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Unit 1 PresentationChapters 1 & 2

Shatondra Surulere, MBA, RHIA, CCS

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Chapter 1

Overview of Coding

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Introduction

Coding systems:International Classification of Disease, 9th

Revision, Clinical Modification (ICD-9-CM)Current Procedural Terminology (CPT)Healthcare Common Procedure Coding System

(HCPCS) level II

Starting a coding career

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Coder

Acquire working knowledge of coding systems and rules, as well as payer requirements

Ensure coding accuracyCommunicate with providers about

documentation and compliance issues, as well as assignment of codes

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Professional Associations Offering Coding Credentials

American Health Information Management Association (AHIMA)

American Academy of Professional Coders (AAPC)

American Medical Billing Association (AMBA)

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Employment Opportunities

ClinicsConsulting firmsGovernment

agenciesHospitalsInsurance

companies

Nursing facilitiesHome health care

agenciesHospice

organizationsPhysician officesWork at home

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Coding Overview

Facilities, providers, and third-party payers use coding systems and medical nomenclature to collect, store, and process data.Used for healthcare reimbursement

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Codes

Numeric and alphanumeric charactersAssigned to diagnoses, procedures, and

servicesReported to payers and external agenciesUsed internally for education, research,

and statistical purposes

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Coding References

Coding ClinicsConditions of Participation (CoP) and

Conditions for Coverage (CfC)CPT Assistant and HCPCS Assistant

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Coding References

Compliance program guidance by DHHS OIGICD-9-CM Official Guidelines for Coding and

ReportingNational Correct Coding Initiative (NCCI) and

Outpatient Code Editor (OCE) with Ambulatory Payment Classification (APC)

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Fraudulent Coding

UnbundlingUpcodingOvercodingJammingDowncoding

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Documentation Issues

Health care providers are responsible for documenting and authenticating patient records as legible, complete, and timely.

Health care providers must properly correct or alter errors in patient record documentation.

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Patient Record

Primary purposes:Serves as official business recordDocuments services and treatment providedStores demographic dataSupports diagnosesJustifies treatmentFacilitates continuity of careServes as communication toolAssists in planning individual patient care

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Patient Record

Secondary purposes:Evaluates quality of patient careProvides data for use in clinical research and

epidemiology studiesProvides information to third-party payers for

reimbursement of submitted claimsServes medicolegal interests of patient, facility,

and providers

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Medical Necessity

Patient diagnosis must justify procedures or services provided by documenting procedures, services, and supplies that are:Needed for diagnosis and treatmentPerformed to diagnose the patient, direct patient care,

and/or treat the patient’s conditionConsistent with standards of good medical practice in

local areaNot performed primarily for convenience of physician or

health care facility

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If It Wasn’t Documented,It Wasn’t Done

Patient record serves as medicolegal document and facility’s business record

If provider performs service, but does not document it, payer can refuse to pay

Patient record is defense of quality of care administered to patient

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Assumption Coding

Assignment of codes based on assuming that patient has certain diagnoses or received certain procedures or services

Considered fraud

NOTE: Implement physician query process to avoid fraud risks associated with assumption coding.

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Physician Query Process

Contact responsible physicianQuery physician regarding

documentationDetermine whether query will be

generated concurrently or retrospectively

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Patient Record Formats

ManualSource-oriented record (SOR)Problem-oriented record (POR)

AutomatedElectronic health record (EHR)Optical disk imaging

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Patient Record Formats

HybridAutomated lab data

reports and handwritten physician progress notes

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Verifying Codes

Coders are responsible for reviewing patient records to select the appropriate diagnosis and procedure or service.

Claims can be denied if the medical necessity of procedures or services is not established.

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Any Questions so far?

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Chapter 2

Introduction toICD-9-CM Coding

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Disease Classifications

ICDICD-9-CMICD-10

Permission to reuse granted by Ingenix, Inc.

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ICD-9-CM

Volume 1: Tabular ListVolume 2: Index to DiseasesVolume 3: Index to Procedures and

Tabular List

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Oversight of ICD-9-CM

National Center for Health Statistics (NCHS)

Centers for Medicare and Medicaid Services (CMS)

UpdatesApril 1 and October 1 of each year

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Coding Tools

Non-automatedCoding manualsReference materials

AutomatedComputer-based encodersWeb-based products

UpdateableICD-9-CM coding manuals

Permission to reuse granted by Ingenix, Inc.

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Tabular List of DiseasesArrangement

Numerical order17 chaptersTwo supplementary classificationsFour appendices

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Disease and Injury Codes

Category codesThree digitsFor example, 436

Subcategory codesThree digits followed by decimal point and one

additional digitFor example, 401.9

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Disease and Injury Codes

Sub-classification codeThree digits followed by decimal point and two

additional digitsFor example, 402.90

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Procedure Codes

Category codesTwo digitsFor example, no valid two-digit ICD-9-CM

Volume 3 codes

Subcategory codesTwo digits followed by decimal point and one

additional digitFor example, 10.6

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Procedure Codes

Sub-classification codeTwo digits followed by decimal point and two

additional digitsFor example, 82.01

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Supplementary Classifications

V codesHealth status factorsV58.0-Encounter for Radiation therapy

E codesExternal causes of injuryE888.0-Fall onto a sharp object

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Appendices

A-Morphology of Neoplasms (M codes)Indicates the tissue types of a neoplasm

Sarcoma, adenocarcinoma

B-Glossary of Mental DisordersRemoved from ICD-9-CM in 2004

C-Classification of drugs by AHFSNumerical arrangementFor example, 76:00 Oxytocics

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Appendices

D- Classification of Industrial Accidents Used to classify industrial

accidents

E-List of Three-Digit CategoriesFor example, 390–392-

Acute rheumatic fever

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Index to Diseases Arrangement

AlphabeticMain terms (e.g., conditions)Nonessential modifiers in parenthesesEssential modifiers indented

Sub-terms

Qualifiers further indentedSecond and third

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Basic Steps to Coding Diseases

Locate main term in Index to Diseases.Alphabetic

Follow directional terms (e.g., see, see also, see category).

Review diagnostic statement to locate essential modifiers in Index to Diseases (e.g., sub-terms).

Select and verify code in Tabular List of Diseases.

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Tabular List of Procedures and Index to Procedures

Volume 3 of ICD-9-CMAlphabetic listing of main terms (e.g.,

procedures)Nouns, adjectives, or eponymsUse of “with” and “without”Sub-terms

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Basic Steps to Coding Procedures

Locate main term in Index to Procedures.Follow directional terms (e.g., omit code).Review procedural statement to locate

essential modifiers in Index to Procedures (e.g., sub-terms).

Select and verify code in Tabular List of Procedures.

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Guidelines for Coding and Reporting and Using ICD-9-CM

Cooperating parties for ICD-9-CMImpact of HIPAACoding guidelinesUse of terms “encounter” and “provider”

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Questions