Unit #2 Exploration, Discovery, & Colonization Chapters 1—3.
Unit 1 Presentation Chapters 1 & 2
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Transcript of Unit 1 Presentation Chapters 1 & 2
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Unit 1 PresentationChapters 1 & 2
Shatondra Surulere, MBA, RHIA, CCS
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Chapter 1
Overview of Coding
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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
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Coder
Acquire working knowledge of coding systems and rules, as well as payer requirements
Ensure coding accuracyCommunicate with providers about
documentation and compliance issues, as well as assignment of codes
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Professional Associations Offering Coding Credentials
American Health Information Management Association (AHIMA)
American Academy of Professional Coders (AAPC)
American Medical Billing Association (AMBA)
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Employment Opportunities
ClinicsConsulting firmsGovernment
agenciesHospitalsInsurance
companies
Nursing facilitiesHome health care
agenciesHospice
organizationsPhysician officesWork at home
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Coding Overview
Facilities, providers, and third-party payers use coding systems and medical nomenclature to collect, store, and process data.Used for healthcare reimbursement
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Codes
Numeric and alphanumeric charactersAssigned to diagnoses, procedures, and
servicesReported to payers and external agenciesUsed internally for education, research,
and statistical purposes
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Coding References
Coding ClinicsConditions of Participation (CoP) and
Conditions for Coverage (CfC)CPT Assistant and HCPCS Assistant
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Coding References
Compliance program guidance by DHHS OIGICD-9-CM Official Guidelines for Coding and
ReportingNational Correct Coding Initiative (NCCI) and
Outpatient Code Editor (OCE) with Ambulatory Payment Classification (APC)
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Fraudulent Coding
UnbundlingUpcodingOvercodingJammingDowncoding
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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.
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Patient Record
Primary purposes:Serves as official business recordDocuments services and treatment providedStores demographic dataSupports diagnosesJustifies treatmentFacilitates continuity of careServes as communication toolAssists in planning individual patient care
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Patient Record
Secondary purposes:Evaluates quality of patient careProvides data for use in clinical research and
epidemiology studiesProvides information to third-party payers for
reimbursement of submitted claimsServes medicolegal interests of patient, facility,
and providers
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Medical Necessity
Patient diagnosis must justify procedures or services provided by documenting procedures, services, and supplies that are:Needed for diagnosis and treatmentPerformed to diagnose the patient, direct patient care,
and/or treat the patient’s conditionConsistent with standards of good medical practice in
local areaNot performed primarily for convenience of physician or
health care facility
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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
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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.
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Physician Query Process
Contact responsible physicianQuery physician regarding
documentationDetermine whether query will be
generated concurrently or retrospectively
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Patient Record Formats
ManualSource-oriented record (SOR)Problem-oriented record (POR)
AutomatedElectronic health record (EHR)Optical disk imaging
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Patient Record Formats
HybridAutomated lab data
reports and handwritten physician progress notes
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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.
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Any Questions so far?
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Chapter 2
Introduction toICD-9-CM Coding
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Disease Classifications
ICDICD-9-CMICD-10
Permission to reuse granted by Ingenix, Inc.
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ICD-9-CM
Volume 1: Tabular ListVolume 2: Index to DiseasesVolume 3: Index to Procedures and
Tabular List
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Oversight of ICD-9-CM
National Center for Health Statistics (NCHS)
Centers for Medicare and Medicaid Services (CMS)
UpdatesApril 1 and October 1 of each year
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Coding Tools
Non-automatedCoding manualsReference materials
AutomatedComputer-based encodersWeb-based products
UpdateableICD-9-CM coding manuals
Permission to reuse granted by Ingenix, Inc.
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Tabular List of DiseasesArrangement
Numerical order17 chaptersTwo supplementary classificationsFour appendices
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Disease and Injury Codes
Category codesThree digitsFor example, 436
Subcategory codesThree digits followed by decimal point and one
additional digitFor example, 401.9
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Disease and Injury Codes
Sub-classification codeThree digits followed by decimal point and two
additional digitsFor example, 402.90
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Procedure Codes
Category codesTwo digitsFor example, no valid two-digit ICD-9-CM
Volume 3 codes
Subcategory codesTwo digits followed by decimal point and one
additional digitFor example, 10.6
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Procedure Codes
Sub-classification codeTwo digits followed by decimal point and two
additional digitsFor example, 82.01
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Supplementary Classifications
V codesHealth status factorsV58.0-Encounter for Radiation therapy
E codesExternal causes of injuryE888.0-Fall onto a sharp object
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Appendices
A-Morphology of Neoplasms (M codes)Indicates the tissue types of a neoplasm
Sarcoma, adenocarcinoma
B-Glossary of Mental DisordersRemoved from ICD-9-CM in 2004
C-Classification of drugs by AHFSNumerical arrangementFor example, 76:00 Oxytocics
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Appendices
D- Classification of Industrial Accidents Used to classify industrial
accidents
E-List of Three-Digit CategoriesFor example, 390–392-
Acute rheumatic fever
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Index to Diseases Arrangement
AlphabeticMain terms (e.g., conditions)Nonessential modifiers in parenthesesEssential modifiers indented
Sub-terms
Qualifiers further indentedSecond and third
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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.
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Tabular List of Procedures and Index to Procedures
Volume 3 of ICD-9-CMAlphabetic listing of main terms (e.g.,
procedures)Nouns, adjectives, or eponymsUse of “with” and “without”Sub-terms
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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.
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Guidelines for Coding and Reporting and Using ICD-9-CM
Cooperating parties for ICD-9-CMImpact of HIPAACoding guidelinesUse of terms “encounter” and “provider”
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Questions