I. Insurance billing coding.
A. Coding is a way to standardize medical information for various purposes:
1. Collecting health care statistics
2. Performing a medical care review
3. Mainly for health insurance claims processing.
B. Coding is linked to reimbursement, it is imperative to code accurately and precisely.
C. Incorrect, insufficient or incomplete coding on claim forms can lead to improper reimbursement for the hospital or individual physicians as well as an inaccurate database.
D. Claim is the tool used to request insurance payment under an insurance contract
E. Patient- one who receives medical care
F. Provider-physician or supplier who provides medical care and supplies
G. Coordination of benefits prevents duplication of benefits for the same medical expense (selecting which insurance company to bill first)
II. The Coder’s Rule
A. Define QIO.
B. Distinguish between Medicare Part A and Part B.
C. Interpret rules of Health Insurance Portability and Accountability Act (HIPAA).
D. Locate information in the Federal Register.
III. Health Care Fraud and Abuse
A. Understand the framework of Medicare Fraud and Abuse.
B. Identify the major components of Managed Health Care
IV. Three coding systems
A. International classification of diseases ICD-9 CM is a statistical classification system based on the international 9th version (ICD-9) developed by the World Health Organization (WHO).
1. ICD-9 represents the most current and comprehensive statistical classification of its kind.
2. Contains more than 10,000 diagnostic codes and over 1,000 procedure codes
3. Consist of three volumes:
a. Volume 1: Tabular, numerical list of diseases
b. Volume 2: Alphabetic index of diseases
c. Volume 3: Tabular list and alphabetic index of procedures, used primarily in hospitals. Note: Volumes 1 and 2 are used in physician’s offices in order to complete insurance claims.
4. Diagnostic coding was developed for the following reasons:
a. Tracking of disease processes
b. Classification of medical procedures
c. Medical research purposes
d. Evaluation of hospital utilization.
B. Physician’s current procedural terminology (CPT) is a comprehensive listing of medical terms and codes for the uniform coding of procedures and services provided by physicians.
1. CPT-4 was developed by the American Medical Association and is updated annually for modifications and additions.
2. The purpose of CPT coding is to provide a uniform language that accurately identifies medical, surgical, and diagnostic services, resulting in a reliable means of nationwide communication between physicians, patients, and third parties.
3. CPT-4 uses a 5-digit system for coding physician services, plus 2-digit modifiers to indicate complications or special circumstances.
4. Code numbers represent diagnostic and therapeutic procedures on medical insurance claims forms.
5. Procedural coding considers two categories of patients.
a. A new patient is one who has not received any professional services from the physician or group in the past 3 years.
b. An established patient is one who has received such services within the past 3 years.
C. Health Care Common Procedure Coding System
1. Posted by centers for Medicare and Medicaid services
2. Two principle sub-systems
a. Level one- CPT
b. Level two- Standardized coding system for products, supplies, and services not included in CPT codes
V. An Overview of ICD-10-CM
A. Explain the development of the ICD-10-CM.
B. Describe how the ICD-10-CM replaces the ICD-9-CM, Volumes 1 and 2.
C. Identify the improvements in the ICD-10-CM.
D. List the official instructional notations in ICD-10-CM.
E. Analyze the ICD-10-CM Official Guidelines for Coding And Reporting.
F. Describe the format of ICD-10-CM.
VI. An Overview of ICD-9-CM
A. List the uses of the ICD-9-CM.
B. Identify the characteristics of the Tabular List, Volume 1.
C. Identify the characteristics of the Alphabetic Index, Volume 2.
D. Explain the uses of coding conventions when assigning codes.
E. Identify the characteristics of the Procedures Index and Tabular List, Volume 3.
F. Demonstrate use of ICD-9-CM.
VII. Principles of coding.
A. Procedural Coding: Current Procedural Terminology, (CPT)
1. Updated on an annual basis
2. New codes added and deleted shown by the use of symbols
3. Should have a current CPT book on hand for reference
4. Transformation made of written descriptions of procedures and professional services into code numbers by use of a five-digit coding system with two digit modifiers
5. Procedure codes are a standardized method used to precisely describe the services provided by physicians and allied health personnel to report medical, surgical, and diagnostic services they provide.
6. Codes are used by payers for appropriate reimbursement for services.
7. Six primary sections, each beginning with guidelines that cover definitions and terms unique to that section
a. Evaluation and management
1) New patient versus established patient
2) Referral versus consultation
1) Global period
2) Surgical package
3) Laceration repair
e. Pathology and Laboratory
9. Main terms and sub-terms
10. Code ranges
11. Cross-References and conventions
a. See synonyms, eponyms and abbreviations
b. See also Common Procedure Coding System; Health Care Financing Administration (HCFA) Common procedure Coding System, (HCPCS)
B. Common Procedure Coding System; Health Care Financing Administration (HCFA) Common procedure Coding System, (HCPCS).
1. Standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.
2. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes are established for submitting claims for these items.
3. Updated on an annual basis
4. Alpha numeric codes assigned and maintained by each local or regional Medicare fiscal agent or carrier.
a. Alpha numeric range from W0000 through Z9999
b. Special alpha modifiers are used to further explain a given service, ranging from WA through ZZ.
5. Procedural Coding Steps
a. Become familiar with the CPT and HCPCS coding books.
b. Determine procedures and services to report from the superbill, fee ticket, or encounter form.
c. Identify the correct code(s).
d. Determine the need for appropriate modifiers.
e. Record the procedure code in the computer software system or type on the claim form.
C. Diagnostic Coding; International Classification of diseases, 9th edition, Clinical Modification. These are known as the ICD-9-CM codes.
1. Data on the types and number of diseases in the United States provide important information to help us understand the overall condition of our nation’s health.
2. The World Health Organization collaborates with the United State to strengthen their health services where ever possible. The ICD-9-CM consists of:
a. Volume I is a tabular list containing a numerical list of the disease code numbers in tabular form.
b. Volume II is an alphabetical index to the disease entries, organized by condition not anatomical site:
1) Main terms bold type
2) Sub-terms indented two spaces to the right under main term
3) Sub-term to a sub-term
4) Non-essential modifiers
6) Carryover lines
8) V codes
9) Neoplasm table
10) Hypertension table
11) 5th digits
c. Volume III is a classification system for surgical, diagnostic, and therapeutic procedures alphabetic index and tabular list).
3. Volumes I and II are utilized in physicians’ offices.
4. Updated on an annual basis.
5. Transformation of a written diagnosis into a three to five digit code number. The more digits the higher the specificity.
a. Primary diagnosis
b. Secondary diagnosis
6. Diagnostic Coding steps
a. Determine the primary diagnosis, condition, or symptom(s).
b. Locate the term in the alphabetical index.
c. Use any supplementary terms in the diagnostic statement to help locate the main term.
d. Read and follow any notes below the main term.
e. Review the sub-terms to find the most specific match to the diagnosis.
f. Read and follow any cross-references.
g. Verify the code in the tabular list.
h. Read include or excludes notes.
i. Be alert for and observe fifth-digit requirements.
j. Follow any instructions requiring the selection of additional codes.
k. List multiple codes in the correct order.