1. Introduction to Coding & Reimbursement
Chapter 10
Introduction to Coding & Reimbursement

2. Nomenclatures & Classification Systems
Medical nomenclature
Coding/classification system

3. Nomenclatures Basle Nomina Anatomica
Standardized Nomenclature of Disease (SND)
Standardized Nomenclature of Diseases and Operations (SNDO)
Systematized Nomenclature of Pathology (SNOP)

4. Nomenclatures (Continued)
Systematized Nomenclature of Medicine (SNOMED)
Current Medical Information and Terminology (CMIT)
Unified Medical Language System (UMLS)

5. Medical Classification & Coding Systems
London Bills of Mortality
Nosologia Methodica
Bertillon International Statistical Classification of Causes of Diseases
Manual of the International Statistical Classification of Diseases, Injuries, and Cause of Death (ICD-6)

6. Medical Classification & Coding Systems (Continued)
International Classification of Diseases adapted for use in US (ICDA)
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Current Procedural Terminology (CPT)
International Classification of Diseases for
Oncology, third edition (ICD-0-3)

7. Medical Classification & Coding Systems (Continued)
International Classification of Injuries, Disabilities, and Handicaps (ICIDH)
HCPCS Level II (national codes)
Current Dental Terminology (CDT)
National Drug Codes (NDC)
Alternative Billing Codes (ABCcodes™)

8. Third-Party Payers Blue Cross and Blue Shield (BCBS) Commercial payers
Employer self-insurance plans
Government-sponsored programs
Managed care
Workers’ compensation

9. Health Care Reimbursement Systems
Medicare Severity DRGs (MS-DRGs)
Resource Utilization Groups (RUG)
Home Health Resource Groups (HHRG)
Ambulatory Payment Classifications (APC)
Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)

10. Health Care Reimbursement Systems (Continued)
Long-Term Care Diagnosis-Related Groups (LTC DRG)
End-Stage Renal Disease Composite Payment Rate System

11. Case Mix Analysis & Severity of Illness Systems
Case mix - types and categories of patients
Case mix index - indicates the average weight
of a hospital’s diagnosis-related groups
Severity of illness physiologic complexity of
extent and interaction of patient’s disease
Critical pathways

12. Processing Insurance Claims
Chargemaster and encounter form
CMS-1450 (or UB-04) and CMS-1500
Electronic data interchange (EDI)

13. Fraud & Abuse Medical necessity
Medicare Fraudulent practices regulated by
The Civil Monetary Penalties Act
Department of Health and Human Services
Office of the Inspector General
The National Correct Coding Initiative
Never Events
Hospital-Acquired conditions and Present on
Admission Indicator Reporting