Medical Coding concepts

IG CPT Code
descriptions
By Chinnathambi Thangam
 Definition – Medical
Coding
 Medical coding is the transformation of healthcare diagnosis,
procedures, medical services, and equipment into universal medical
alphanumeric codes.
 The diagnoses and procedure codes are taken from medical record
documentation, such as transcription of physician's notes, laboratory
and radiologic results, etc.
 Medical coding professionals help ensure the codes are applied
correctly during the medical billing process, which includes
abstracting the information from documentation, assigning the
appropriate codes, and creating a claim to be paid by insurance
carriers.
 Medical coding happens every time you see a healthcare provider.
Medical codes translate that documentation into standardized
codes that tell payers the following”

 Patient's diagnosis
 Medical necessity for treatments, services, or supplies the patient
received
 Treatments, services, and supplies provided to the patient
 Any unusual circumstances or medical condition that affected those
treatments and services
 Medical Coder is to review clinical statements and assign standard
codes using CPT® ICD-10-CM, and HCPCS Level II classification
systems.
 Medical billers, on the other hand, process and follow up on claims
sent to health insurance companies for reimbursement of services
rendered by a healthcare provider.
 The Medical Coder and medical biller may be the same person or
may work with each other to ensure invoices are paid properly.
Why is Medical Coding Needed?
 A patient's diagnosis, test results, and treatment must be
documented, not only for reimbursement but to
guarantee high quality care in future visits.
 A patient's personal health information follows them through
subsequent complaints and treatments, and they must be easily
understood.
 This is especially important considering the hundreds of millions of
visits, procedures, and hospitalizations annually in the United States.
Medical coding process
 Types of Codes Used
 ICD-10-CM (International Classification of Diseases, 10th Edition, Clinically
Modified)
 CPT® (Current Procedure Terminology)
 ICD-10-PCS (International Classification of Diseases, 10th Edition, Procedural
Coding System)
 HCPCS Level II (Health Care Procedural Coding System, Level II)
 CDT® (Code on Dental Procedures and Nomenclature)
 NDC (National Drug Codes)
 Modifiers
 APC (Ambulatory Payment Categories)
 Types of CPT Codes
 Coders assign a code for every service or procedure a
provider performs.

 CPT Category I: The largest body of codes, consisting of those commonly

used by providers to report their services and procedures
 CPT Category II: Supplemental tracking codes used for performance
management
 CPT Category III: Temporary codes used to report emerging and
experimental services and procedures
 Category I Codes:
 Most CPT® codes are Category I codes. These represent existing services or
procedures widely used.
 Category I codes, typically denoted by five numeric characters, are arranged
in numerical order.

The 6 main sections of CPT® Category I codes are:

