Chapter 1 Overview of Coding

Introduction Coding systems: Starting a coding career 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

Coder Acquire working knowledge of coding systems and rules, as well as payer requirements Ensure coding accuracy Communicate with providers about documentation and compliance issues, as well as assignment of codes

Training Formal course work Non-paid coding internship e.g., medical terminology, anatomy, physiology Non-paid coding internship On-site at health care facility

Professional Associations Offering Coding Credentials American Health Information Management Association (AHIMA) American Academy of Professional Coders (AAPC) American Medical Billing Association (AMBA)

Employment Opportunities Clinics Consulting firms Government agencies Hospitals Insurance companies Nursing facilities Home health care agencies Hospice organizations Physician offices Work at home

Benefits of Joining a Professional Association Reduced membership fee Many of the same benefits as active members Eligibility for scholarships and grants Networking opportunities Publications Reduced certification exam fees Expanded website access

Professional Networking Attend professional association conferences and meetings Join online discussion boards (listservs)

Coding Overview Facilities, providers, and third-party payers use coding systems and medical nomenclature to collect, store, and process data

Purpose of Coding Systems Organize medical nomenclature Vocabulary of clinical and medical terms e.g., Systematized Nomenclature of Medicine (SNOMED) Codes assigned for similar diseases and procedures e.g., CPT, HCPCS level II, ICD-9-CM, ICD-10-CM, ICD-10-PCS

Codes Numeric and alphanumeric characters Assigned to diagnoses, procedures, and services Reported to payers and external agencies Used internally for education, research, and statistical purposes

Health Insurance Portability and Accountability Act (HIPAA) Portability and continuity of coverage Fraud and abuse Medical savings accounts Access to long-term care services Administration simplification Electronic transactions Privacy and security

Code Sets Large Encode diseases, causes of injury, disease prevention, equipment, and supplies Small Encode race, ethnicity, type of facility, and type of unit

Required Code Sets HIPAA requires specific code sets to be adopted for use by clearinghouses, health plans, and providers (covered entities) (continued)

Required Code Sets Code sets include the following: ICD-9-CM CPT HCPCS level II National codes Current Dental Terminology (CDT) National Drug Code (NDC)

Covered Entities Health care clearinghouses Health plans Providers Not a third-party administrator (TPA) TPA processes health care claims and performs related business functions for health plan Health plans Providers

Coding References Coding clinics Conditions of Participation (CoP) and Conditions for Coverage (CfC) CPT Assistant and HCPCS Assistant National Correct Coding Initiative (NCCI) and Outpatient Code Editor (OCE) with Ambulatory Payment Classification (APC) (continued)

Coding References Compliance program guidance documents ICD-9-CM Official Guidelines for Coding and Reporting

Fraudulent Coding Unbundling Upcoding Overcoding Jamming Downcoding

Documentation Issues Health care providers 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

Patient Record Primary purposes: Serves as official business record Documents services and treatment provided Stores demographic data Supports diagnoses Justifies treatment (continued)

Patient Record Primary purposes: Facilitates continuity of care Serves as communication tool Assists in planning individual patient care (continued)

Patient Record Secondary purposes: Evaluates quality of patient care Provides data for use in clinical research and epidemiology studies Provides information to third-party payers for reimbursement of submitted claims Serves medicolegal interests of patient, facility, and providers

Teaching Hospitals Engaged in approved graduate medical education (GME) residency program Residents involved in patient care (continued)

Teaching Hospitals Patient record documentation includes: Services furnished by residents Participation of teaching physician in provision of services Whether teaching physician was physically present when care was provided

Medical Necessity Patient diagnosis must justify procedures or services provided Providers document procedures, services, and supplies that are: Needed for diagnosis and treatment Performed to diagnose patient, direct patient care, and/or treat patient’s condition (continued)

Medical Necessity Providers document procedures, services, and supplies that are: Consistent with standards of good medical practice in local area Not performed primarily for convenience of physician or health care facility

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

Assumption Coding Assignment of codes based on assumption that patient has certain diagnoses or has received certain procedures or services Considered fraud Note: Implement physician query process to avoid fraud risks associated with assumption coding

Physician Query Process Contact responsible physician Query physician regarding documentation Determine whether query will be generated concurrently or retrospectively (continued)

Physician Query Process Designate individual to serve as physician’s contact during process Use query form to document query and physician’s response

Patient Record Formats Manual Source-oriented record (SOR) Problem-oriented record (POR) Automated Electronic health record (EHR) Optical disk imaging (continued)

Patient Record Formats Hybrid Automated lab data reports and handwritten physician progress notes

Health Data Collection Planning administrative tasks Submitting statistics to state and federal government agencies Reporting health claims data to third-party payers for reimbursement purposes

Reporting Data to Payers Use of automated software e.g., case abstracting software, medical management software Data entered and imported into claims for submission e.g., CMS-1500, UB-04 (continued)

Reporting Data to Payers Reports generated for statistical analysis and reimbursement purposes

Sample Data Entry Screen Permission to reuse granted by QuadraMed.

Verifying Codes Coders responsible for reviewing patient records to select appropriate diagnosis and procedure or service Claims can be denied if medical necessity of procedures or services not established