Chapter 1 - Introduction To The Languages Of Coding Flashcards
Terminology
Treatment
The provision of medical care for a disorder or disease.
Condition
The state of abnormality or dysfunction.
Medical necessity
- based on Health Care industry’s ‘standards of care’
- explains the valid medical reason why a procedure, service, or treatment was provided
The determination that the health care professional was acting according to standard practices in providing a particular procedure For an individual with a particular diagnosis.
Reimbursement
Third party payers use our coding data to determine how much they should pay Health Care Professionals for the attention and services they provide patients.
This is the role that coding plays in the reimbursement process.
The process of paying for health care services after they have been provided.
External causes
Used to explain HOW a patient got injured and WHERE, place of occurrence, he or she was when the injury happened.
The explanation of how a patient became injured or poisoned, as well as other necessary details about the event; a health concern caused by something outside the body.
Diagnosis
A physician’s determination of a patient’s condition, illness, or injury.
Procedure
Action taken, in accordance with the standards of Care, by The Physician to accomplish a predetermined objective (result); a surgical operation.
Classification system
The category term used in healthcare to identify ICD-10-CM, CPT, ICD-10-PCS, and HCPCS Level II code sets.
Inpatient
A patient admitted into a hospital for in overnight stay or longer.
Services
Spending time with a patient and/or family about health care situations.
Outpatient
Healthcare Services provided to individuals without an overnight stay in the facility.
Eponym
A disease or condition named for a person.
Coding languages communicate information that is key to the following aspects of Health Care system.
- reimbursement
- medical necessity
- resources allocation
Coding is accurately interpreting Healthcare terms and definitions into ____________ that specifically conveyed diagnoses and procedures.
Numbers or number-letter combinations
A diagnosis explains
Why the patient requires attention of the provider.
A procedure explains
What the provider did for the patient.
The code book that contains all the codes to report the reason why the healthcare provider cared for the patient during a specific encounter.
ICD-10-CM code book
The part of the ICD-10-CM code book that you use to confirm that a diagnosis code is accurate.
The Tabular List
Diagnostic descriptions are listed by
- eponyms such as Epstein-Barr syndrome.
- conditions such as fractures.
other descriptors such as family history.
The following would be an example of an eponym.
Arnold-Chiari disease
The index to external causes list the causes of
Injuries and poisoning.
An example of an ICD-10-CM code is
H61.022
When ICD-10-CM codes support medical necessity, this means that
There was a valid medical reason to provide care.
The why justifies the
What.
Surgical removal of a skin tag is an example of a
Procedure.
_____________ tests or procedures are performed to provide the physician with additional information to support the determination of a confirmed diagnosis.
Diagnostic
The code set(s) available for the coding specialist to use to translate Health Care procedures, services, and treatments into codes is/are
- ICD-10-PCS code book.
- CPT code book.
- HCPCS Level II code book
The main body of the CPT book has _____________ sections.
6
An example of a category II code is
1134F
The code set used for Hospital facility reporting a procedures, services, and treatments provided to a patient who has been admitted as an inpatient is
ICD-10-PCS code book
HCPCS Level II codes are presented as
One letter followed by four numbers.
An example of a HCPCS Level II code is
J3285
Diagnosis code
Explains WHY the patient requires the attention of a healthcare provider
Procedure code
Explains WHAT the physician or healthcare provider did for the patient
Statistical analysis
Research organizations and government agency evaluate in study the data provided by codes to:
- develop programs
- identify research areas
- allocate funds
- write Public Health policies that will best address areas of concern for the health of our nation’s population
Resource allocation
Administrators and managers must ensure that all resources - human and Equipment - are employed in the most efficient and effective manner.
Codes can be analyzed by computers to identify the:
- largest patient population diagnoses
- most frequently provided treatments and services
With these details, staff members, equipment, and money can be directed to those patients and locations that need them the most.
Types of codes
diagnosis coding uses ICD-10-CM codes
What does it stand for?
• International Classification of Diseases - 10th revision - Clinical Modification
Types of codes
Procedure coding uses CPT, HCPCS Level II, ICD-10-PCS codes.
What do each stand for?
