TOPIC: INTRODUCTION TO REIMBURSEMENT &

CODING
CUE Column
1. What are the 2 major coding systems?
2. What is the ICD used for?
3. What are the key components for accurate reimbursement?
4. What are the steps in the billing process?
5. What’s the difference between private and public payers?
6. What types of code are used for different medical services?
7. How does coverage depend on the payer?
8. What is HTA (Health Technology Assessment)?
9. What are some of the factors for accurate reimbursement?

NOTES
Two major coding systems:
ICD (International Classification of Diseases): Originated in the 17th century
with the "London Bills of Mortality" and classified medical information based on
diagnoses and services provided.
CPT (Current Procedural Terminology): Used for categorizing medical
procedures.
NCHS (National Center for Health Statistics): Collects data related to health
statistics.

ICD usage:
ICD helps in classifying medical diagnoses and the services rendered to patients.
Coding: Accurate codes ensure reimbursement.
Coverage and Payment: Understand what’s covered by insurance providers.

Steps in the billing process:

Collect demographic data from patients.
Submit claims to insurance companies.
Payment and adjudication: Payers review claims for payment.

Difference between private and public payers:

Private payers (Commercial Health Insurers):
 Employer-based insurance plans.
 Individual health insurance purchased by individuals.
Public payers (Government Insurance):
 Medicare: For those aged 65+ or with permanent disabilities.
 Medicaid: State-funded for low-income individuals or families.

Types of medical code:

CPT codes: Used for medical/surgical services.
ICD codes: Used for signs, symptoms, and diseases.
DRG code: Used for inpatient services.

Coverage determination:
Technology and Medical Necessity: Is technology reasonable and necessary for
treatment?
Population Subtypes: Specific conditions like severe diseases or cases with failed
therapies may affect coverage.

Health Technology Assessment (HTA):

Evaluates medical devices and treatments to inform healthcare decisions.
Agencies like AHRQ provide assessments to inform decisions by CMS (Centers for
Medicare & Medicaid Services).

Accurate reimbursement factors:

Safety and Effectiveness: Evaluation by FDA.
Risk-Benefit Analysis: Ensuring the benefits outweigh any potential risks.
Clinical and Economic Outcomes: Improved patient outcomes and cost-
effectiveness.

SUMMARY
1. Reimbursement in medical coding relies on accurate coding, payer
understanding, and specific steps in the billing process.
2. Private and public payers differ, with private insurance funded through
premiums and public insurance through taxes.
3. Medical coding impacts reimbursement accuracy and case management.
Specific codes (CPT, ICD, DRG) are used for different services.
4. HTA ensures that new technologies and treatments are effective and
beneficial, and health insurers assess the economic outcomes and clinical benefits
of medical procedures.

TOPIC: ICD-10-CM
CUE COLUMN

ICD-10-CM Conventions
• What are the conventions of ICD-10-CM?
• How is ICD-10-CM structured?
• What is the purpose of the Alphabetic Index and Tabular List?
• What are the key formatting rules in ICD-10-CM?
• What do abbreviations like NEC and NOS mean?
• How do Excludes1 and Excludes2 notes function?

Acute and Chronic Conditions

• Code both acute and chronic when described as such.
• Sequence acute (subacute) first.

Combination Code
• Combines two diagnoses, diagnosis + manifestation, or diagnosis +
complication.
• Assign only the combination code unless specificity requires additional
coding.

Sequela (Late Effects)

• Residual effects after the acute phase of illness/injury.
• Requires 2 codes:
o Residual condition/nature sequenced first.
o Sequela code sequenced second.
• Exception: Sequela code expanded to include manifestation.
• Do not use acute-phase code with sequela code.
 Impending or Threatened Condition
• If occurred: Code as confirmed.
• If not occurred:
o Check for subterms under “Impending” or “Threatened.”
o If no subterms: Code the underlying condition.

Laterality
• Use codes that specify side (left, right, bilateral).
• If no bilateral code exists, assign separate codes for left and right.
• Unspecified side codes should rarely be used.
• Laterality can be documented by other clinicians.

Reporting Same Diagnosis Code More Than Once

• Each unique diagnosis code is reported only once per encounter.

