1. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 15 Procedural and Diagnostic Coding

2. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. What is Coding? Converting descriptions of disease, injury, procedures, and services into numeric or alphanumeric descriptors Accurate coding maximizes reimbursement

3. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. The History of Coding International Classification of Diseases (ICD) – 1890s: a physician classified causes of death – The American Public Health Association recommended this system to be used to classify deaths in North America – 1938: ICD-5 – 1978: ICD-9 – 2013: ICD-10 (adopted in the US)

4. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. The History of Coding Current Procedural Terminology (CPT) – 1966: First published by the American Medical Association – 1970: 5 digit codes introduced – 1983: Adopted as part of HCPCS – 2004: New, revised, and deleted codes must be implemented every January 1

5. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. HCPCS Healthcare Common Procedural Coding System – Level I: CPT Codes – Level II: National Codes Services and products not covered by CPT codes – Codes published annually

6. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. CPT Codes for procedures or services 6 sections of the CPT Manual 1.Evaluation & Management 2.Anesthesiology 3.Surgery 4.Radiology 5.Pathology and Laboratory 6.Medicine

7. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. CPT Modifiers – Appendix A – Used when procedure/services needs to be clarified or altered Unlisted codes CPT code symbols

8. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. CPT Coding Rules Select the name of the procedure or service that most accurately identifies the service performed – Typically marked on encounter form – If clarification is needed to determine the correct code, seek the provider

9. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. ICD Codes for diseases or conditions Establishes medical necessity ICD-9 Manual – Volume I: Tabular List – Volume II: Alphabetic Index – Volume III: Used by hospital coders

10. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. ICD Coding Rules Follow the reason rule Code each problem to the highest level of specificity

11. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. ICD-10 10 th clinical modification – ICD-9 is not adequate to meet today’s needs – Allows for greater specificity in reporting diseases Coding system in place worldwide since 1990 Contains over 68,000 codes

12. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Electronic Coding Encoders Computer-assisted coding

13. Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Coding Accuracy Bundling or Unbundling Upcoding or Downcoding Medicare Audit