2.01: LEARN MORE ABOUT MEDICAL CODING
Medical coding is a little bit like translation. Coders take medical reports from doctors, which may include a patient’s condition, the doctor’s diagnosis, a prescription, and whatever procedures the doctor or healthcare provider performed on the patient, and turn that into a set of codes, which make up a crucial part of the medical claim.
WHY WE CODE
Let’s start with a simple question about medical coding: Why do we code medical reports? Wouldn’t it be enough to list the symptoms, diagnoses, and procedures, send them to an insurance company, and wait to hear which services will be reimbursed?
To answer that, we have to look at the massive amount of data that every patient visit entails. If you go into the doctor with a sore throat, and present the doctor with symptoms like a fever, sore throat, and enlarged lymph nodes, these will be recorded, along with the procedures the doctor performs and the medicine the doctor prescribes.
In a straightforward case like this, the doctor will only officially report his diagnosis, but that still means the portion of that report that will be coded contains a diagnosis, a procedure, and a prescription.
Take a step back, and this is suddenly a lot of very specific information. And that’s just for a relatively simple doctor’s visit. What happens when a patient comes into the doctor with a complicated injury or sickness, like an ocular impairment related to their Type-2 diabetes? As injuries, conditions, and illnesses get more complex, the amount of data that needs to be conveyed to insurance companies increases significantly.
According to the Centers for Disease Control (CDC), there were . That’s a stat that includes visits to physician offices, hospital outpatient facilities and emergency rooms. If there were just five pieces of coded information per visit, which is an almost unrealistically low estimate, that’d be 6 billion individual pieces of information that needs to be transferred every year. In a system loaded with data, medical coding allows for the efficient transfer of huge amounts of information.
Coding also allows for uniform documentation between medical facilities. The code for streptococcal sore throat is the same in Arkansas as it is in Hawaii. Having uniform data allows for efficient research and analysis, which government and health agencies use to track health trends much more efficiently. If the CDC, for example, wants to analyze the prevalence of viral pneumonia, they can search for the number of recent pneumonia diagnoses by looking for the ICD-9-CM code 480.
Finally, coding allows administrations to look at the prevalence and effectiveness of treatment in their facility. This is especially important to large medical facilities like hospitals. Like government agencies tracking, say, the incidence of a certain disease, medical facilities can track the efficiency of their practice by analyzing
Now that we understand the importance of this practice, let’s take a look at the three types of code that you’ll have to become familiar with as a medical coder.
THREE TYPES OF CODE YOU’LL HAVE TO KNOW
There are three sets of code you’ll use on a daily basis as a medical coder.
ICD
These are diagnostic codes that create a uniform vocabulary for describing the causes of injury, illness and death. This code set was established by the (WHO) in the late 1940s. It’s been updated several times in the 60-plus years since it’s inception. The number following “ICD” represents which revision of the code is in use.
For example, the code that’s currently in use in the United States is ICD-9-CM. This means it’s the ninth revision of the ICD code. That “-CM” at the end stands for “clinical modification.” So the technical name for this code is the International Classification of Diseases, Ninth Revision, Clinical Modification. The clinical modification is a set of revisions put in place by the (NCHS), which is a division of the (CMS).
The Clinical Modification significantly increases the number of codes for diagnoses. This increased scope gives coders much more flexibility and specificity, which is essential for the profession. To give you an idea of how important the clinical modification is, the ICD-10 code, which we will discuss more thoroughly in Course 2-5, has 14,000 codes. It’s clinical modification, ICD-10-CM, contains over 68,000.
ICD codes are used to represent a doctor’s diagnosis and the patient’s condition. In the billing process, these codes are used to determine medical necessity. Coders must make sure the procedure they are billing for makes sense with the diagnosis given. To return to our strep throat example, if a coder listed a strep throat diagnosis as the medical justification for an x-ray, that claim would likely be rejected.
ICD codes are updated by the NCHS on a regular basis. One of the biggest issues in coding—and, indeed, in the health information business at large—is the upcoming switchover from ICD-9-CM to ICD-10-CM. We’ll cover this in upcoming courses, but the quick summary is that ICD-9-CM has reached its capacity of use as a coding system. ICD-10-CM provides significantly more codes and thus more flexibility and accuracy in the coding process. The entire medical system is set to change over from ICD-9-CM to ICD-10-CM in October of 2015.