• How are external cause codes sequenced for cataclysmic events?

o Codes for cataclysmic events like hurricanes take priority over other external
cause codes, except for child/adult abuse and terrorism.
o Sequence hurricane codes first, followed by other external cause codes.
• What codes should be assigned for injuries during a hurricane?
o Assign as many external cause codes as necessary to fully explain each
cause.
o For hurricane-related injuries:
 Code for injuries first.
 Assign X37.0-, Hurricane (with appropriate 7th character).
 Include codes for other related causes (e.g., building collapse).
• What codes apply to flooding caused by a hurricane?
o Assign X37.0-, Hurricane, for flooding caused by levee breaks due to a
hurricane.
o Use X38.-, Flood, for injuries from direct flooding caused by the storm.
o Do not assign X36.0-, Collapse of dam/man-made structure, when the
collapse is due to the hurricane.
• What if the injury is unrelated to the hurricane?
o Assign appropriate external cause codes (e.g., motor vehicle accident).
o Do not assign X37.0-, Hurricane unless it is clear the injury is hurricane-
related.
o If documentation is unclear, assume the injury is due to the hurricane and
assign X37.0-.
• What Z codes are applicable for healthcare encounters during disasters?
o Z codes may explain reasons for healthcare visits (e.g., transfers, facility
inaccessibility).
o Examples of applicable Z codes:
 Z59.0-, Homelessness
 Z59.1, Inadequate housing
 Z59.5, Extreme poverty
 Z75.3, Unavailability of healthcare facilities
 Z99.12, Ventilator dependence during power failure
o Assign as many codes as needed to fully explain the encounter.

Locating a Code in ICD-10-CM

1. Steps for Selecting a Code:
o Alphabetic Index first → Locate the main term.
o Tabular List second → Verify the code, its specificity, laterality, and 7th
character if applicable.
2. A dash (-) in the Alphabetic Index indicates additional characters are
required.
3. Even if a dash is absent, the Tabular List must be checked to ensure
completeness.
2. Level of Detail in Coding
4. Codes must be reported at the highest specificity available.
5. ICD-10-CM codes can be 3-7 characters long:
o 3-character codes are category headings and should only be used if not
further subdivided.
o A code is invalid if not reported to its full length, including the 7th character if
required.
3. Valid Code Ranges
6. Diagnosis codes must come from the valid ICD-10-CM ranges:
o A00.0 – T88.9 → Diseases, injuries, and external causes.
o Z00 – Z99.8 → Factors influencing health status & encounters.
o U00 – U85 → Reserved codes for emerging conditions (e.g., COVID-19).
4. Signs and Symptoms
7. Symptom codes (R00-R99) can be reported if a definitive diagnosis is not
established.
8. If a confirmed diagnosis is available, do not report symptoms separately
unless necessary.
5. Conditions Integral to Disease
9. Do not code signs/symptoms separately if they are routinely part of a
disease.
10. Example: Cough is not separately coded for pneumonia.
6. Conditions Not Integral to a Disease
11. Code additional signs & symptoms if they are not routinely associated with a
disease.
12. Example: Fever with pneumonia is not separately coded, but chest pain might
be.
7. Multiple Coding for a Single Condition
13. Some conditions require more than one code (not just etiology/manifestation
pairs).
14. "Use additional code" notes mean an extra code is needed for full description.
15. Example: Bacterial infections (outside of Chapter 1) often need an additional
organism code:
o Primary code: Infection site (e.g., pneumonia).
o Secondary code: B95-B96 to identify bacteria.
16. "Code first" notes indicate an underlying condition must be sequenced first.
17. "Code if applicable, any causal condition first" applies when a causal
condition is unknown or not applicable.
o Example: A chronic condition with an unknown cause may be listed first.
o If the cause is later identified, it should be sequenced as the principal
diagnosis.
18. Multiple codes may be required for:
o Sequela (late effects of a condition).
o Complications.
o Obstetric cases.
o Specific conditions requiring additional documentation.
Documentation by Clinicians (Non-Providers)
19. Codes may be assigned based on documentation from non-providers for:
o BMI, pressure ulcer stage, coma scale, NIH stroke scale, SDOH, laterality,
blood alcohol level.
20. Diagnosis must be documented by the provider.
21. Use secondary diagnoses for these codes.
Syndromes
22. Follow Alphabetic Index guidance.
23. If no guidance, assign codes for documented manifestations.
Complications of Care
24. Must have a documented cause-and-effect relationship between care and
condition.
25. Not all conditions after surgery are complications.
26. Query provider if unclear.
Borderline Diagnoses
27. Code as confirmed unless a specific “borderline” code exists.
28. Applies to both inpatient and outpatient settings.
29. Query provider if unclear.
Sign/Symptom/Unspecified Codes
30. Acceptable when a definitive diagnosis isn’t established.
31. Unspecified codes should reflect what is known during the encounter.
32. Avoid selecting unsupported specific codes.
Hurricane Aftermath Coding
33. Use external cause of morbidity codes to identify cause and intent of injuries.
34. Sequence injury code before external cause codes.
35. Do not assign external cause codes for medical conditions without injury or
poisoning.
 Notes
Conventions Overview
1. Conventions are general rules for classification, independent of guidelines.
2. Found in Alphabetic Index and Tabular List as instructional notes.
Alphabetic Index & Tabular List
3. Alphabetic Index includes:
o Index of Diseases and Injury
o Index of External Causes of Injury
o Table of Neoplasms
o Table of Drugs and Chemicals
4. Tabular List is structured by body system or condition.
Format & Structure
5. Categories: 3 characters (letter/number).
6. Subcategories: 4 or 5 characters.
7. Codes: Can be 3-7 characters.
8. 7th Character: Required when specified; placeholder "X" is used if necessary.
Use of Codes
9. Only complete codes (not categories/subcategories) can be reported.
10. Placeholder “X” allows for future code expansion (e.g., T36-T50 poisoning
codes).
Abbreviations
11. NEC ("Not Elsewhere Classifiable") = Other specified
12. NOS ("Not Otherwise Specified") = Unspecified
Punctuation Usage
13. [ ] Brackets: Synonyms, explanatory phrases, manifestation codes.
14. ( ) Parentheses: Nonessential modifiers.
15. : Colons: Incomplete terms needing additional words.
Use of "And"
16. "And" can mean "and/or" in code descriptions.
Other & Unspecified Codes
17. "Other" codes: Used when no specific code exists.
18. "Unspecified" codes: Used when insufficient detail is available.
Excludes Notes
19. Excludes1 ("NOT CODED HERE!") → Cannot code conditions together unless
clearly unrelated.
20. Excludes2 ("Not included here") → Conditions can be coded together when
appropriate.
Reporting Codes
21. Only codes (not categories/subcategories) are used for reporting.
22. Placeholder “X” is used when necessary (e.g., T36-T50 categories).
B. Coding Conventions
1. Etiology/Manifestation Convention
23. Code first underlying condition, then manifestation.
24. "In diseases classified elsewhere" = manifestation code, never first-listed.
25. Example: Parkinson’s Disease Dementia (G20 first, F02.80/F02.81 second).
2. “With” or “In” Convention
26. Implies causal relationship unless documentation states otherwise.
3. “See” and “See Also” Instructions
27. See: Must reference another term.
28. See Also: Optional reference for additional info.
4. “Code Also” Note
29. Two codes may be required but sequencing is case-dependent.
5. Default Codes
30. Listed next to main term in the Alphabetic Index.
31. Used when no additional details (e.g., acute/chronic) are given.
6. Code Assignment & Clinical Criteria
32. Diagnosis code is based on provider's statement.
33. Clinical criteria alone are not required to assign a code.