 Evaluation & Management (99202–99499)
 Anesthesia (00100–01999)
 Surgery (10021–69990) — further broken into smaller groups by body area
or system within this code range
 Radiology Procedures (70010–79999)
 Pathology and Laboratory Procedures (80047–89398)
 Medicine Services and Procedures (90281–99607)
 Category II Codes
 Category II codes, consisting of four numbers and the letter F, are
supplemental tracking and performance measurement codes that
providers can assign in addition to Category I codes..
 Providers use Category II codes — which track specific information
about their patients, such as whether they use tobacco — to help
deliver better healthcare and achieve better outcomes for patients.
 Category II Codes
1. Composite Measures (0001F–0015F)
2. Patient Management (0500F–0584F)
3. Patient History (1000F–1505F)
4. Physical Examination (2000F–2060F)
5. Diagnostic/Screening Processes or Results (3006F–3776F)
6. Therapeutic, Preventive, or Other Interventions (4000F–4563F)
7. Follow-up or Other Outcomes (5005F–5250F)
8. Patient Safety (6005F–6150F)
9. Structural Measures (7010F–7025F)
10.Nonmeasure Code Listing (9001F–9007F)
 Category III Codes
 Category III codes, depicted with four numbers and the letter T,
 Category III codes are temporary codes that represent new technologies,
services, and procedures.
 Temporary codes describing new services and procedures can remain in
Category III for up to five years.
 Modifier
 The modifier provides additional information about the medical procedure,
service, or supply involved without changing the meaning of the code. Medical
coders use modifiers to tell the story of a particular encounter.
 For instance, a coder may use a modifier to indicate a service did not occur
exactly as described by a CPT or HCPCS Level II code descriptor, but the
circumstance did not change the code that applies.
 Modifiers are the codes that are adopted by the Physician to confirm the
Insurance that the procedure performed was altered or modified due to certain
unavoidable circumstances.
 Modifiers also gives additional information about the procedure. And it is
attached only to the procedure codes
 A medical coding modifier is two characters (letters or numbers) appended to a
CPT or HCPCS Level II code.
 Format : αα, αx, xx
 Example: RT-Right Side, Q6-Locum Doctor, 50-Bilateral Procedure
 Usage of Modifiers
 The service or procedure has both professional and technical
components.
 More than one provider performed the service or procedure.
 More than one location was involved.
 A service or procedure was increased or reduced in comparison to
what the code typically requires.
 The procedure was bilateral.
 The service or procedure was provided to the patient more than
once.
 Examples of CPT modifiers:
 22 – Increased procedural services
 23 – Unusual anesthesia
 24 – Unrelated evaluation and management service by the same physician or
other qualified health care professional during a postoperative period
 25 – Significant, separately identifiable evaluation and management service by
the same physician or other qualified health care professionals on the same day
of the procedure or other service
 52- Reduced services
 53- Discontinued procedure
 55- Postoperative management only
 56- Preoperative management only
 57- Decision for surgery
 59- Distinct Procedural Services
 99- Multiple modifiers
 Examples of HCPCS modifiers:
 AA- Anesthesia services performed by anesthesiologists
 AD- Medical supervision by a physician, more than four concurrent anesthesia
procedures
 AH- Clinical Psychologist (CP) Services. [Used when a medical group employs a
CP and bills for the CP’s service]
 AJ- Clinical Social Worker (CSW). [Used when a medical group employs a CSW
and bills for the CSW’s service]
 GW- Service not related to the hospice patient’s terminal condition
 GY- Item or service statutorily excluded or does not meet the definition of any
Medicare benefit
 GZ- Item or service expected to be denied as not reasonable and necessary
 QN- Ambulance service furnished directly by a provider of services
 Diagnosis Code
 Dx Codes represents the illness/sickness of the patient

 World Health Org developed this concept and named as ICD Code (International
Classification of Disease). Finally, this concept is re-designed by CMS and called as,
Centre for Medicare and Medicaid services
 ICD-10-CM (10th Revision – Clinical Modification) -- ICD 11- at present.

 The ICD-10-CM code manual is divided into three volumes.

A) Volume I is the tabular index.

B) Volume II is the alphabetic index.

C) Volume III lists procedure codes that are only used by hospitals.
 ICD-10-CM - LAYOUT AND ORGANIZATION
 ICD-10-CM is a seven-character, alphanumeric code.
 Each code begins with a letter, and that letter is followed by two numbers.
 The first three characters of ICD-10-CM are the “category.” The category
describes the general type of the injury or disease.
 The category is followed by a decimal point and the subcategory.
 This is followed by up to two sub classifications, which further explain the
cause, manifestation, location, severity, and type of injury or disease.
 The last character is the extension.
 The extension describes the type of encounter this is. That is, if this is the
first time a healthcare provider has seen the patient for this
condition/injury/disease, it’s listed as the “initial encounter.”
 Every encounter after the first is listed as a “subsequent encounter.”
 Patient visits related to the effects of a previous injury or disease are listed
with the term “sequela.”
 To review: the first digit of an ICD-10-CM code is always an alpha, the
second digit is always numeric, and digits three through seven may be
alpha or numeric. Here’s a simplified look at ICD-10-CM’s format.
 A01 – {Disease}
A01.0 {Disease] of the lungs
A01.01 … simple
A01.02 … complex
A01.020 … affecting the trachea
A01.021 … affecting the cardiopulmonary system
A01.021A … initial encounter
A01.021D … subsequent encounter
A01.021S … sequela
ICD-10-CM
Injury: Closed fracture of distal phalanx of right index finger

•S00-T88 – Injury, poisoning and certain other consequences of external causesS60-S69 –

Injuries to the wrist, hand and fingersS62 – Fracture at wrist and hand level
• S62.0 – fracture at navicular [scaphoid] bone of wrist
• …
• S62.5 – fracture of thumb
• S62.6 – fracture of other and unspecified finger(s)
• S62.60 – fracture of unspecified phalanx of finger
• S62.61 – displaced fracture of proximal phalanx of finger
• …
• S62.63 – displaced fracture of distal phalanx of finger
• S62.630 – Displaced fracture of distal phalanx of right index finger
• S62.630A – … initial encounter for closed fracture
• S62.630B – … initial encounter for open fracture
• S62.630D – … initial encounter for fracture with routine healing
• Etc.