Unit 1 Presentation Chapters 1 & 2

1. Unit 1 PresentationChapters 1 & 2 Shatondra Surulere, MBA, RHIA, CCS

2. Chapter 1 Overview of Coding

3. Introduction • Coding systems: • International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) • Current Procedural Terminology (CPT) • Healthcare Common Procedure Coding System (HCPCS) level II • Starting a coding career

4. Coder Acquire working knowledge of coding systems and rules, as well as payer requirements Ensure coding accuracy Communicate with providers about documentation and compliance issues, as well as assignment of codes

5. Professional Associations Offering Coding Credentials American Health Information Management Association (AHIMA) American Academy of Professional Coders (AAPC) American Medical Billing Association (AMBA)

6. Employment Opportunities Clinics Consulting firms Government agencies Hospitals Insurance companies Nursing facilities Home health care agencies Hospice organizations Physician offices Work at home

7. Coding Overview • Facilities, providers, and third-party payers use coding systems and medical nomenclature to collect, store, and process data. • Used for healthcare reimbursement

8. Codes Numeric and alphanumeric characters Assigned to diagnoses, procedures, and services Reported to payers and external agencies Used internally for education, research, and statistical purposes

9. Coding References Coding Clinics Conditions of Participation (CoP) and Conditions for Coverage (CfC) CPT Assistant and HCPCS Assistant

10. Coding References • Compliance program guidance by DHHS OIG • ICD-9-CM Official Guidelines for Coding and Reporting • National Correct Coding Initiative (NCCI) and Outpatient Code Editor (OCE) with Ambulatory Payment Classification (APC)

11. Fraudulent Coding Unbundling Upcoding Overcoding Jamming Downcoding

12. Documentation Issues • Health care providers are responsible for documenting and authenticating patient records as legible, complete, and timely. • Health care providers must properly correct or alter errors in patient record documentation.

13. Patient Record • Primary purposes: • Serves as official business record • Documents services and treatment provided • Stores demographic data • Supports diagnoses • Justifies treatment • Facilitates continuity of care • Serves as communication tool • Assists in planning individual patient care

14. Patient Record • Secondary purposes: • Evaluates quality of patient care • Provides data for use in clinical research and epidemiology studies • Provides information to third-party payers for reimbursement of submitted claims • Serves medicolegal interests of patient, facility, and providers

15. Medical Necessity • Patient diagnosis must justify procedures or services provided by documenting procedures, services, and supplies that are: • Needed for diagnosis and treatment • Performed to diagnose the patient, direct patient care, and/or treat the patient’s condition • Consistent with standards of good medical practice in local area • Not performed primarily for convenience of physician or health care facility

16. If It Wasn’t Documented,It Wasn’t Done Patient record serves as medicolegal document and facility’s business record If provider performs service, but does not document it, payer can refuse to pay Patient record is defense of quality of care administered to patient

17. Assumption Coding Assignment of codes based on assuming that patient has certain diagnoses or received certain procedures or services Considered fraud NOTE: Implement physician query process to avoid fraud risks associated with assumption coding.

18. Physician Query Process • Contact responsible physician • Query physician regarding documentation • Determine whether query will be generated concurrently or retrospectively

19. Patient Record Formats • Manual • Source-oriented record (SOR) • Problem-oriented record (POR) • Automated • Electronic health record (EHR) • Optical disk imaging

20. Patient Record Formats • Hybrid • Automated lab data reports and handwritten physician progress notes

21. Verifying Codes Coders are responsible for reviewing patient records to select the appropriate diagnosis and procedure or service. Claims can be denied if the medical necessity of procedures or services is not established.

22. Any Questions so far?

23. Chapter 2 Introduction toICD-9-CM Coding

24. Disease Classifications • ICD • ICD-9-CM • ICD-10 Permission to reuse granted by Ingenix, Inc.

25. ICD-9-CM Volume 1: Tabular List Volume 2: Index to Diseases Volume 3: Index to Procedures and Tabular List

26. Oversight of ICD-9-CM • National Center for Health Statistics (NCHS) • Centers for Medicare and Medicaid Services (CMS) • Updates • April 1 and October 1 of each year

27. Coding Tools UpdateableICD-9-CM coding manuals Permission to reuse granted by Ingenix, Inc. • Non-automated • Coding manuals • Reference materials • Automated • Computer-based encoders • Web-based products

28. Tabular List of DiseasesArrangement Numerical order 17 chapters Two supplementary classifications Four appendices

29. Disease and Injury Codes • Category codes • Three digits • For example, 436 • Subcategory codes • Three digits followed by decimal point and one additional digit • For example, 401.9

30. Disease and Injury Codes • Sub-classification code • Three digits followed by decimal point and two additional digits • For example, 402.90

31. Procedure Codes • Category codes • Two digits • For example, no valid two-digit ICD-9-CM Volume 3 codes • Subcategory codes • Two digits followed by decimal point and one additional digit • For example, 10.6

32. Procedure Codes • Sub-classification code • Two digits followed by decimal point and two additional digits • For example, 82.01

33. Supplementary Classifications • V codes • Health status factors • V58.0-Encounter for Radiation therapy • E codes • External causes of injury • E888.0-Fall onto a sharp object

34. Appendices • A-Morphology of Neoplasms (M codes) • Indicates the tissue types of a neoplasm • Sarcoma, adenocarcinoma • B-Glossary of Mental Disorders • Removed from ICD-9-CM in 2004 • C-Classification of drugs by AHFS • Numerical arrangement • For example, 76:00 Oxytocics

35. Appendices • D- Classification of Industrial Accidents • Used to classify industrial accidents • E-List of Three-Digit Categories • For example, 390–392-Acute rheumatic fever

36. Index to Diseases Arrangement • Alphabetic • Main terms (e.g., conditions) • Nonessential modifiers in parentheses • Essential modifiers indented • Sub-terms • Qualifiers further indented • Second and third

37. Basic Steps to Coding Diseases • Locate main term in Index to Diseases. • Alphabetic • Follow directional terms (e.g., see, see also, see category). • Review diagnostic statement to locate essential modifiers in Index to Diseases (e.g., sub-terms). • Select and verify code in Tabular List of Diseases.

38. Tabular List of Procedures and Index to Procedures Volume 3 of ICD-9-CM Alphabetic listing of main terms (e.g., procedures) Nouns, adjectives, or eponyms Use of “with” and “without” Sub-terms

39. Basic Steps to Coding Procedures Locate main term in Index to Procedures. Follow directional terms (e.g., omit code). Review procedural statement to locate essential modifiers in Index to Procedures (e.g., sub-terms). Select and verify code in Tabular List of Procedures.

40. Guidelines for Coding and Reporting and Using ICD-9-CM Cooperating parties for ICD-9-CM Impact of HIPAA Coding guidelines Use of terms “encounter” and “provider”

41. Questions