- Current Procedural Terminology (CPT)
- Healthcare Common Procedure Coding System, Level II (HCPCS Level II)
- International Classification of Diseases - 10th revision - Procedure Coding System (ICD-10-PCS)
ICD-10-CM Diagnosis Codes
Used by all Healthcare Providers and Facilities.
Report WHY the patient needed care
• Medical Necessity
Consists of a three-character code category and at least three additional characters:
- Always begins with a letter, up to seven alphanumeric
- Always a DOT between third and fourth characters.
* Example: A12.3K5A
CPT Procedure Codes
Used by physicians to report Services provided at any/all facilities.
Also used by outpatient care facilities for example Ambulatory Surgery centers, hospital emergency rooms, Hospital outpatient surgery centers, Etc.
- Report WHAT was done for the patient.
- Always consist of five numbers, no punctuation.
* Example: 12345
ICD-10-PCS Procedure Codes
- Used only by hospitals for reporting facility services to inpatients.
- Always consists of seven alphanumeric characters.
* Example: 012B4LZ
HCPCS Level II Services and Supplies Codes
Used to report services and supplies not already represented by a code in CPT.
• such as Transportation, drugs administered by a healthcare professional, durable medical equipment, Etc.
Use by any facility or provider.
- Always consists of a letter followed by four numbers.
* Example: A1234
Chapter Summary
Essentially, the process of coding begins with the physician’s document stating why the patient needed care and what was done for this patient during this visit.
As a professional coding specialist, you will interpret the documentation in the patient’s record from medical terminology into codes: diagnosis codes to explain why, along with how and where if the patient is injured; and procedure codes to report what the physician or facility did for the patient during this encounter. You will need to confirm that the diagnosis code or codes support medical necessity for the procedures, services, and treatments provided.
What is the purpose of coding?
Around the world, languages exist to enable clear and accurate communication between individuals in similar groups or working together in similar functions.
The purpose of using Healthcare coding languages is to enable the sharing of information, in a specific and efficient way, between all those involved in healthcare.
there are three parties involved in reimbursement
- the health care provider = First party
- the patient = Second party
- the insurance company or other organization financially responsible = Third-party payer
The alphabetic index
- in alphabetical order, the terms used by The Physician to describe the reasons why the patient required attention from a healthcare professional.
- list all diagnoses and other reasons to provide Health Care by their basic description alphabetically from A to Z.
- diagnostic descriptions are listed by
* condition (infection, fracture and wound)* Eponym (Epstein-Barr syndrome and Cushing's disease)
- other descriptors (personal history, family history)
Index to diseases and injuries.
Nonessential modifiers
When the note provides you with alternative words or phrases that the physician might use that mean the same condition
There are three terms used to describe actions that the physician can take to support a patient’s good health or to improve a current condition
- procedures - our actions, or a series of actions, taking two accomplished an objective (result). For example, surgically
- services - our actions that will most often involve counseling, educating, and advising the patient, such as discussing test results were sharing recommendations for risk reduction.
- Treatments - are typically an Application of a health care service, such as radiation treatments for tumor reduction or acupuncture.
Once the Physician has determine the patient’s condition or problem he or she can establish a treatment plan. These actions provided by The Physician, or other health-care professional, are done for one of the three reasons:
- Diagnostic - tests or procedures are performed to provide the position with additional information required to determine a confirmed diagnosis.
- Preventative - procedures and services are provided to keep a healthy patient healthy. In other words… To avoid illness or injury. These also include early detection testing, known as screenings.
- Therapeutic - procedures, treatments, and services are performed with the intention of removing, correcting, or repairing an abnormality condition.
There are three different codes sets available for you to use to translate Health Care procedures, services, and treatments into codes. These three codes sets are:
- CPT - Current Procedural Terminology
- ICD-10-PCS - International Classification of Diseases - 10th revision - Procedure Coding System
- HCPCS Level II - Healthcare Common Procedure Coding System
The organization of the CPT Code Book
• has two parts
- has six sections, which are generally presented in numeric order by code number.
