Medical Coding II – Seminar #1 HI255P – 01

1. Medical Coding II – Seminar #1HI255P – 01 Deborah A. Balentine M.Ed., RHIA, CCS-P Kaplan University

2. Agenda • Introductions • General Class Information • Tips and Strategies for Success • What is Medical Coding? • Basic ICD-9-CM Coding Guidelines • Basic CPT Coding Guidelines • V-Codes • Looking Ahead – Unit 2

3. Introductions Welcome to the Class! About Your Instructor: 15 + years in HIM 8 + years as an Instructor About You: Where were you on New Years Eve? What is the one thing that you would like to accomplish this year?

4. General Class Information About the Class Continuation of Medical Coding I Advanced Study of Medical Coding • Circulatory System • Respiratory System • Pregnancy and Congenital Anomalies • Health Status (V-Codes) • Late Effects • Reimbursement Topics (POA) Guidelines

5. General Class Information Course Outcomes and Expectations: • Accurately locate and report ICD-9-CM and HCPCS codes following all applicable guidelines. • Use coding software to accurately report ICD-9-CM and HCPCS codes. • Interpret and apply coding and billing guidelines for accurate reimbursement. • Perform data quality reviews to validate code assignment.

6. General Class Information More Information: Seminars: Sundays, 7:00 – 8:00 pm EST Virtual Office Hours: Monday – Friday, 9:30 – 10:30 am EST Other Contact Information: E-mail – Dbalentine@kaplan.edu Mobile – (708) 305-7848 No texts please

7. Tips and Strategies for Success • Remember that Medical Coding is a language and it requires a working knowledge of medical terminology, anatomy and physiology. • Always, always look up any unfamiliar terms and phases. Utilize medical dictionaries and your text books. • Attend as many Seminars  as you can. It the best way to get you questions answered in “real time”.  • Remember that one of your best resources is your instructor. Please feel free to contact me with your questions and concerns.

8. What is Medical Coding? • Translating narrative descriptions into numbers • Generally Accepted Guidelines and Conventions • ICD-9-CM • CPT/HCPCS • Other Coding and Classification Systems • DSM-IV (Behavioral Sciences) • ABC Codes (Alternative Medicine)

9. What is Medical Coding? Diagnosis vs. Procedure Codes • Diagnosis Codes – The “Why” Diagnosis codes identify the disease, problem or condition that is the reason for the visit. • Procedure Codes – The “What” Procedure codes identify the treatment that is given to the patient for the disease, problem or condition that is the reason for the visit. When reporting and coding a complete scenario always sequence the “why” before the “what”.

10. What is Medical Coding? Facility vs. Professional Fee Coding Facility Fee Coding – The resources expended by the facility when performing a service or procedure. Professional Fee Coding - The skill, time and effort expended by the practitioner when performing a service or procedure.

11. What is Medical Coding? When coding for Hospital Inpatient Facility Services, you use ICD-9-CM diagnosis and procedure codes. When coding for Hospital Outpatient Facility Services, you use ICD-9-CM for diagnosis and HCPCS/CPT codes for procedures. When coding for professional (i.e. physician services) you use ICD-9-CM for diagnosis and HCPCS CPT codes for procedures regardless of the clinical setting.

12. General ICD-9-CM Coding Guidelines • Use both the ICD-9-CM Index to Diseases and the Tabular List of Diseases. • Locate term in the Index to Diseases first, and verify the code in the Tabular List of Diseases. • Assign the highest level of digits available.

13. Basic ICD-9-CM Coding Guidelines Principal Diagnosis (Inpatient): The principal diagnosis is the condition established after study found to be chiefly responsible for the admission of the patient into the hospital for care.

14. Example #1 What is the Principal Diagnosis? A patient is admitted complaining of chest pain, congestion, and shortness of breath. Diagnostic testing includes a chest x-ray that reveals patchy infiltrates and a sputum culture is consistent with bacterial pneumonia. Answer: For this scenario, you would only report the bacterial pneumonia. The signs and symptoms have been linked to the more definitive diagnosis of pneumonia. The diagnostic testing also confirms the presence of the pneumonia.

15. Basic ICD-9-CM Coding Guidelines Principal Diagnosis (Outpatient): In the Outpatient setting you must code to the Highest Level of Certainty. List the ICD-9-CM code for the condition, problem or other reason for the encounter/visit found to be chiefly responsible for the services provided

16. Example #2 What is the “First-Listed” diagnosis? A patient presents for an outpatient MRI due to a swollen ankle. The MRI is inconclusive for any degenerative changes. First Listed Dx: Swelling of ankle joint A patient presents for an outpatient MRI due to a swollen ankle. The MRI reveals bursitis of the ankle joint. First Listed Dx: Bursitis

17. Practice Exercises Determine the principal diagnosis for each scenario: • A female patient is admitted with severe abdominal pain. An exploratory laparotomy is done which reveals appendicitis and the appendix is removed. • A patient who is suffering from chest pain presents to an imaging center for a chest x-ray. The x-ray is inconclusive for any cardiovascular issues.

18. Answers • The principal diagnosis is appendicitis. The abdominal pain is a symptom that has been linked to a more definitive diagnosis. • The ‘first-listed’ diagnosis is the chest pain. The results of the chest x-ray was inconclusive, therefore you must code to the highest level of certainty.

