Medical Coding Flashcards
Procedure Coding
-To classify the type of care given to patients
Reasons for development
1. To justify medical service to insurance
2. To collect stats about outcome and effectiveness of treatment
3. To help physicians and hospitals set fees
HCPCS
Healthcare Common Procedure Coding System
CPT
Current Procedural Terminology
Level 1 Procedure Coding
- First level of HCPCS does and 95- 98% of codes used for Medicare Part B + current CPT codes
- Updated annually but the AMA
Level II Procedure Coding
- HCPCS codes for procedure, injections, and durable medical equipment covered by Medicare Part B that are not included in the CPT system
- Update books every year
- Ex. supplies, materials, specific meds, ambulance services, and some procedures
- 5 digits, 1 letter + 4 digits
CPT Codes/ Manual
- Narrative description and a 5 digit codes for each procedure or service a physician or other licensed provider may perform for a patient
- CPT manual contains CPT (HCPCS Level 1)
- A darkened circle in front of a code = a code is new
- Darkened triangle = coded has been changed or modified
- Organized by section, subsection, subheading, category
Relative Value unit (RVU)
- A quantified amount of a physicians labor, resources, and expertise that are necessary to provide the service resented by the codes
- Medicare and HMO’s is based on RVU
Diagnosis- related groups (DRGs)
A system for grouping hospitals inpatients who are expected to utilize a similar amount of hospital resources as a basis for Medicare reimbursement
Category II Codes (of CPT)
- Optional codes that use to track performance
- Not reported to insurance carriers
- Last character of codes uses F instead of a digit
- Updated twice a year
Category III Codes (of CPT)
- Used to report services that represent emerging tech.
- 4 digits + T
- Updated 2x a year
Modifiers
- An addition to a procedure codes that indicates unusual circumstance related to the procedure
- All modifier are listed in Appendix A
- Added to main coded after a hyphen and are 2 digits
that can be 2 numbers or 2 letter to indicate body location (ex. F5- right hand, thumb)
Index of CPT manual
Can be used for looking for procedures. They may be located by looking under the name of the procedure, the anatomic location, and sometimes diagnosis
Choosing (CPT) code for procedure
- Location
- Size of lesion or repair
- Method of performing
- Number of minutes allowed for treatment
- Complexity fo procedure or service
Evaluation and Management (E/M) CPT Level 1 Coding
Contains codes for office visits provide by primary care practitioners and specialists. Covers the service-oriented, rather then the procedure oriented
- E/M section attempt to link reimbursement to the completeness of the examination and the amount of skill required to manage the patients’s problems
Proper E/M Coding considerations
- Type of patient: established, outpatient, inpatient
- Type fo Service
- Level of service: medical history, physical exam, or complexity of decision making
E/M Level of Service: Medical History
- Problem focused- Chief complaint, w/ brief history
- Expanded problem focused- problem focused + review of systems that have to do with child complain
- Detailed history- Expanded problem focused + other systems beyond those of chief complaint. Family history is also reviewed
- Comprehensive history- Detailed history + complete family history. For patients w/ severe, acute med conditions or serious changes in long term conditions
E/M Level of Service: Physical Exam
- Problem focused- only affected body system
- Expanded problem- focused- problem focused + other organ systems that may be symptomatic
- Detailed exam- affected body system and other related system or organs
- Comprehensive exam- multi-system examination or complete examination of one system
E/M Level of Service: Medical Decision Making
Straightforward, low complexity, moderate complexity, and high complexity
E/M Secondary Factors
- Coordination of care
- Counseling
- Nature of the patient’s problems
- The amount of time spent with the patient