Medical Coding-Medical Coding-20172017Dr. Santosh Kumar Guptha Trainer/Author

CCS-P, CCS , CPC, COC, CIC, CPC-P, CRC, CCC, CPCO, CANPC, CPB,CPMA, CEMC, CEDC, CIMC, CFPC, CUC, COBGC, CPCD, COSC, CPRC, CPEDC, CHONC, CENTC, CRHC, CGIC, CASCC, CGSC, CSFAC, CCVTC, RMC, RMA, CMBS, CMRS, CSCS, CSBB, FCR, FNR, FOR, CHA, CHL7,

AHIMA Approved ICD-10 Trainer, AHIMA ICD-10 Ambassador, India.

World Record Holder-42 Certifications

The medical industry is experiencing a high demand for individuals with knowledge of medical office operations, transcription, billing and coding. The business office of every health care provider must submit the proper documentation to a number of insurance companies for reimbursement in order to financially succeed and avoid fraud charges

The requirement has created numerous opportunities for trained individuals to be employed in medical offices, clinics, hospitals, insurance companies and do home-based opportunities

Medical coding means coverting medical record to codes. Assigning proper codes for Diagnosis, Procedure and supplies/drugs

ICD-10-CM is for DiagnosisICD-10-PCS is for Hospital ServicesCPT-4 is for Physician ServicesHCPCS is for Supplies and Drugs

ICD-10 represents the “WHY” it was doneMedical Necessity--------- R07.9

(Chest Pain) CPT-4 represents the “WHAT” was done to the

patient-Physician ServiceProcedure------------------- 93010 (EKG)

ICD-10-PCS Represents Hospital Service 0DTJ4ZZ  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.

Resources You NeedICD-10-CM Manual-2017 ICD-10-PCS Manual-2017CPT 2017HCPCS 2017

AKA’s of the Medical AKA’s of the Medical Coder Coder

Health Information Technician Health Information Coder Medical Record Coder Coder / Abstractor Coding Specialist Insurance Specialist

Qualities of the Medical Qualities of the Medical Coder Coder Knowledge of medical terminology Knowledge of anatomy & physiology Detail oriented Accuracy Critical thinking Willingness to learn Self-motivated • Flexibility •

Computer skills

Principle of Medical Principle of Medical Coding Coding

If it’s not documented, it wasn’t done

ICD-10-CM-2017ICD-10-CM-2017The 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.

The WHO is currently crafting the 11th revision, which is expected to be release in 2018/2019.

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-CMBenefits to ICD-10-CMinclude 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 timelyProper documentation is required

Medical Record Medical Record Documentation:-Documentation:-1. The medical record should be complete and

legible.

2. The documentation of each patient encounter should 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)

3. Past and present diagnoses should be accessible to the treating and/or consulting physician.

4. The reasons for—and results of—x-rays, lab tests, and 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 written plan for care should include, when appropriate: treatments and medications, specifying frequency and dosage; any referrals and consultations; patient/family education; and 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.

ICD-10-CM codes are all alphanumeric, starting with an alpha character

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 services 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.

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 K= Diseases of the Digestive System L = Diseases of the Skin and Subcutaneous Tissue M = Diseases of the Musculoskeletal System

ICD-10-CM ChaptersICD-10-CM Chapters

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 = Injury, Poisoning and Certain Other Consequences of

External Causes V = Transport accidents - External Causes of Morbidity W = Other 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

XX XX XX XX

Category

.Etiology, anatomic

site, severity

Added 7th character for obstetrics, injuries, and external causes of injury

ICD-10-CM Coding ICD-10-CM Coding CharactersCharacters

XX XX XXAAMMSS 00 22 66. 55 xx AA

Additional CharactersAlpha

(Except U)

2 Numeric3-7 Numeric or Alpha

3–7 Characters

55thth Character “x” Character “x”Character “x” is used as a 5th character

placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character

Examples: T46.1x5A – Adverse effect of calcium-

channel blockers, initial encounter; and T15.02xD – Foreign body in cornea, left eye,

subsequent encounter.

XX XX XX XX

Category

.Etiology, anatomic

site, severity

Added 7th character for obstetrics, injuries, and external causes of injury

Coding and Seventh Character Coding and Seventh Character

XX XX XXAAMMSS 00 22 66. 55 xx AA

Additional CharactersAlpha

(Except U)

2 Numeric3-7 Numeric or Alpha

3–7 Characters

CODING AND USE OF SEVENTH CODING AND USE OF SEVENTH CHARACTERCHARACTER

•Used in these chapters:

• Obstetrics• Injury• External

cause• Musculoskel

etal•Either alpha or numeric•Placeholder X•Meanings vary

Surgeon performs an open cholecystectomy for acute cholecystitis with cholelithiasis.

K80.00 Calculus of gallbladder with acute cholecystitis, without obstruction

0FT40ZZ Open resection of gallbladder

Introduction to CPT Introduction to CPT CodingCoding

CPT-4 represents the “WHAT” was done to the patientProcedure------------------- 93010 (EKG)-5 Digit Code

Text organized in 6 major sections Evaluation and Management (99201 - 99499) Anesthesiology (00100 - 01999,

99100 - 99140) Surgery (10040 - 69990) Radiology (70010 - 79999) Pathology and Laboratory (80049 - 89399) Medicine (90281 - 99199)

CPT CodesCPT 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 biopsy25105 for synovectomy

Seven Character Alphanumeric Code◦ AllAll procedure codes will be seven

characters long◦ “II” and “OO” (letters) are never used

34 possible values for each character◦ Digits 0 – 9◦ Letters A-H, J-N, P-Z

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ICD-10-PCS: Code StructureICD-10-PCS: Code Structure

A charactercharacter is a stable, standardized code component◦ Holds a fixed place in the code◦ Retains its meaning across a range of

codes

A valuevalue is an individual unit defined for each character

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ICD-10-PCS StructureICD-10-PCS Structure(Characters and Values)(Characters and Values)

1st character = SSection2nd character = BBody System3rd character = RRoot

Operation4th character = BBody Part5th character = AApproach6th character = DDevice7th character = QQualifier

SSusie usie BBuys uys RRoot oot BBeer eer AAt t DDairy airy QQueenueen

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ICD-10-PCS Code FormatICD-10-PCS Code Format

S 3 2 0 1 0 ASection

Body System

Root Operation

Body Part

Approach

Device

Qualifier

ICD-10 Procedure Code 0DN90ZZ Release of duodenum, open

approach 0FB03ZX Excision of liver, percutaneous

approach, diagnostic 02PS0CZ Removal, extraluminal device from

pulmonary vein, right, open

Board Exams-USA (AAPC and Board Exams-USA (AAPC and AHIMA)AHIMA) AAPC: American Academy of Professional Coders-

USAExam-CPC: Certified Professional CoderFees: 500 USD, 2 attemptsExam Center- Delhi, Mumbai, Chennai, Bangalore,

HyderabadRequired minimum 200 hours of training to clear the

exam. Should learn Coding conventions, HIPAA complaince, Medical Billing

Medesun Healthcare Solutions-

Board Exam-USABoard Exam-USAAHIMA: American Health Information

Management AssociationExam-CCS: Certified Coding SpecialistFees: 299 USD, 1 attemptExam Center- Delhi, Mumbai, Chennai, Bangalore,

HyderabadRequired minimum 250 hours of training to clear the exam.

Should learn Coding conventions, HIPAA compliance, Hospital Coding and Medical Billing

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