19. Basic CPT Coding Guidelines CPT Notes and Guidelines • Location • Provides information on: • Alternate Codes • Deleted Codes • Add-on Codes • Other information

20. Basic CPT Coding Guidelines CPT Coding Guidelines: • At the beginning of a chapter Evaluation and Management Guidelines (pg.1) • At the beginning of a section heading Surgery, Removal of Skin Tags (pg.47) • Within parentheses before or after a code CPT code 23660 (pg.81) • At the end of a code range. CPT code 43101 (pg.159)

21. Basic CPT Coding Guidelines The Steps to Basic CPT Coding (cont.) • Step One: Read the source document and code only from the information listed. • Step Two: Identify the main term and modifying terms (if applicable) for the procedure to be coded. • Step Three: Locate the main term in the CPT index. •  Step Four: Look for sub terms indented below the main terms in the index.

22. Basic CPT Coding Guidelines The Steps to Basic CPT Coding •  Step Five: Jot down the tentative code or range of codes for each procedure. • Step Six: Locate each tentative code in the appropriate section of the code book. • Step Seven: Read any instructional notes, and watch for diagnoses or specific procedures within code descriptions.

23. Basic CPT Coding Guidelines The Steps to Basic CPT Coding • Step Eight: Verify that the code matches the procedure statement provided in the record.  • Step Nine: Assign a modifier to the code if necessary. • Step Ten: Assign the code.

24. Example Bill for the surgeon’s procedural services only A patient who was recently diagnosed with a carcinoma of the left kidney presents today for a partial nephrectomy. Step One – Read the source document Step Two – Identify the main term and any modifying terms Main Term - “Nephrectomy” Modifying Term – “Partial”

25. Example Bill for the surgeon’s procedural services only A patient who was recently diagnosed with a carcinoma of the left kidney presents today for a partial nephrectomy. • Step Three: Locate the main term in the CPT index CPT Alpha Index pg. 576 • Step Four: Look for sub terms indented below the main terms in the index. Nephrectomy Partial………………50240 Laparoscopic……50543

26. Example Bill for the surgeon’s procedural services only A patient who was recently diagnosed with a carcinoma of the left kidney presents today for a partial nephrectomy. • Step Five: Jot down the tentative code or range of codes for each procedure. Nephrectomy, partial………….50240 • Step Six: Locate each tentative code in the appropriate section of the code book. Surgery Section pg. 183 • Step Seven: Read any instructional notes, and watch for diagnoses or specific procedures within code descriptions. Instructional Note: For laparoscopic partial nephrectomy, use 50543…

27. Example Bill for the surgeon’s procedural services only A patient who was recently diagnosed with a carcinoma of the left kidney presents today for a partial nephrectomy. • Step Eight: Verify that the code matches the procedure statement provided in the record.  • Step Nine: Assign a modifier to the code if necessary. In the procedural statement, the nephrectomy is being performed on the left kidney, therefore modifier (-LT) may be used. • Step Ten: Assign the code. The correct code to report would be - 50240-LT

28. Practice Exercise Code the following procedural statement. Code for the surgeon’s services only: Repair of forearm extensor tendon sheath with free graft

29. Answer Main term: Repair/Tendon Sheath Modifying terms: Tendon sheath, extensor, forearm, free graft CPT Code Range: 25275 Modifiers: None Code(s) to Report: 25275

30. Supplemental Classifications: V-codes

31. V - Codes Classification of Factors Influencing Health Status and Contact with Health Service Code Range: V01 – V89 V-codes are used for the following situations: • When a patient who is currently not sick uses the health services for some reason. • Aftercare Services • Encounters for the sole purpose of receiving special therapeutic Services (i.e. chemotherapy)

32. V-codes • To indicate that a person has a history, health status or other problem that is not a current illness but may influence patient care. • To indicate the outcome of delivery for obstetric patients. • To indicate the birth status of newborns.

33. V-codes Locating V-codes • Main terms for V-codes are located within the Alphabetical Index of Diseases (Volume 2) • The Tabular listing for V-codes is located within the Tabular Listing of Diseases (Volume 1) • Main terms for V-codes describe situations as opposed to conditions, diseases, or disorders. • Some main terms used for locating V-codes include the following: • Status • Management • Procedure • Encounter/Admission (for) • Aftercare • Screening

34. V-Codes V-Code Guidelines • V-codes may be used as principal or secondary diagnoses • An extensive listing of V-code guidelines is located in your ICD-9-CM coding book.

35. V-codes Examples: Aftercare for a healing traumatic fracture of the tibia V54.16 Admission for HPV vaccination V04.89 Status post breast reconstruction V43.82 Outcome of delivery – liveborn twins V27.2 Encounter for Chemotherapy V58.11

36. V-Codes Coding Practice – Code the diagnostic portion only of the following scenarios: • A patient with a humerus fracture is seen for the removal of an internal fixation device. • A patient presents to the doctor’s office for a refill of their birth control pills. • A patient presents for a screening colonoscopy due to a family history of colon cancer. • Single liveborn infant born in hospital via C-section • 29 y/o Egg Donor

37. Answers • V54.01 – Main terms include “Removal” and “Aftercare” • V25.41 – Main term is “Contraception”. • V76.51 and V16.0 – Main terms are “Screening” and “History”. • V30.01 – Main term is “Newborn” • V59.71 – Main term is “Donor”

38. Looking Ahead – Unit 2 Next Seminar – Sunday, January 15th, 2012 7:00 – 8:00 pm EST Topics to Cover: Inpatient Reimbursement Methodologies Newborn/Congenital Anomalies Study Smart!