________________________________________
ICD-10-CM Coding Guidelines Summary
1. Coding Acute and Chronic Conditions: Sequence acute conditions before
chronic ones.
2. Combination Codes: Use when a single code covers all elements of a
diagnosis (e.g., two diagnoses, complications, or manifestations). Avoid multiple
coding if a combination code suffices.
3. Sequela (Late Effects): Sequence the residual condition first, followed by the
sequela code. Never use the acute phase code with the sequela.
4. Code Sequencing: Follow "Code first" and "Use additional code" instructions
to ensure proper etiology/manifestation order.
5. Specificity and Structure: Use the Alphabetic Index and Tabular List to assign
the most specific codes (3-7 characters). Employ placeholders ("X") to maintain
validity, and apply 7th characters for added detail.
6. Excludes Notes:
o Excludes1: Prohibits simultaneous coding unless conditions are unrelated.
o Excludes2: Allows dual coding when applicable.
7. Symptoms and Signs: Only code symptoms (R00-R99) if no definitive
diagnosis is provided.
8. Documentation: Accurate and complete provider documentation is critical,
especially for complications and borderline diagnoses.
9. External Cause Codes: Supplement data to describe the cause and intent of
injuries but are never the principal diagnosis.
10. Conventions: Follow ICD-10-CM conventions, including the meanings of NEC
("Other specified") and NOS ("Unspecified").
11. Sequence hurricane codes first (X37.0-), followed by other external cause
codes.
12. Use multiple external cause codes as needed to describe injuries.
13. When documentation is unclear, assume injuries are hurricane related.
14. Z codes provide additional context for healthcare encounters (e.g.,
homelessness, inaccessibility).
15. Comprehensive coding relies on accurate documentation to assign
appropriate external cause and Z codes.

