© 2010 Delmar, Cengage Learning Chapter 1 Overview of Coding

© 2010 Delmar, Cengage Learning General Information Assignments –Check weekly on how and if submitted Late Work – not accepted –Contract me is there is an issue Discussion Board –Check weekly if there is a discussion –Weeks 3, 5, 7, 8, 9

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning Training Formal course work (e.g., medical terminology, anatomy, physiology) Nonpaid coding internship –On-site at health care facility

© 2010 Delmar, Cengage Learning Professional Associations Offering Coding Credentials American Health Information Management Association (AHIMA) American Academy of Professional Coders (AAPC) American Medical Billing Association (AMBA)

© 2010 Delmar, Cengage Learning Employment Opportunities Clinics Consulting firms Government agencies Hospitals Insurance companies Nursing facilities Home health care agencies Hospice organizations Physician offices Work at home

© 2010 Delmar, Cengage Learning 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 Web site access

© 2010 Delmar, Cengage Learning Professional Networking Attend professional association conferences and meetings Join online discussion boards (listservs)

© 2010 Delmar, Cengage Learning Coding Overview Facilities, providers, and third-party payers use coding systems and medical nomenclature to collect, store, and process data.

© 2010 Delmar, Cengage Learning 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 (e.g., CPT, HCPCS level II, ICD-9-CM)

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning Code Sets Large –Encode diseases, causes of injury, disease prevention, equipment, and supplies Small –Encode race, ethnicity, type of facility, and type of unit

© 2010 Delmar, Cengage Learning Required Code Sets HIPAA requires specific code sets to be adopted for use by clearinghouses, health plans, and providers (covered entities). Code sets include ICD-9-CM, CPT, HCPCS level II (national codes), Current Dental Terminology (CDT), and National Drug Code (NDC).

© 2010 Delmar, Cengage Learning Covered Entities Health care clearinghouses Health plans Providers NOTE: A health care clearinghouse is not a third-party administrator (TPA), which processes health care claims and performs related business functions for a health plan.

© 2010 Delmar, Cengage Learning 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)

© 2010 Delmar, Cengage Learning Coding References Compliance program guidance documents ICD-9-CM Official Guidelines for Coding and Reporting

© 2010 Delmar, Cengage Learning Fraudulent Coding Unbundling Upcoding Overcoding Jamming Downcoding

© 2010 Delmar, Cengage Learning 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.

© 2010 Delmar, Cengage Learning Patient Record Primary purposes: –Serves as official business record –Documents services and treatment provided –Stores demographic data –Supports diagnoses –Justifies treatment –Facilitates continuity of care –Serves as communication tool –Assists in planning individual patient care (continued)

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning Teaching Hospitals Engaged in approved graduate medical education (GME) residency program Residents involved in patient care 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

© 2010 Delmar, Cengage Learning Medical Necessity Patient diagnosis must justify procedures or services provided (continued)

© 2010 Delmar, Cengage Learning Medical Necessity Providers document procedures, services, and supplies that are: –Needed for diagnosis and treatment –Performed to diagnose the patient, direct patient care, and/or treat the patient’s condition –Consistent with standards of good medical practice in local area –Not performed primarily for convenience of physician or health care facility

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning 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.

© 2010 Delmar, Cengage Learning Physician Query Process Contact responsible physician Query physician regarding documentation Determine whether query will be generated concurrently or retrospectively (continued)

© 2010 Delmar, Cengage Learning Physician Query Process Designate individual to serve as physician’s contact during the process Use query form to document query and physician’s response

© 2010 Delmar, Cengage Learning Patient Record Formats Manual –Source-oriented record (SOR) –Problem-oriented record (POR) Automated –Electronic health record (EHR) –Optical disk imaging (continued)

© 2010 Delmar, Cengage Learning Patient Record Formats Hybrid –Automated lab data reports and handwritten physician progress notes

© 2010 Delmar, Cengage Learning 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

© 2010 Delmar, Cengage Learning 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) Reports generated for statistical analysis and reimbursement purposes

© 2010 Delmar, Cengage Learning Sample Data Entry Screen Permission to reuse granted by QuadraMed.

© 2010 Delmar, Cengage Learning 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.

© 2010 Delmar, Cengage Learning