the codes.

c. Use next year’s book to validate accuracy of the codes.

Apply Your Knowledge - AnswerAnswer

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End of Chapter