Topic: Topic: Chapter-Specific Coding Guidelines (ICD-10-CM FY 2025)

Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9
Chapter 1
CUE Column
What are the guidelines for coding HIV infections?
Code only confirmed cases.
Confirmation does not require serology or culture; provider’s statement is sufficient.
Sequencing guidelines for HIV:

a) HIV-related condition admission:

Principal diagnosis: B20, followed by codes for HIV-related conditions.
Exception: If hemolytic-uremic syndrome is the reason for admission, sequence
D59.31 first, followed by B20.
b) Admission for unrelated conditions:
Principal diagnosis: Code for the unrelated condition, followed by B20 and any HIV-
related conditions.
c) Asymptomatic HIV: Use Z21 unless "AIDS" or HIV-related illness is documented, in
which case, use B20.

d) Previously diagnosed HIV illness: Always assign B20, regardless of subsequent

encounters.

e) Pregnancy with HIV: Use O98.7- as the principal code, followed by B20 or Z21,
and codes for related conditions.

f) HIV testing:
Screening: Z11.4 (Encounter for screening for HIV).
Positive results: Assign B20 or Z21 as appropriate.
Counseling: Z71.7 for HIV counseling.

g) PrEP (pre-exposure prophylaxis): Assign Z29.81, and code risk factors if

applicable.

h) HIV managed with antiretrovirals: Assign B20 with Z79.899 for long-term drug
therapy.
How should infectious agents be coded?
Use additional codes from B95-B97 to identify the organism if not included in the
primary infection code.
Check for instructional notes at the infection code for organism specification.
How are infections resistant to antibiotics coded?
Assign a codefrom Z16 (Resistance to antimicrobial drugs) after the infection code,
unless resistance is already identified in the infection code.
What are the guidelines for coding sepsis and related conditions?
a) Sepsis:
Code for the underlying systemic infection.
If unspecified, assign A41.9 (Sepsis, unspecified organism).
Severe sepsis: Assign R65.2 only if severe sepsis or acute organ dysfunction is
documented.
b) Negative/Inconclusive cultures:
Sepsis can still be coded if clinical evidence supports the diagnosis; provider query
may be needed.
c) Urosepsis:
Urosepsis is nonspecific and not synonymous with sepsis. Query provider for
clarification.
d) Sepsis with organ dysfunction:
Follow severe sepsis coding guidelines if associated with acute organ dysfunction or
MOD (multiple organ dysfunction).
e) Organ dysfunction unrelated to sepsis:
Do not assign R65.2 if documentation indicates organ dysfunction is unrelated to
sepsis. Query provider if unclear.
Key Points/Questions
1. How is Sepsis coded?
o Assign the code for the underlying systemic infection.
o Use A41.9 (Sepsis, unspecified organism) if the infection or organism is not
specified.
o Do not assign R65.2 (Severe sepsis) unless there is documentation of severe
sepsis or acute organ dysfunction.
2. What if blood cultures are negative or inconclusive for sepsis?
o Sepsis can still be diagnosed based on clinical evidence. Query the provider if
clarification is needed.
3. How should "urosepsis" be coded?
o Urosepsis is a nonspecific term and not equivalent to sepsis. Query the
provider for clarification.
4. What is the guideline for coding Sepsis with organ dysfunction?
o If sepsis causes acute organ dysfunction, follow the guidelines for severe
sepsis.
o Do not assign R65.2 if the organ dysfunction is unrelated to sepsis.
5. How is Severe Sepsis coded?
o Use two codes:
1. The systemic infection (e.g., A41.9 if unspecified).
2. A code from R65.2 for severe sepsis.
o Add additional codes for acute organ dysfunction.
o Query the provider for unclear documentation.
6. What about Septic Shock?
o Septic shock indicates circulatory failure associated with severe sepsis.
o Sequence:
1. Systemic infection code (e.g., A41.9).
2. R65.21 for septic shock or T81.12 for postprocedural septic shock.
3. Additional codes for organ dysfunctions.
o Septic shock cannot be assigned as a principal diagnosis.
7. How is Severe Sepsis sequenced?
o If present on admission:
1. The systemic infection is the principal diagnosis, followed by R65.2.
o If it develops during the encounter:
1. Sequence as secondary diagnoses.
8. How is Sepsis with a localized infection coded?
o For admissions due to sepsis and a localized infection (e.g., pneumonia):
1. Assign the systemic infection code first, then the localized infection.
2. Add R65.2 for severe sepsis if present.
o If sepsis develops after admission, sequence the localized infection first.
9. What is the guideline for Postprocedural Sepsis and Septic Shock?
o Assign codes for the postprocedural infection (e.g., T81.41), followed by
sepsis codes.
o For septic shock, use T81.12 (Postprocedural septic shock) instead of R65.21.
10. What if a noninfectious process causes sepsis?
o Sequence the noninfectious condition (e.g., trauma or burn) as the principal
diagnosis, followed by codes for infection and severe sepsis (if present).
o Assign only one code from R65 (e.g., R65.2) and do not use R65.1 (SIRS of
non-infectious origin) in these cases.
11. How is sepsis associated with pregnancy, abortion, or newborns coded?
o See specific sections for:
1. Pregnancy and puerperium: Section I.C.15.
2. Newborns: Section I.C.16.f.
12. How is hemolytic-uremic syndrome associated with sepsis coded?
o Sequence D59.31 (Infection-associated hemolytic-uremic syndrome) as the
principal diagnosis, followed by the systemic infection and other related conditions.
13. Methicillin Resistant Staphylococcus Aureus (MRSA) Conditions
o Combination codes for MRSA infections (sepsis, pneumonia, etc.)
o MRSA colonization vs. infection
o Coding MRSA infection and colonization
o Specific MRSA-related codes to use
14. Zika Virus Infections
o Code only confirmed cases of Zika
o Do not assign code for suspected/probable cases
o Assign codes for signs/symptoms or exposure
15. Coronavirus Infections (COVID-19)
o Coding for confirmed COVID-19 cases
o Sequencing of COVID-19 codes
o Respiratory and non-respiratory manifestations
o Contact/exposure, screening, antibody tests
o Post COVID-19 condition, multisystem inflammatory syndrome (MIS)

