Medical Coding II – Seminar #1HI255P – 01

Deborah A. Balentine M.Ed., RHIA, CCS-PKaplan University

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

IntroductionsWelcome to the Class!

About Your Instructor:15 + years in HIM8 + 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?

General Class InformationAbout the ClassContinuation of Medical Coding IAdvanced Study of Medical Coding Circulatory System Respiratory System Pregnancy and Congenital Anomalies Health Status (V-Codes) Late Effects Reimbursement Topics (POA) Guidelines

General Class InformationCourse 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.

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

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.

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)

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”.

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.

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.

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.

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.

Example #1What 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.

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

Example #2What 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 jointA patient presents for an outpatient MRI due to

a swollen ankle. The MRI reveals bursitis of the ankle joint.

First Listed Dx: Bursitis

Practice ExercisesDetermine the principal diagnosis for each

scenario:1.A female patient is admitted with severe

abdominal pain. An exploratory laparotomy is done which reveals appendicitis and the appendix is removed.

2.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.

Answers1. The principal diagnosis is appendicitis. The

abdominal pain is a symptom that has been linked to a more definitive diagnosis.

2. 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.

Basic CPT Coding GuidelinesCPT Notes and Guidelines

Location Provides information on:

Alternate Codes Deleted Codes Add-on Codes Other information

Basic CPT Coding GuidelinesCPT 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)

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.

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.

Basic CPT Coding GuidelinesThe 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.

ExampleBill for the surgeon’s procedural services

onlyA patient who was recently diagnosed with a

carcinoma of the left kidney presents today for a partial nephrectomy.

Step One – Read the source documentStep Two – Identify the main term and any

modifying termsMain Term - “Nephrectomy”Modifying Term – “Partial”

ExampleBill for the surgeon’s procedural services onlyA 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 indexCPT Alpha Index pg. 576  Step Four: Look for sub terms indented below the

main terms in the index.NephrectomyPartial………………50240

Laparoscopic……50543

ExampleBill for the surgeon’s procedural services onlyA 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…

ExampleBill for the surgeon’s procedural services onlyA 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

Practice Exercise

Code the following procedural statement. Code for the surgeon’s services only:

Repair of forearm extensor tendon sheath with free graft

AnswerMain term:Repair/Tendon SheathModifying terms:Tendon sheath, extensor, forearm, free graftCPT Code Range:25275Modifiers:None Code(s) to Report:

25275

Supplemental Classifications: V-codes

V - CodesClassification of Factors Influencing Health

Status and Contact with Health ServiceCode Range: V01 – V89V-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)

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.

V-codesLocating 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

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.

V-codesExamples:Aftercare for a healing traumatic fracture of the

tibiaV54.16Admission for HPV vaccinationV04.89Status post breast reconstructionV43.82Outcome of delivery – liveborn twinsV27.2Encounter for ChemotherapyV58.11

V-CodesCoding Practice – Code the diagnostic portion

only of the following scenarios:1.A patient with a humerus fracture is seen for

the removal of an internal fixation device.2.A patient presents to the doctor’s office for a

refill of their birth control pills.3.A patient presents for a screening colonoscopy

due to a family history of colon cancer.4.Single liveborn infant born in hospital via C-

section5.29 y/o Egg Donor

Answers1. V54.01 – Main terms include “Removal” and

“Aftercare”2. V25.41 – Main term is “Contraception”.3. V76.51 and V16.0 – Main terms are

“Screening” and “History”.4. V30.01 – Main term is “Newborn”5. V59.71 – Main term is “Donor”

Looking Ahead – Unit 2

Next Seminar – Sunday, January 15th, 20127:00 – 8:00 pm ESTTopics to Cover:Inpatient Reimbursement MethodologiesNewborn/Congenital Anomalies

Study Smart!