Chapter 11 & 12: Procedural & Diagnostic Coding

Upcoding

billing for higher fee for service than what was actually performed saying you did more than you did

Conventions

general notes, symbols, typeface, format, and punctuation that direct and guide the coder to the most complete and accurate ICD 9 ("legend/key"- Dr. Rob)

ICD

international classification of diseases

Downcoding

keep services less suspect to investigation or audit saying you did less than you actually did receives lower payment

Coding suspected conditions

outpatient: symptom codes inpatient: diagnostic codes

Special codes

used if unlisted code/something new

Steps for locating a CPT Code (1-11)

1. Identify the exact procedure performed 2. Obtain the documentation of the procedure in the patient's chart 3. Choose the proper codebook 4. Using the alphabetic index, locate the procedure 5. Locate the code or range of codes given in the tabular section 6. Read the descriptors to find the one that most closely describes the procedure 7. Check the section guidelines for any special circumstances 8. review the documentation to be sure it justifies the code 9. Verify the diagnosis for the procedure and determine if it meets medical necessity standards for the procedure. The diagnosis must justify the reason for performing the reason for performing the procedure or service 10. Determine if any modifiers are needed 11. Select the code and place it in the appropriate field of the CMS-1500 form

Steps for locating a diagnostic code (1-7)

1. Using the diagnosis "chronic rheumatoid arthritis", choose the main term within the diagnostic statement. If necessary, look up the word(s) in your dictionary 2. Locate the main term in Volume 2 3. Refer to all notes and conventions under the main term 4. Find the appropriate indented subordinate term. 5. Follow any relevant instructions, such as "See also". 6. Confirm the selected code by cross-referencing to the Tabular List (Volume 1 in ICD-9-CM). Make sure you have added any necessary additional digits. 7. Assign the code

Medical Necessity and why it is important?

A determination made by a third party that a certain service or procedure was necessary based on a sound medical practice. It is important b/c it is used to defend the reason for performing any procedure Ex. come in for chest congestion and they give a chest x-ray and then also get a foot x-ray. Foot x-ray is not a medical necessity.

Procedure

A series of steps required to perform a given task; a medical service or test that is coded for reimbursement

CPT

Current Procedural Terminology - provides accurate identification of services provided to the patient

Descriptors

Description of service/procedure

E/M Codes

Evaluation and Management codes

Outpatient

Everything Else - receive care but not admitted to a facility

HCPCS

Healthcare Common Procedure Coding System

Placeholder X

Holds the place; X is used to fill in the missing digits up to the seventh digit -some disorders will require 7th character but will not need 5th or 6th so an "X" is used in its place

HCPCS levels I

I: CPT 4 (Current Procedural Terminology)

Figures 11-1 & 11-2 -How many chapters do ICD-9-CM and ICD-10-CM have?

ICD-9-CM: 17 chapters ICD-10-CM: 21 chapters

HCPCS level II

II: Medicare but can be used by other carriers; lists ambulance services, prosthetics, durable medical equipment, etc.

Inpatient

Patients are admitted for treatment = stay 24 hours or more at a hospital

Modifier and where is it found?

Provides additional info about a procedure or service and is found in Appendix A of CPT 4