Procedural andpr Diagnostic Coding. Copyright 2012 Delmar, Cengage Learning. All rights reserved.

Transcription

1 Procedural andpr Diagnostic Coding

2 What is Coding? Converting descriptions of disease, injury, procedures, and services into numeric or alphanumeric descriptors Accurate coding maximizes reimbursement

3 The History of Coding International Classification of Diseases (ICD) 1890s: a physician classified causes of death The American Public Health Association recommended this system to be used to classify deaths in North America 1938: ICD : ICD : ICD-10 (adopted in the US)

4 The History of Coding Current Procedural Terminology (CPT) 1966: First published by the American Medical Association 1970: 5 digit codes introduced 1983: Adopted as part of HCPCS 2004: New, revised, and deleted codes must be implemented every January 1

5 HCPCS Healthcare Common Procedural Coding System Level I: CPT Codes Level II: National Codes Services and products not covered by CPT codes Codes published annually

6 one physician each nominated from Blue Cross and Blue Shield Association, the America s Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS);

7 CPT Codes for procedures or services 6 sections of the CPT Manual 1. Evaluation & Management 2. Anesthesiology 3. Surgery 4. Radiology 5. Pathology and Laboratory 6. Medicine

8 CPT Codes A-codes (example: A0021): Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental B-codes (example: B4034): Enteral and Parenteral Therapy C-codes (example: C1300): Temporary Hospital Outpatient Prospective Payment System D-codes: Dental Procedures

9 E-codes (example: E0100): Durable Medical Equipment G-codes (example: G0008): Temporary Procedures & Professional Services H-codes (example: H0001): Rehabilitative Services J-codes (example: J0120): Drugs Administered Other Than Oral Method, Chemotherapy Drugs K-codes (example: K0001): Temporary Codes for Durable Medical Equipment Regional Carriers

10 L-codes (example: L0112): Orthotic/Prosthetic Procedures M-codes (example: M0064): Medical Services P-codes (example: P2028): Pathology and Laboratory Q-codes (example: Q0035): Temporary Codes R-codes (example: R0070): Diagnostic Radiology Services

11 S-codes (example: S0012): Private Payer Codes T-codes (example: T1000): State Medicaid Agency Codes V-codes (example: V2020): Vision/Hearing Services

12 CPT Modifiers Appendix A Used when procedure/services needs to be clarified or altered Examples when one would use modifiers: a. If an unusual event occurred b. If more than one provider performed the procedure

13 Unlisted codes CPT code symbols (see next slide)

14 CPT Symbols Description has been substantially altered Appears the first year the code is added to the manual + Add on codes that never stand alone; code primary procedure first, then add on code. New or revised text Ө Codes exempt from the modifier, but that do not have designated add-on procedures or services

15 CPT Coding Rules Select the name of the procedure or service that most accurately identifies the service performed Typically marked on encounter form pg 291 If clarification is needed to determine the correct code, seek the provider Primary reason is coded first; then put in order of importance (pertaining to that reason).

16 CPT Coding Rules When coding, you isolate the main term from the provider s statement and then look it up in the index. Warning: do not code directly from the index.

17 The Evaluation and Management The Evaluation and Management (E/M) section codes are divided into 17 categories of provider services, beginning with Office and Other Outpatient Services and ending with Other Procedures. See pg for more about E/M

18 ICD Codes for diseases or conditions Establishes medical necessity ICD-9 Manual (in use until Sept 30, 2015) Volume I: Tabular List Volume II: Alphabetic Index Volume III: Used by hospital coders

19 Volume I Volume I is a tabular list, organized into 17chapters, with conditions listed by body systems in one chapter and by conditions according to their causes in another chapter. Includes supplementary classifications such as V-codes (factors influencing health status and contact with health service) and E-codes (external causes of injury and poisoning).

20 Other information in Volume I Volume I also contains appendices of: M-codes Morphology of Neoplasms Classification of Drugs by the American HospitalFormulary Classification of Industrial Accidents According toagency List of Three-Digit Categories

21 Volume II Volume II is an alphabetic index organized into three main sections: Section 1 Alphabetic Index to Diseases and Injuries Section 2 Table of Drugs and Chemicals Section 3 Index to External Causes of Injuries and Poisonings (for assigning E-codes)

22 Volume III Hospital coders use Volume III to code procedures.(providers offices use the CPT coding for their procedures, so this section or volume is not used for coding in the medical office.) Some references include this content as Section 4 Index to Procedures within Volume II, not as a separate volume.

23 ICD Coding Rules Follow the reason rule Code each problem to the highest level of specificity

24 ICD-10 th clinical modification ICD-9 is not adequate to meet today s needs (it is running out of capacity.) Allows for greater specificity in reporting diseases will result in improved efficiency of care and lower costs Helps reduce coding error Coding system in place worldwide since 1990 Contains over 68,000 codes

25 Electronic Coding general equivalence mappings (will assist going from ICD9 to ICD 10 coding) pg 296 Encoders Computer-assisted coding

26 Coding Accuracy Bundling or Unbundling Upcoding or Downcoding pg 296 Assigning CPT procedural codes that do not match patient documentation for the purpose or increasing reimbursement is known as upcoding Medicare Audit if a procedure is not documented (CC, ROS, SOAP) the audit considers it NOT to have happened