NOTES
HIV coding emphasizes proper sequencing, based on the condition's
relevance to the encounter.
HIV-related conditions or antiretroviral use always require B20, not Z21 or R75.
Infections classified outside Chapter 1 may need additional organism codes (B95-
B97) as noted in instructional guidelines.
Sepsis requires specific documentation to distinguish it from related or unrelated
acute organ dysfunction.
Sepsis due to inconclusive lab results can still be diagnosed if supported by clinical
findings
MRSA Infection Coding
• If infection is due to MRSA and combination code exists (e.g., A41.02 for
sepsis), do not add B95.62 or Z16.11 (penicillin resistance).
• If no combination code, assign MRSA infection code plus B95.62.
• Colonization: Code Z22.322 (for MRSA), Z22.321 (for MSSA), only when
documented as colonization (not an active infection).
• Both colonization and infection: Use both colonization (Z22.322) and MRSA
infection codes.
Zika Virus Coding
• Confirm diagnosis: Code A92.5 for confirmed Zika virus.
• Suspected or probable cases: Do not code A92.5.
• Use symptom codes (fever, rash, etc.) or Z20.821 for suspected exposure.
COVID-19 Infections
• Confirmed diagnosis: Code U07.1 for COVID-19.
• If suspected or probable, do not assign U07.1.
• Sepsis and COVID-19: Follow guidelines for sepsis sequencing.
• Respiratory manifestations: Pneumonia (J12.82), ARDS (J80), Bronchitis
(J20.8).
• Non-respiratory: Assign U07.1 + diagnosis code for associated symptoms
(e.g., viral enteritis).
• Exposure: For asymptomatic individuals exposed to COVID-19, use Z20.822.
• Screening: Code Z11.52 for preoperative COVID-19 testing.
• Multisystem inflammatory syndrome: Code M35.81 + U07.1 for MIS with
COVID-19.
• Post-COVID-19: For symptoms after COVID-19 resolves, use U09.9 (Post
COVID-19 condition).
• Vaccination Status: Code Z28.310 (unvaccinated), Z28.311 (partially
vaccinated).

Summary
• Sepsis coding depends on the documentation of the infection, organism, and
any associated organ dysfunction or complications.
• Severe sepsis and septic shock require additional codes for organ dysfunction
and must follow specific sequencing rules.
• Query providers for clarification when terms like "urosepsis" are used or when
documentation is unclear.
• Always follow special guidelines for postprocedural infections, pregnancy-
related sepsis, or conditions associated with newborns or hemolytic-uremic
syndrome.

• For MRSA, ensure correct use of combination codes and only add B95.62
when necessary.
• Zika virus coding requires confirmation and exclusion of suspected cases.
• COVID-19 coding covers a wide range of scenarios, including exposure,
screening, and follow-up for residual effects like MIS and Post COVID-19 conditions.

Topic:

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Topic: Introduction to Reimbursement & Coding

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Topic: Introduction to Reimbursement & Coding

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Topic: Introduction to Reimbursement & Coding

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Topic: Introduction to Reimbursement & Coding

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Topic: Introduction to Reimbursement & Coding

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