1
Q
Procedure Coding
A
-To classify the type of care given to patients
Reasons for development
1. To justify medical service to insurance
2. To collect stats about outcome and effectiveness of treatment
3. To help physicians and hospitals set fees
2
Q
HCPCS
A
Healthcare Common Procedure Coding System
3
Q
CPT
A
Current Procedural Terminology
4
Q
Level 1 Procedure Coding
A
- First level of HCPCS does and 95- 98% of codes used for Medicare Part B + current CPT codes
- Updated annually but the AMA
5
Q
Level II Procedure Coding
A
- HCPCS codes for procedure, injections, and durable medical equipment covered by Medicare Part B that are not included in the CPT system
- Update books every year
- Ex. supplies, materials, specific meds, ambulance services, and some procedures
- 5 digits, 1 letter + 4 digits
6
Q
CPT Codes/ Manual
A
- Narrative description and a 5 digit codes for each procedure or service a physician or other licensed provider may perform for a patient
- CPT manual contains CPT (HCPCS Level 1)
- A darkened circle in front of a code = a code is new
- Darkened triangle = coded has been changed or modified
- Organized by section, subsection, subheading, category
7
Q
Relative Value unit (RVU)
A
- A quantified amount of a physicians labor, resources, and expertise that are necessary to provide the service resented by the codes
- Medicare and HMO’s is based on RVU
8
Q
Diagnosis- related groups (DRGs)
A
A system for grouping hospitals inpatients who are expected to utilize a similar amount of hospital resources as a basis for Medicare reimbursement
9
Q
Category II Codes (of CPT)
A
- Optional codes that use to track performance
- Not reported to insurance carriers
- Last character of codes uses F instead of a digit
- Updated twice a year
10
Q
Category III Codes (of CPT)
A
- Used to report services that represent emerging tech.
- 4 digits + T
- Updated 2x a year
11
Q
Modifiers
A
- An addition to a procedure codes that indicates unusual circumstance related to the procedure
- All modifier are listed in Appendix A
- Added to main coded after a hyphen and are 2 digits
that can be 2 numbers or 2 letter to indicate body location (ex. F5- right hand, thumb)
12
Q
Index of CPT manual
A
Can be used for looking for procedures. They may be located by looking under the name of the procedure, the anatomic location, and sometimes diagnosis
13
Q
Choosing (CPT) code for procedure
A
- Location
- Size of lesion or repair
- Method of performing
- Number of minutes allowed for treatment
- Complexity fo procedure or service
14
Q
Evaluation and Management (E/M) CPT Level 1 Coding
A
Contains codes for office visits provide by primary care practitioners and specialists. Covers the service-oriented, rather then the procedure oriented
- E/M section attempt to link reimbursement to the completeness of the examination and the amount of skill required to manage the patients’s problems
15
Q
Proper E/M Coding considerations
A
- Type of patient: established, outpatient, inpatient
- Type fo Service
- Level of service: medical history, physical exam, or complexity of decision making
16
Q
E/M Level of Service: Medical History
A
- Problem focused- Chief complaint, w/ brief history
- Expanded problem focused- problem focused + review of systems that have to do with child complain
- Detailed history- Expanded problem focused + other systems beyond those of chief complaint. Family history is also reviewed
- Comprehensive history- Detailed history + complete family history. For patients w/ severe, acute med conditions or serious changes in long term conditions
17
Q
E/M Level of Service: Physical Exam
A
- Problem focused- only affected body system
- Expanded problem- focused- problem focused + other organ systems that may be symptomatic
- Detailed exam- affected body system and other related system or organs
- Comprehensive exam- multi-system examination or complete examination of one system
18
Q
E/M Level of Service: Medical Decision Making
A
Straightforward, low complexity, moderate complexity, and high complexity
19
Q
E/M Secondary Factors
A
- Coordination of care
- Counseling
- Nature of the patient’s problems
- The amount of time spent with the patient
20
Q
Coordination of Care
A
The time spent arranging other services for the patient, such as home care or admission to a hospital or nursing home
21
Q
Anesthesia (CPT coding Level 1)
A
The administration of a drug that causes a total or partial loss of sensation
22
Q
Anesthesia Formula
A
(B+T) x CF
- B: Base value
- T: time which is measured from the time the anesthesiologist first begins to the patient is on longer in their care
