Coding IS how you will make your living!
This may come as a surprise to you.
• ICD-IO represents the "WHY" it was done Medical Necessity-———— R07 9 (Chest Pain)
CPT-4 represents the "WHAT" was done to the patient- Physician Service Procedure—-— 93010 (EKG)
ICD-10-PCS Represents Hospital Service oDTJ4ZZ Resection of Appendix, Percutaneous Endoscopic Approach
HCPCS-is for Supplies and Drugs-Not used in India
• Key medical terms are identified & abstracted from the medical record.
• Specific codes are assigned to each term.
• ICD-10-CM Manual-2020• ICD-10-PCS Manual-2020 • CPT 2020• HCPCS 2020
AKA's of the Medical Coder
Health Information Technician
0 Health Information Coder
Medical Record Coder
Coder / Abstractor
Coding Specialist
Insurance Specialist
Knowledge of medical terminology
e Knowledge of anatomy & physiolow
Detail oriented
Accuracy
• Critical thinking
Willingness to learn
Self-motivated • Flexibility • Computer
skills
Principle of Medical Coding
If it's not documented, it wasn't done
The International Classification of Diseases (ICD) is the international standard diagnostic classification for all general epidemiological purposes, many health management purposes, and for clinical use. ICD-10, Clinical Modification (ICD-10-CM) was developed by the U.S. National Center for Health Statistics (NCHS) along with an advisory panel to ensure accuracy and utility in 1993.
ICD-10, Clinical Modification (ICD-10-CM) was developed by the U.S. National Center for Health Statistics (NCHS) along with an advisory panel to ensure accuracy and utility in 1993. ICD-10 codes allow for greater specificity and exactness in describing a patient's diagnosis and in classifying inpatient procedures.
Benefits to ICD-10-CM include but are not limited to the following: •Improving payment systems and reimbursement accuracy •Measuring the quality, safety and efficacy of care •Improve disease management •Conducting research, epidemiogical studies, and clinical trials •Setting health policy •Monitoring resource utilization •Preventing and detecting healthcare fraud and abuse
Clinical documentation is a vital component that represents the medical condition of the patient and, therefore, has always played a vital role in medical coding. billing, medical research, hospital/physician outcome studies, etc. Complete, accuracy, specific and timely Proper documentation is required
Medical Record Documentation:- 'Ihe medical record should be complete and legible. The documentation of each patient encounter should 2. include: the date; the reason for the encounter; appropriate history and physical exam in relationship to the patient's chief complaint; review of lab, x-ray data, and other ancillary services, where appropriate; assessment; and a plan for care (including discharge plan, if appropriate) Past and present diagnoses should be accessible to 3. the treating and/or consulting physician. The reasons for—and results of—x-rays, lab tests, and 4. other ancillary services should be documented or included in the medical record.
• Relevant health risk factors should be identified. • The patient's progress, including response to treatment, change in treatment, change in diagnosis, and patient noncompliance, should be documented. • The plan for care should include when appropriate: treatments and medications, specifying frequency and dosage• any referrals and consultations; patient/family Education; an specific instructions for follow-up. • The documentation should support the intensity of the patient evaluation and/or treatment, Including thorough processes and the complexity of medical decision-making as it relates to the patient's chief complaint for the encounter. • All entries to the medical record should be dated and authenticated.
A medical record should be kept clear and legible For the documentation of each patient encounter, the following information should be included: reason for the encounter, date, laboratory and tests data, physical examinations, medical history, assessments, and plan of care. The medical professional should make sure that previous and current diagnoses are always accessible to whomever will handle the case. Ancillary servicß should be clear, including the results and/or any intervention initiated. All of the following should also be documented regarding patient response: reactions to treatments, changes on the procedures, noncompliance on the part of the patient, and any changes on the diagnosis.
ICD-10-CM Chapters A & B = Certain Infectious and Parasitic Diseases C & D = Neoplasms • D = Diseases of the Blood and Blood-forming Organs E = Endocrine Nutritional and Metabolic Diseases F = Mental, Behavioral, Neurodevelopmental Disorders G = Diseases of the Nervous System • H = Diseases of the Eye and Adnexa • H = Diseases of the Ear and Mastoid Process I = Diseases of the Circulatory System • J = Diseases of the Respiratory System Diseases of the Digestive System L = Diseases of the Skin and Subcutaneous Tissue • M = Diseases of the Musculoskeletal System
• • • • N = Diseases of the Genitourinary System O = Pregnancy, Childbirth and the Puerperium P = Certain Conditions Originating in the Perinatal Period Q = Congenital Malformations, Deformations and Chromosomal Abnormalities R = Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified S & T = Injun', Poisoning and Certain Other Consequences of External Causes V = Transport accidents - External Causes Of Morbidity W = Other F„external Causes of Accidental Injury X = Exposure to smoke, fire and flames X - Y = Assault Z = Factors Influencing Health Status and Contact With Health Services Medical coding training hyderabad
K80.O Calculus Of gallbladder with acute cholecystitis Any condition listed in K802 with acute cholecystitis K80.OO Calculus Of gallbladder with acute cholecystitis without obstruction K80.Of Calculus of gallbladder with acute cholecystitis with obstruction K80.1 Calculus of gallbladder with other cholecystitis K80.10 KSO.II K80.12 K80.13 K80.18 K80.19 Calculus Of gallbladder with chronic cholecystitis without obstruction Cholelithiasis with cholecystitis NOS Calculus Of gallbladder with chronic cholecysTItis with obstruction Calculus of gallbladder with acute and chronic cholecystitis without obstruction Calculus Of gallbladder with acute and chronic cholecystitis with obstruction Calculus Of gallbladder with other cholecystitis without Obstruction Calculus Of gallbladder with Other cholecystitis with obstruction K80.2 Calculus Of gallbladder without cholecystitis
Introduction to CPT Coding CVr-4 represents the "WHAT' was done to the patient Procedure-— Code 93010 (EKG)-5 Digit Text organized in 6 rnAior sections Evaluation and Management Anesthesiolow Surgery Radiolow Patholow and Laboratory Medicine (99201 - 99499) (00100 - 01999, 99100 - 99140) (10040 - 69990) (70010 - 79999) (80049 - 89399) (90281- 99199)
CPT Codes • Developed as a stand-alone descriptions of the procedures • To conserve space, some are not printed in their entirety but refer back to a common portion listed in a preceding entry* * Example: 25100-arthrotomy, wrist joint; for biopsy 25105 for synovectomy
ICD-IO-PCS: Code Structure Seven Character Alphanumeric Code All procedure codes will be seven characters long "I" and "O" (letters) are never used • 34 possible values for each character Digits o — 9 Letters A-H, J-N, P-Z
Clip slide ICD- I O-PCS Structure (Characters and Values) A is a stable, standardized code component Holds a fixed place in the code Retains its meaning across a range of codes • A value is an individual unit defined for each character
Susie Buys Root Beer At Dairy— Queen ISt character = Section '2nd character = Body System e character = Root Operation e 4th character = Body Part 5th character = Approach 6th character = Device e 7th character = Qualifier
• ICD-10 Procedure Code • oDN90ZZ Release of duodenum, open approach • oFB03ZX Excision of liver, percutaneous approach, diagnostic • 02PSoCZ Removal, extraluminal device from pulmonary vein, right, open
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