Let’s turn our attention now to the two types of procedure codes.
CPT
current procedure terminology CPT, codes, are used to document the majority of the medical procedures performed in a physician’s office. This code set is published and maintained by the american medical association (AMA). These codes are copyrighted by the AMA and are updated annually.
CPT codes are five-digit numeric codes that are divided into three categories. The first category is used most often, and it is divided into six ranges. These ranges correspond to six major medical fields: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.
The second category of CPT codes corresponds to performance measurement and, in some cases, laboratory or radiology test results. These five-digit, alphanumeric codes are typically added to the end of a Category I CPT code with a hyphen.
Category II codes are optional, and may not be used in the place of Category I codes. These codes are useful for other physicians and health professionals, and the AMA anticipates that Category II codes will reduce the administrative burden on physicians’ offices by providing them with more, and more accurate, information, specifically related to the performance of health professionals and health facilities.
The third category of CPT codes corresponds to emerging medical technology.
As a coder, you’ll spend the vast majority of your time with the first two categories, though the first will undoubtedly be more common.
CPT codes also have addendums that increase the specificity and accuracy of the code used. Since many medical procedures require a finer level of detail than the basic Category I CPT code offers, the AMA has developed a set of CPT modifiers. These are two-digit numeric or alphanumeric codes that are added to the end of the Category I CPT code. CPT modifiers provide important additional information to the procedure code. For instance, there is a CPT modifier that describes which side of the body a procedure is performed on, and there’s also a code for a discontinued procedure.
HCPCS
healthcare common procedure coding system (HCPCS), commonly pronounced as “hick picks,” are a set of codes based on CPT codes. Developed by the CMS (the same organization that developed CPT), and maintained by the AMA, HCPCS codes primarily correspond to services, procedures, and equipment not covered by CPT codes. This includes durable medical equipment, prosthetics, ambulance rides, and certain drugs and medicines.
HCPCS is also the official code set for outpatient hospital care, chemotherapy drugs, Medicaid, and Medicare, among other services. Since HCPCS codes are involved in Medicaid and Medicare, it’s one of the most important code a medical coder can use.
The HCPCS code set is divided into two levels. The first of these levels is identical to the CPT codes that we covered earlier.
Level II is a set of alphanumeric codes that is divided into 17 sections, each based on an area of specificity, like Medical and Laboratory or Rehabilitative Services.
Like CPT codes, each HCPCS code should correspond with a diagnostic code that justifies the medical procedure. It’s the coders responsibility to make sure whatever outpatient procedure is detailed in the doctor’s report makes sense with the listed diagnosis, typically described via an ICD code.
Now that you’ve got a better idea of what each of these codes is and what they do, let’s start exploring each code set in a little more detail.
2.02: MEDICAL CODING VOCABULARY & KEY TERMS
There are a number of important terms you’ll want to familiarize yourself with as you learn more about coding. Let’s look at some of these now.
CATEGORY (CPT)
The CPT code set is divided into three Categories. Category I, which is the largest and most commonly used, describes medical procedures, technologies and services. Category II is used for performance management and additional data. Category III houses the codes for emerging and experimental medical procedures and services.
CATEGORY (ICD)
In ICD, the category is the first three characters of the code, which describes the basic manifestation of the injury or sickness. In some cases, the category is all that is needed to accurately describe the condition of the patient, but more often than not the coder must list a more detailed description of the injury or illness (see “Subcategory,” and “Subclassification”). In ICD-9-CM, categories are three numbers, except in the case of E- and V-codes, which are alphanumeric. In ICD-10-CM, all categories are alphanumeric.
CLINICAL MODIFICATION
This designation, created by the National Center for Health Statistics, is added to the ICD codes sets when they are implemented in the United States. Many countries expand and clarify ICD code sets for their national use; the US, for example, expanded ICD-10 from 14,000 codes to over 68,000 individual codes. This term is abbreviated “-CM” and is added to the end of the ICD code title. For instance, ICD-9-CM can be read “International Classification of Diseases, Ninth Revision, Clinical Modification.
CMS
The CENTRE FOR MEDICARE SERVICES. This federal agency updates and maintains the HCPCS code set and is one of the most important organizations in healthcare today.