- CF: Conversion factor is based on the locality of the service to determine payment of anesthesia service
23
Q
Anesthesia modifiers
A
- Standard modifiers are those used throughout the CPT code manual
- Physical status modifiers indicate the patient’s conditions at the time anesthesia was administered
24
Q
Surgery (CPT Coding Level 1)
A
Organization by organ system and within the system by types of procedure
25
Surgical Package
The code conveys all routine services related to a surgery
- One E/M visti
- Local or topical anesthesia
- Immediate postoperative care
- Writing orders for care after surgery
- Evaluation the patient in the recovery
- Typical follow-up postoperative care
26
Radiology
- Includes radiology, nuclear medicine, diagnostic ultrasound, and radiation oncology
- In an outpatient setting, there is typically no additional charge for the physician interpretation of the radio graph
27
Pathology and Lab
- Organized by type of tests performed
28
Medicine
Gives the proper codes for noninvasive diagnostic and treatment service, many of which are performed in the offices of primary care physicians and specialists
29
Diagnosis Coding History
- Purpose: To track processes, to classify the cause of death, to collect data for medical research, and to evaluate hospital service utilization
- 1948 was developed so that more accurate stats could be collected about how often diseases and accidents occurred and were treated.
30
ICD-9-CM
International Classification of Disease, 9th Revision, Clinical Modifications
- Became system of choice after 1989
- 5 alphanumeric character with a decimal point after the 3rd character
- Letter + 4 numbers
31
ICD-10-CM
- 10th addition was published in 1993 but the US was not required until Oct 2015 to use them. Contains 5x more then 9th version
- More extensive info on ambulatory care and managed care, new combinations diagnosis and symptoms codes, added 6th and 7th digit for some conditions, and increases ability to locate and choose specific codes
32
ICD-10-CM Index
List of disease and conditions arranged in alphabetic order
33
ICD-10-CM Tabular List
The section in which the actual codes are displayed, arranged in 21 chapters according to classification of the disease or condition or factors influencing health status or contract with heath services
- Chapter 1: Infectious or parasitic disease
- Chapter 3-14: Diseases or conditions of specific body system
- Chapter 21: Factors influencing health status (health screening or preventative care)
34
ICD-10-CM Format
First 3: Letter + Digit + Digit . _ _ _
- They show where the code occurs in the tabular list and stand for basic conditions
- Can have up to total 7 characters
- After decimal: First 3 charters can be digits or letters, and the final character (if needed) is a letter
- x can be used as a place holder
35
Z Codes (ICD-10-CM)
Used when a patient does not have a disease or injury. May be used as the first listed diagnosis if the patient has sought health care to receive an immunization or for a physical examination
- May be used as a secondary code when a patient seeks care for a specific disease or condition
36
External Causes Codes (V01 to y99) (ICD-10-CM)
Cover external causes of injury or poisoning. ex car crash
37
NOS
Not otherwise specified
38
NEC
Not elsewhere classified
39
Include- Instructional Notes
Used under a category and will identify additional names for conditions in the category or a description of conditions
40
Exclude 1- Instructional Notes
The conditions are not coded here, and the patient cannot have both the excluded condition and the condition listed above
41
Exclude 2- Instructional Notes
The condition is not included in this code, but the patient may have 2 conditions, one included in the current code, as well as the condition using the correct code for the excluded condition
42
Medical necessity
A term for health care that is reasonable and necessary for a patient based on evidence-based clinical standards of care. 3rd payers make payment decisions based on medical necessity
43
Upcoding
Medical codes are misused in order to obtain a higher level of reimbursement than is allowed
44
Downcoding
Using procedure codes that do not reflect a high enough level of services
45
Established Patient
A patient who has been seen by one of the physicians in the practice in the same specialty within the past 3 years
46
Inpatient
A patient who has been formally admitted to a health care facility.
47
Outpatient
A patient who has not been admitted to a health care facility.
48
Sequela
Any condition that results from disease, injury, or treatment for a disease or injury
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