Introduction to Coding

E&M Codes Format

5 digit codes beginning with 99 used to define the degree of services provided in an encounter specific groups of codes for each setting and several levels within each modifiers are added when separate E&M occurs during pt encounter

CPT Codes Procedure

5 digits assigned to every procedure may be multiple codes that vary based on small differences

HCPCS Codes

5 digits assigned to supplies and materials specific to each item ex: carpal tunnel splint = S8451 minor surgical tray= A4550

Components of an Expanded Problem Focused History

CC 1-3 HPI elements 1 system ROS (problem pertinent) No Past, Family or Social Hx

Components of Problem Focused History

CC 1-3 HPI elements No ROS No Past, Family or Social Hx

Components of a Detailed History

CC 4+ HPI elements 2-9 System ROS Pertinent Past, Family or Social Hx

Components of a Comprehensive History

CC 4+ HPI elements Complete ROS (10+ Systems) Complete Past, Family or Social Hx

Coding Summary

Code for what you do Document what you do Be as specific as possible Include diagnoses appropriate for every service delivered and "IN ORDER" Use "pain" code when indicated Never under code Keep learning

CPT Codes Purpose

Current Procedural Terminology for services delivered (procedure codes) designed by AMA includes codes for evaluation and management services, surgical procedures, and other types of services

Types of Codes for Services (3)

E&M CPT National HCPCS

E&M Codes Purpose

Evaluation and Management for visits

Basics of E&M Coding

Extent of history taken (oriented to specific problems, comprehensive, somewhere in between) Amount of physical exam performed (how many systems examined? in how much detail?) Complexity of medical decision making required (# diagnosed considered, amount of data reviewed, risk level)

National HCPCS Codes Purpose

Healthcare Common Procedure Coding System (Hick-pic) for supplies designed by centers for medicare and medicaid services covers supplies and some services not include in level I

7 Components of Level of E/M Services

History PE Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time

Two Categories of ICD10

ICD-CM (clinical modification)- all providers use ICD-PC-S (procedure coding system)- only for inpatient reporting (hospital billing and coding)

Diagnosis Codes

ICD9- 5 digit codes ICD10- 7 digit codes; put into effect October 1st, 2015

System Structure 16 Sections

Medical and Surgical Obstetrics Placement Administration Measurement & Monitoring Extracorporeal Assistance & Performance Extracorporeal Therapies Osteopathic Miscellaneous Chiropractic Imaging Nuclear Medicine Radiation Oncology Physical Rehab and Diagnostic Audiology Mental Health Substance Abuse

Patient Types (2)

New Established

ICD9 or 10 Coding Tips

Use signs and symptoms if you're not certain of the diagnosis ex: pt admitted to hospital for a "rule out MI"... MI should NOT be coded... instead code "chest pain, unspecified" List ALL diagnoses for which you provided services Code for only those problems addressed in the encounter

New Patient

an individual who has not received professional services from the provider or another physician of the same specialty who belongs to the same group practice within the previous 3 years

Established Patient

an individual who has received professional services from the provider or another provider of the same specialty who belong to the same group practice within the previous 3 years

What is coding used for?

billing and reimbursement practice profiling quality measurement

Service Codes

codes for services rendered all come from health care financing agency's common procedural coding system (HCPCS) there are several levels of these codes

Consequences of ICD 10

extensive training when fully implemented may force small practices to contract with billing services to keep billing consistent and correct

Documentation

if it isn't documented, you didn't do it! must be legible remember the chart is a legal document

Major Development Goals of ICD 10

improve accuracy and efficiency of coding reduce training effort improve communication with physicians ***Always be as specific as possible

CPT Code Bundling

many of the procedure codes also include subordinate procedures and the supplies that are routinely necessary to perform the procedure only services not typically performed or material not typically used should be billed separately *charging for items included in bundle separately is known and unbundling/fragmenting and is illegal

Categories of E&M Codes

office/other outpatient services hospital/inpatient consults ED services critical care nursing facility home services

Coding in captivated systems

overall coding patterns used to determine severity of illness in patient populations and levels of services rendered may be used to determine or re-negotiate capitation rates

Coding in fee for service settings

reimbursement (to patient or provider) depends directly on what was coded

Global Surgical Package

the following are always included in addition to the operation itself -local or topical anesthesia or digital block -one encounter immediately prior to the procedure (including pre-op H&P) -immediate post-op care including talking with the family -evaluating the patient in recovery -typical post-op follow up visits

What is coding?

uniform systems for documentation and tracking of services delivered

Coding and Individual Providers

used to measure individual productivity among providers may be used to determine incentive payments

Diagnosis ICD9 Codes

used to record the diagnoses for which a patient was seen/treated format: 3 digits followed by a decimal point and up to 2 more digits