comprehensive health insurance billing, coding, and reimbursement

COMPREHENSIVE HEALTH INSURANCEBILLING, CODING, AND REIMBURSEMENT

Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

DEFINITION OF DIAGNOSIS CODING

Describes services and procedures diagnoses

ICD-9-CM:

Volumes are now used for coding the appropriate medical conditions


CODING HISTORY

Bills of mortality 1665: some of the earliest uses of coding

Warnings of plague epidemics

Diagnoses were often wrong or vague

18th century: Cause of death was noted


PURPOSE OF THE ICD-9-CM

Establishes medical necessity

Translates written terminology into common language

Provides data for statistical analysis


THE YEARLY ADDENDA

Includes the addition of new codes

Deletes old codes

Includes descriptor revisions


THE THREE VOLUMES OF THE ICD-9-CM

Volume 1: Tabular/numerical list of diseases

Volume 2: Alphabetic index of disease

Volume 3: Tabular and alphabetic index of procedures


ICD-10-CM

Replaces volumes 1 and 2 of the ICD-9-CM

Uses alphanumeric codes

Is much more detailed than ICD-9-CM

Includes ambulatory and managed care encounters

Contains injury codes


ICD-10-CM

Combines many codes to give a more detailed description of the injury or illness

No implementation date has been set yet for the ICD-10-CM. Implementation will be based on the process for adoption of standards under HIPAA.


COMMON TERMINOLOGY

Encounter: Refers to all healthcare settings

Provider: Physician or qualified healthcare provider

Diagnostic statement: The main reason for encounter

Primary diagnosis: The main reason for visit or encounter


COMMON TERMINOLOGY

Principal diagnosis: The final diagnosis

Manifestation: The sign or symptom of a disease

NEC: Not elsewhere classified

NOS: Not otherwise specified


SYMBOLS AND TYPEFACE AND TERMS

Boldface: Main term

Subterms: Indented two spaces to the right

Supplementary term: Assists coder in finding correct term

( ): Parentheses enclose supplementary words


SYMBOLS AND TYPEFACE AND TERMS

Colon (:) is used after incomplete phrase or term requiring indented term(s)

[ ]: used to enclose synonyms, alternate wordings, or explanatory phrases

Instructional terms: Assists coder in finding most specific term


VOLUME 2, THE ALPHABETICAL INDEX

Use this volume first to search for the correct code or condition.

After you find the code, use Volume 1 (tabular list) to research the specific code.


VOLUME 1, THE TABULAR LIST

Used to research the specific code

Punctuation has various meanings.

A colon : is used after an incomplete phrase or when a modifier is needed.

Square brackets, [ ], are used to enclose synonyms, alternate wordings, or explanations.


VOLUME 1, THE TABULAR LIST

Punctuation has various meanings.

Parentheses () are used to enclose supplementary words that may be present or absent in a statement of disease without affecting the code assignment


THREE STEPS FOR ACCURATE CODING

1. Determine the reason for the encounter.

2. Locate the term in alphabetic index Volume 2.

3. Verify the code in the tabular list (Volume 1).


KEY CODING GUIDELINES

Code the primary diagnosis first, followed by current coexisting conditions.

Code to the highest level of certainty.

Code to the highest level of specificity.


CODE TO THE HIGHEST LEVEL OF CERTAINTY

Code condition of encounter.

Sign: Objective

Symptom: Subjective

Signs, symptoms, ill-defined conditions

Use Volume 2, alphabetic index, for sign or symptom

Use Volume 1, Chapter 16, to verify


CODE TO HIGHEST DEGREE OF SPECIFICITY

Assign three-digit codes if there are no four-digit codes in the category.

Assign four-digit codes if there are no five-digit codes in the category.

Claims submitted with three- or four-digit codes will be returned if four- to five-digit codes are available.


PROPER ORDER FOR CODING

Main reason for encounter

Any current coexisting condition

Do not code conditions that were previously treated and no longer exist.


SUBSEQUENT CODING

Surgical coding: Diagnosis for which surgery is performed

Late effects/residual effects: Condition that remains after an acute illness or injury

Acute and chronic conditions

Combination codes


SUBSEQUENT CODING

V codes: Supplemental code that describes problems, services, or facts

E codes: Supplemental classifications of external causes of injuries and poisonings


NINE STEPS OF ACCURATE ICD-9-CM

CODING

Locate main term in the diagnostic statement.

Locate the main term in Volume 2, the alphabetic index.

Refer to all notes under the main term. Use instructions in any notes appearing in a box after the main term.



CODING

Examine any modifiers.

Note any subterms that provide greater specificity.



CODING

Follow any cross-reference instructions.

Confirm the code selection in the tabular list (Volume 1).

Follow the instructional terms in Volume 1.

Assign the correct code number.

comprehensive health insurance billing, coding, and reimbursement

Documents

ann braceland

elizabeth rollins

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main reason

main termsubterms

encounterprimary diagnosis

cmreplaces volumes

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