CPT
CURRENT PROCEDURAL TERMINOLOGY. Published, copyrighted, and maintained by the American Medical Association, CPT is a large set of codes that describe what procedure or service was performed on a patient. This code is divided into three Categories, with the first Category being the most important and widely used. CPT codes are an integral part of the reimbursement process. These codes are five characters long and may be numeric or alphanumeric.
HCPCS
HEALTHCARE COMMON PROCEDURE CODING SYSTEM, pronounced hick-picks. This is main procedural code set for reporting procedures to Medicare, Medicaid, and a large number of other third-party payers. Maintained by CMS (See “CMS”), HCPCS is divided into two levels. Level I is identical to CPT, and is used in the same way. Level II describes the equipment, medication, and out-patient services not included in CPT.
E-CODES
E-codes are a set of ICD-9-CM codes that includes codes for external causes of injury, such as auto accidents, poisoning, and homicide.
EVALUATION AND MANAGEMENT (CPT)
Evaluation and Management, or E&M, is a section of CPT codes used to describe the assessment of a patient’s health and the management of their care. The codes for visits to doctor’s office and trips to the emergency room, for instance, are included in E&M. E&M is found at the front of the CPT manual, despite being out of numerical order. The codes for E&M are 99201 – 99499.
ICD
The INTERNATIONAL CLASSIFICATION OF DISEASES is a set of medical diagnostic codes established over a hundred years ago. Maintained today by the WHO (See “WHO”), ICD codes create a universal language for reporting diseases and injury. In the United States, we use ICD-9-CM (See “Clinical Modification”), while the rest of the world uses some form of ICD-10. The US is slated to upgrade to ICD-10-CM in 2015. ICD codes are numeric or alphanumeric. They have a three-character category (See “category (ICD)”), which describes the injury or disease, which is typically followed by a decimal point and two-to-four more characters, depending on the code set, which give more information about the manifestation and/or location of the disease.
MODIFIER
A modifier is a two-character code that is added to a procedure code to demonstrate an important variation that does not, by itself, change the definition of the procedure. CPT codes have numeric modifiers, while HCPCS codes have alphanumeric modifiers. These are added at the end of a code with a hyphen, and may provide information about the procedure itself, that’s procedure’s Medicare eligibility, and a host of other important facets. The CPT modifier -51, for example, notifies the payer that this procedure was one of multiple procedures. The HCPCS modifier –LT, on the other hand, describes a bilateral procedure that was performed only on the left side of the body.
MODIFIER EXEMPT (CPT)
Certain codes in CPT cannot have modifiers added to them. This is a fairly short list that can be found in the appendices of the CPT manual.
NCHS
The NATIONAL CENTRE FOR HEALTH STATISTICS. The NCHS is a government agency that tracks health information, and is responsible for creating and publishing both the clinical modifications to ICD codes (See “Clinical Modification”) and their annual updates.
PATHOLOGY
The science of the causes and effects of disease.
SUBCATEGORY
In ICD codes, the subcategory describes the digit that comes after the decimal point. This digit further describes the nature of the illness or injury, and gives additional information as to its location or manifestation.
SUBCLASSIFICATION
The subclassification follows the subcategory (See “Subcategory”) in ICD codes. The subclassification further expands on the subcategory, and gives additional information about the manifestation, severity, or location of the injury or disease. In ICD-10-CM there is also a subclassification that describes which encounter this is for the doctor—whether this is a first treatment for the ailment, a follow-up, or the assessment of a condition that is the result of a previous injury or disease (See “Sequela”). There is one subclassification character in ICD-9-CM; in ICD-10-CM there may be as many as three.
TECHNICAL COMPONENT
The portion of a medical procedure that concerns only the technical aspect of the procedure, but not the interpretative, or professional aspect (See “Professional component”). A technical component might include the administration of a chest X-ray, but would not include the assessment of that X-ray for disease or abnormality.
V-CODES
V-codes are a special section of ICD-9-CM that describe patient visits related to circumstances other than disease or injury. This includes live-born infants, people with risk or disease due to family history, people encountering health services for specific or mandated evaluation or aftercare, and a host of other not easily classifiable situations. V-codes have been replaced in ICD-10-CM by Z-codes (See “Z-codes”).
WHO
The WORLD HEALTH ORGANISATION
Z-CODES
Much like V-codes in ICD-9-CM (See “V-codes”), these codes describe circumstances outside of injury or disease that cause a patient to visit a health professional. This may include a patient visiting a doctor because of family medical history
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