1. Medical Coding Chapter 16 Medical Assisting
PowerPoint® presentation to accompany:
Medical Assisting
Third Edition
Booth, Whicker, Wyman, Pugh, Thompson

2. Learning Outcomes
16.1 Explain the purpose and format of the ICD-9-CM volumes that are used by medical offices.
16.2 Describe how to analyze diagnoses and locate correct codes using the ICD-9-CM.
16.3 Identify the purpose and format of the CPT.
16.4 Name three key factors that determine the level of Evaluation and Management codes that are selected.

3. Learning Outcomes (cont.)
16.5 Identify the two types of codes in the Health Care Common Procedure Coding System (HCPCS).
16.6 Describe the process used to locate correct procedure codes using CPT.
16.7 Explain how medical coding affects the payment process.
16.8 Define fraud and provide examples of fraudulent billing and coding.

4. Introduction Medical coding
Translation of medical terms for diagnoses and procedures into code numbers from standardized code sets
Tells payers that the services provided
Were medically necessary
Complied with payer’s rules
Accurate claims bring maximum appropriate reimbursement for the medical office

5. Diagnosis Codes: The ICD-9-CM
The Diagnosis Process
Patient Chief
Complaint
Physician Medical
Diagnosis
Insurance
Diagnosis
Code
The diagnosis codes are found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9)
The use of ICD-9 codes in health care is mandated by HIPAA for reporting:
 Patient’s diseases
 Conditions
 Signs and symptoms

6. Diagnosis Codes: The ICD-9-CM (cont.)
Alphabetic Index (Volume 2)
Diagnoses appear in alphabetical order
The index is organized by condition
Use initially to look up conditions
Cross-references
Look up term that follows “see”
The Alphabetical Index is never used alone to find a diagnosis code because it does not contain all the necessary information.

7. Diagnosis Codes: The ICD-9-CM (cont.)
Tabular List (Volume 1)
Diagnoses appear in numerical order
Listing is organized according to source or body system
Code Structure
Codes are made up of three, four, and five digits and a description
Three-digit categories are used for diseases, injuries, and symptoms
Categories are further divided into four- and five-digit codes

8. Diagnosis Codes: The ICD-9-CM (cont.)
V Codes
Supplementary classification of factors influencing health status and contact with health services
Identify encounters for reasons other than illness or injury
May be a primary code or additional code
E Codes
“E” – external
Only a supplemental classification of external causes of injuries and poisoning

9. [ ] NEC NOS ( ) Diagnosis Codes: ICD-9-CM Conventions Conventions
A list of abbreviations, punctuation, symbols, typefaces, and notes that provide guidelines for using the code set.
Conventions
NEC
An abbreviation that means “not elsewhere classified”; used when the ICD-9 does not provide a specific code to describe the patient’s condition
[ ]
Brackets are used around synonyms, alternate wording, or explanations
( )
Parentheses are used around alternative wording
NOS
An abbreviation that means “not otherwise specified” or “unspecified”

10. § } : Diagnosis Codes: ICD-9-CM Conventions (cont.) Conventions
Indicates that the footnote is applicable to all subdivisions in that code }
Brace encloses a series of terms :
Used in the Tabular List after an incomplete term
Excludes
Indicates that the entry is not classified as part of the preceding code
Includes
Refines content of preceding entry

11. Code first underlying disease
Diagnosis Codes: ICD-9-CM Conventions (cont.)
Conventions
Use additional code
This note means an additional code should be used if available
Excludes
These notes indicate that an entry is not classified as part of the preceding code
Code first underlying disease
This means that the code is not to be used for the primary diagnosis

12. Diagnosis Codes: The ICD-9-CM Codes (cont.)
Record the code on the claim form 
Steps to Locating
an ICD-9-CM
Code
Read all information to find the code that corresponds to the patient’s condition 
Locate the code from the Alphabetic Index in the Tabular List 
Find the diagnosis in the Alphabetic Index 
Locate statement of diagnosis in patient’s medical record 

13. Diagnosis Codes: The ICD-10-CM
ICD-10-CM: A new revision
Major changes
Contains more than 2000 disease categories
Codes are alphanumeric, containing a letter followed by up to five numbers
Codes are added to show the specific side of the body affected by the disease process
Expected to be adopted as HIPAA-required diagnosis code set before 2010

14. Apply Your Knowledge Good Answer!
A medical assistant has looked up a medical term in the alphabetic index, and next to the term is the word “see.” What does this mean?
ANSWER: This means the medical assistant must look up the term that follows the word “see” because another category should be used or cross-referenced.
Good Answer!

