HI 255 Medical Coding II Unit One Seminar Regina L Kraus, MSA,RHIT, CPHQ Kaplan University, School of Health Sciences

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. HI 255 Medical Coding II Instructor Background and Information Education: AAS in Medical Record Technology Sinclair Community College (Dayton, OH) BS in Health Care Administration Capital University (Columbus, OH) MSA in Health Care Administration Central Michigan University

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. HI 255 Medical Coding II Work Experience Medical Record Specialist Consultant/Survey Auditor/Reviewer Department Director Medical Records Director of Quality Assur/Medical Records Executive Director of Behavioral Health Teacher/Instructor IS/QA/Health Information

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. HI 255 Medical Coding II Structure of Course –Nine Seminars –Four Discussion Boards –9 Exercises –4 Quizzes –1 Mid Term Exam –1 Final Exam (Unit Ten)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. HI 255 Medical Coding II Objectives of Course Apply basic and advanced coding guidelines with the aid of professional coding resources and websites. Apply coding guidelines for accurate reimbursement; Perform data quality reviews to validate coding assignment; Use coding software (3M Encoder)

Understanding ICD-9-CM Coding Mary Jo Bowie MS, RHIA, RHIT Regina Schaffer AAS, RHIA, CPC

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 7 Review of Chapters One - Four Coding is the assignment of numerical or alphanumerical digits and characters to diagnostic and procedural phrases Coding is a language; – used by insurance companies –Used by health care providers –Vital to care and treatment of patients Coder needs to be able to “translate” this language

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 8 International Classification of Disease, Ninth Revision, Clinical Modification ICD-9-CM Systematic division of groups of diagnoses and procedures Reflects signs, symptoms, disorders, diseases, examinations, or other reasons for the services billed Gives payers a clear picture of the reasons for the services billed

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 9 ICD-9-CM Coding Book Format Three volumes: –Volume 1: Tabular List of Diseases and Injuries –Volume 2: Alphabetic Index –Volume 3: Tabular List and Alphabetic Index of Procedures

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 10 Sections Series of three-digit codes Unable to assign code at this level Notations also may appear at the section level Subcategories and Subclassifications –Subcategories contain four digits –Subclassifications contain five digits –Most specific categories of code assignment

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 11 Truncated Codes Not carried out to fourth- or fifth-digit level when needed Not valid reporting Payer will reject claim if submitted with a truncated code

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 12 Coding Rules Accurate coding Group of instructional notations, abbreviations, punctuation marks, and symbols to guide the coder Official Guidelines for Coding and Reporting

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 13 Steps in Coding Locate the Main Term–Volume 2 Scan term for instructional notations Identify terms that modify main term Cross-reference notations Verify code–Volume 1 Follow instructional terms

ICD-9-CM Procedural Coding PART III

CHAPTER 25 Introduction to ICD-9-CM Procedure Coding

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16 Volume 3 of ICD-9-CM Alphabetic Index Tabular List Used by hospital Not used in outpatient setting Uniform Hospital Discharge Data Set (UHDDS) defines procedures

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 17 Procedure Code Structure and Volume Format Comprised of four digits Two digits preceding decimal point indicate body system One or two digits following decimal point indicate more specific code

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 18 Procedure Code Structure and Volume Format Alphabetic Index of Procedures –Identify main term –Comprehensive –Listed here not in the Tabular List –Eponym or acronym Identify the indentations Reference Tabular List

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 19 Medical Terminology Prefix Suffix Understanding what type of procedure was done

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 20 Terms Used to Locate Procedures Ablation—destruction with regard to function of a body part Amputation—removal of a body part Biopsy—sampling of tissue for diagnostic purposes

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 21 More Procedure Terms Destruction—eliminate completely Endoscopic—visual internal inspection Graft—transplant tissue Ligation—tie or bind off blood vessels or ducts using catgut, cotton, silk, or wire

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 22 Surgical Code Requires knowledge of intent Diagnostic procedure Procedure done for treatment Know the approach

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 23 Coding Conventions Used as they are in Volumes 1 and 2 Attention to inclusion or exclusion notes “Code also” –Additional code if referenced procedure was performed during operative session

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 24 Coding Conventions “Omit code” –“as operative approach” –Not billed separately

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 25 Canceled and Incomplete Procedures Incomplete surgery –Incision was made Code incision site –Cavity space entered Exploratory procedure –Endoscopic started but did not reach site Endoscopy only

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 26 Cancelled Procedure Patient is admitted but scheduled procedure is cancelled –Code from V64 –Persons encountering health services for specific procedures but not carried out

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 27 Scope Procedures Arthroscopy Bronchoscopy Colonoscopy Cystoscopy

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 28 Scope Procedures Cont. Esophagoscopy Laparoscopy Mediastinoscopy Thoracoscopy

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. HI 255 Medical Coding II Virtual Field Trip Link and Instructions Please watch the following video by clicking on the link on the bottom left box: XTC3AKmtrcs/bronchoscopy/ When done, type done in the chat box and answer the following questions: –What is the bronchoscopy used for? –What is the name of the instrument? 29

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 30 Open Procedure Procedure completed via incision Endoscopic started but switched to open –Code open procedure Laparoscopic started but switched to open –V64.41, V64.42, V64.43