* Evaluation and Management: 99201-99499
* Anesthesia: 00100-01999 and 99100-00140
* Surgery: 10021-69990
* Radiology: 70010-79999
* Pathology and Laboratory: 80047-89398
* Medicine: 90281-99199, 99500-99607
The 2nd part:
- Category II Codes: used for supplemental tracking of performance measurements. These codes are not reimbursable but support research on specific physician actions taken on behalf of a patient’s health.
- Category III Codes: temporary codes used to report emerging technological procedures. Technology in healthcare are innovating and improving every day. These codes enable tracking position adoption and the frequency of you to identify what should stay and what will be deleted.
Formats of CPT codes.
Category I Codes
Are five digit codes. They have all numbers, no letters, no punctuation.
Formats of CPT codes.
Category II Codes
Are five-character codes, with four numbers followed by the letter “F”.
Formats of CPT Codes.
Category III Codes
Are five-character codes. These codes also have four numbers; however, Category III codes are are followed by the letter “T”.
ICD-10-PCS Codes
Tables section to find the listing of characters and their meanings.
Building a code:
- Section - of the ICD-10-PCS code set.
- Body System - upon which the procedure service was performed.
- Root Operation - which explains the category or type of procedure.
- Body Part - which identifies the specific anatomical site involved in the procedure.
- Approach - which reports which method was used to perform the service or treatment.
- Device - Which reports, when applicable, what type of device was involved in the service or procedure.
- Qualifier - which adds any additional detail.
Allogeneic
Means coming from a different individuals of the same species.
Syngeneic
Means coming from a genetic identical, such as from an identical Twin.
Zooplastic
Means the tissue or organ is coming from a donor of another species into a human.
HCPCS abbreviation for Healthcare common procedure coding system, is pronounced
“hick-picks”
A complete, valid ICD-10-CM code will always begin with a 3-character code category: A letter of the alphabet followed by a minimum of 2 characters, either letters or numbers.
When additional characters are required, those codes with fewer characters are invalid. The need for additional characters is mandatory, NOT a suggestion.
HCPCS Level II codes cover specific aspects of health care services, including
- durable medical equipment (e.g. wheelchair or a humidifier).
- Pharmaceuticals administered by a healthcare provider (e.g. a saline solution or a chemotherapy drug).
- medical supplies provided for the patient’s home use (e.g. in eye patch or gradient compression stockings).
- Dental Services (e.g. all services provided by a dental professional).
- transportation services (e.g. ambulance services).
- vision and hearing services (e.g. trifocal spectacles or a hearing aid).
- orthotic and prosthetic procedures (e.g. scoliosis brace or prosthetic arm).
ICD-10-CM ….Diagnosis Codes
- used by all Healthcare Providers and Facilities
- report why the patient needed care (medical necessity)
- ICD-10-CM diagnosis codes = A12.3K5A (up to 7 alphanumeric)
CPT ….Procedure Codes
- used by physicians to report Services provided at any or all facilities
- also use by Outpatient care facilities for example Ambulatory Surgery centers, hospital emergency rooms, Hospital outpatient surgery centers, Etc
- report what was done for the patient
- CPT procedure codes = 12345 (five numbers always)
ICD-10-PCS….Procedure Codes
- used only by hospitals for reporting facility services to inpatients
- ICD-10-PCS procedure codes = 012B4LZ (seven characters always)(alphanumeric)
HCPCS Level II…..Services and Supplies Codes
- used to report services and supplies not already represented by a code in CPT for example, Transportation, drugs administered by a healthcare professional, durable medical equipment, Etc.
- used by any facility or provider
- not all third-party payers except the use of HCPCS Level II codes
- HCPCS Level II codes = A1234 (one letter, four numbers always)
Formats of CPT Codes.
Modifiers
- Are two characters: two numbers, two letters, or one letter and one number.
- are appended to CPT codes Under special circumstances, such as the use of unusual anesthesia, two surgeons working on the same patient at the same time, or a multi-part procedure performed over time. When required, a modifier is added after the main CPT code with a hyphen.
Neoplasm table
Itemizes all of the anatomical sites in the human body that develop a tumor (neoplasm).
The Purpose of Coding
P. 2
- Medical Necessity
- Statistical analysis
- Reimbursement
- Resource allocation