15. Procedure Codes: The CPT
Current Procedural Terminology (CPT) book
The most commonly used system for reporting procedures and services provided to the patient
This is the HIPAA-required code set
Published annually by the American Medical Association (AMA)
Updated annually
Use the appropriate CPT book for the current year

16. Procedure Codes: Using the CPT
Except for the first section, the CPT book is arranged in numerical order
Section
Range of Codes
Evaluation and Management
99201–99499
Anesthesiology
0010–01999
Surgery
10021–69990
Radiology
70010–79999
Pathology and Laboratory
80048–89356
Medicine
90281–99602

17. Procedure Codes: Using the CPT (cont.)
Add-on codes
A plus sign (+) is used
Always used with primary code
Modifiers
One or more two-digit numbers (up to three per procedure) assigned to five-digit main number
Indicate that special circumstance applies

18. Procedure Codes: Using the CPT (cont.)
Category II, III, and Unlisted procedure codes
Category II
Tracks health-care performance measures
Category III
Temporary codes for emerging technologies, services, and procedures
Unlisted codes
Used when no other code is available
Require a written explanation

19. Procedure Codes: Evaluation and Management Services
Used by all physicians in any medical specialty
Key factors that help determine level of service
The extent of the patient history taken
The extent of the examination conducted
The complexity of the medical decision made
New Patient versus Established Patient
New patients – not seen by physician within the past 3 years
Established patients – seen within a 3 year period

20. Procedure Codes: Surgical Procedures
The surgical package
All procedures normally a part of an operation
Anesthesia
Surgery
Routine follow-up care
Global period
The time period covered for follow-up care
If past global period, additional services are reported separately

21. Procedure Codes: The CPT (cont.)
Laboratory Procedures
Panels – organ or disease-oriented
Pathology and Laboratory sections of the CPT
If separate codes are used, they will be rebundled and payment delayed
Immunizations
Injections require two codes
One for the procedure (injection)
One for the medication (vaccine or toxoid)

22. Excellent! Apply Your Knowledge
Which section of the CPT is not arranged in numerical order and why?
ANSWER: The first section, Evaluation and Management, is not in numerical order because the items in this section are used most often and by all physicians in any medical specialty.
Excellent!

23. Excellent! Apply Your Knowledge
The insurance representative has questioned the codes listed on three patient forms that were submitted last year. When re-checking these forms the office medical assistant should:
Excellent!
ANSWER:
Use the current book to validate accuracy of the codes
Use last year’s book to validate accuracy of the codes
Use next year’s book to validate accuracy of the codes

24. HCPCS The Health Care Common Procedure Coding System
Developed by the Centers for Medicare and Medicaid Services (CMS)
Pronounced “hic-picks”

25. HCPCS (cont.) Contains two levels Level I codes Level II codes
Duplicate CPT codes
Level II codes
National codes for supplies and DME (durable medical equipment)
5 characters – numbers, letters, or a combination of both
Can have modifiers

26. Apply Your Knowledge Stellar!
What are HCPCS Level II codes and who issues them?
ANSWER: HCPCS Level II codes are national codes used for supplies, DME, and services not included in the CPT. They are issued by Centers for Medicare and Medicaid Services (CMS).
Stellar!

27. Avoiding Fraud: Coding Compliance
Medical assistants help ensure that maximum appropriate reimbursement is received for services provided
Compliance with federal and state law and payer requirements is mandatory
Code Linkage
A process used by insurance company representatives to evaluate the necessity of medical procedures reported based on the patient’s diagnosis
Diagnostic
Procedures
Prevent errors in coding and incorrect billing by careful attention to details

28. Avoiding Fraud: Insurance Fraud
Investigators look for patterns such as
Reporting services that were not performed
Reporting services at a higher level
Performing and billing for procedures not related to the patient’s condition and therefore not medically necessary
Billing separately for services that are bundled in a single procedure code
Reporting the same service twice

29. Avoiding Fraud: Compliance Plans
Medical offices establish a process for finding, correcting, and preventing illegal medical practices
Goals of compliance plan
Prevent fraud and abuse
Ensure compliance with applicable laws
Help defend physicians if investigation occurs

30. Avoiding Fraud: Compliance Plans (cont.)
Plan demonstrates to payers honest, ongoing attempts to correct any weak areas of compliance
Plan is developed by a compliance officer and committee who also:
Audit and monitor compliance
Develop written policies and procedures that are consistent with regulations and laws
Provide ongoing communication and training to staff
Respond to and correct errors

31. Correct! Apply Your Knowledge
What are the goals of a compliance plan and what does having a plan indicate?
ANSWER: The goals of a compliance plan are to prevent fraud and abuse, ensure compliance with applicable laws, and to help defend physicians if an investigation occurs. Having a plan indicates that the medical office is making honest, ongoing attempts to find and fix weak areas of compliance.
Correct!

32. In Summary ICD-9-CM Diagnostic coding for health-care claims
Updated annually
Two volumes
Tabular list
Alphabetic list
V codes – encounters not related to illness or injury
E codes – injuries related to environmental events

33. In Summary (cont.)
CPT
Standardized procedure codes for medical, surgical, and diagnostic services
Six sections
Evaluation and Management
Anesthesiology
Surgery
Radiology
Pathology and Laboratory
Medicine

34. In Summary (cont.) HCPCS is used for coding Medicare services Claims
CPT
Level II national codes
Claims
Link diagnoses and procedures correctly
Must comply with applicable regulations and requirements
Practices should have a compliance plan with a formal process for review of procedures to guard against fraud

35. Things gained through unjust fraud are never secure.
End of Chapter 16
Things gained through unjust fraud are never secure.
~ Sophocles