About Medical Coding
Medical coding is a little bit like
translation. Coders take medical reports from doctors, which may include a
patient’s condition, the doctor’s diagnosis, a prescription, and whatever
procedures the doctor or healthcare provider performed on the patient, and turn
that into a set of codes, which make up a crucial part of the medical claim.
Is
Code Needed?
Let’s start with a simple question
about medical coding: Why do we code medical reports? Wouldn’t it be enough to
list the symptoms, diagnoses, and procedures, send them to an insurance
company, and wait to hear which services will be reimbursed?
To answer that, we have to look at
the massive amount of data that every patient visit entails. If you go into the
doctor with a sore throat, and present the doctor with symptoms like a fever,
sore throat, and enlarged lymph nodes, these will be recorded, along with the
procedures the doctor performs and the medicine the doctor prescribes.
In a straightforward case like this,
the doctor will only officially report his diagnosis, but that still means the
portion of that report that will be coded contains a diagnosis, a procedure,
and a prescription.
Take a step back, and this is
suddenly a lot of very specific information. And that’s just for a relatively
simple doctor’s visit. What happens when a patient comes into the doctor with a
complicated injury or sickness, like an ocular impairment related to their
Type-2 diabetes? As injuries, conditions, and illnesses get more complex, the
amount of data that needs to be conveyed to insurance companies increases
significantly.
According to the Centers for Disease
Control (CDC), there were over 1.4 billion patient visits in the past year. That’s a stat that includes visits to physician offices,
hospital outpatient facilities and emergency rooms. If there were just five
pieces of coded information per visit, which is an almost unrealistically low
estimate, that’d be 6 billion individual pieces of information that needs to be
transferred every year. In a system loaded with data, medical coding allows for
the efficient transfer of huge amounts of information.
Coding also allows for uniform
documentation between medical facilities. The code for streptococcal sore
throat is the same in Arkansas as it is in Hawaii. Having uniform data allows
for efficient research and analysis, which government and health agencies use
to track health trends much more efficiently. If the CDC, for example, wants to
analyze the prevalence of viral pneumonia, they can search for the number of
recent pneumonia diagnoses by looking for the ICD-10-CM code.
Finally, coding allows
administrations to look at the prevalence and effectiveness of treatment in
their facility. This is especially important to large medical facilities like
hospitals. Like government agencies tracking, say, the incidence of a certain
disease, medical facilities can track the efficiency of their practice by
analyzing
Now that we understand the
importance of this practice, let’s take a look at the three types of code that
you’ll have to become familiar with as a medical coder.
Three
Types of Code to Know
There are three sets of code you’ll
use on a daily basis as a medical coder.
ICD
These are diagnostic codes that
create a uniform vocabulary for describing the causes of injury, illness and
death. This code set was established by the World Health Organization (WHO)
in the late 1940s. It’s been updated several times in the 60-plus years since
it’s inception.
The number following “ICD” represents which revision of the
code is in use.
For example, the code that’s
currently in use in the United States is ICD-10-CM. This means it’s the
10th revision of the ICD code. That “-CM” at the end stands for “clinical
modification.” So the technical name for this code is the International
Classification of Diseases, Tenth Revision, Clinical Modification. The
clinical modification is a set of revisions put in place by the National Center for Health Statistics (NCHS), which is a division of the Center for Medicare and Medicaid Studies (CMS).
The Clinical Modification
significantly increases the number of codes for diagnoses. This increased scope
gives coders much more flexibility and specificity, which is essential for the
profession. To give you an idea of how important the clinical modification is, the
ICD-10 code, has 14,000 codes. It’s clinical modification, ICD-10-CM, contains
over 68,000.
ICD codes are used to represent a
doctor’s diagnosis and the patient’s condition. In the billing process, these
codes are used to determine medical necessity. Coders must make sure the
procedure they are billing for makes
sense with the diagnosis given. To return to our strep throat example, if a
coder listed a strep throat diagnosis as the medical justification for an
x-ray, that claim would likely be rejected.
Let’s turn our attention now to the
two types of procedure codes.
Let’s turn our attention now to the
two types of procedure codes.
CPT
Current Procedure
Terminology, or CPT, codes, are used to
document the majority of the medical procedures performed in a physician’s
office. This code set is published and maintained by the American Medical Association
(AMA). These codes are copyrighted by the AMA and are updated annually.
CPT codes are five-digit numeric
codes that are divided into three categories. The first category is used most
often, and it is divided into six ranges.
These ranges correspond to six major
medical fields:
- Evaluation and Management
- Anesthesia
- Surgery
- Radiology
- Pathology and Laboratory and
- Medicine.
The second category of CPT codes
corresponds to performance measurement and, in some cases, laboratory or
radiology test results. These five-digit, alphanumeric codes are typically
added to the end of a Category I CPT code with a hyphen.
Category II codes are optional, and
may not be used in the place of Category I codes. These codes are useful for
other physicians and health professionals, and the AMA anticipates that
Category II codes will reduce the administrative burden on physicians’ offices
by providing them with more, and more accurate, information, specifically
related to the performance of health professionals and health facilities.
The third category of CPT codes
corresponds to emerging medical technology.
As a coder, you’ll spend the vast
majority of your time with the first two categories, though the first will
undoubtedly be more common.
CPT codes also have addendums that
increase the specificity and accuracy of the code used. Since many medical
procedures require a finer level of detail than the basic Category I CPT code
offers, the AMA has developed a set of CPT modifiers. These are two-digit
numeric or alphanumeric codes that are added to the end of the Category I CPT
code. CPT modifiers provide important additional information to the procedure
code. For instance, there is a CPT modifier that describes which side of the
body a procedure is performed on, and there’s also a code for a discontinued procedure.
HCPCS
Healthcare Common
Procedure Coding System (HCPCS),
commonly pronounced as “hick picks,” are a set of codes based on CPT codes. Developed
by the CMS
(the same organization that developed CPT), and maintained by the AMA, HCPCS
codes primarily correspond to services, procedures, and equipment not covered
by CPT codes. This includes durable medical equipment, prosthetics, ambulance
rides, and certain drugs and medicines.
HCPCS is also the official code set
for outpatient hospital care, chemotherapy drugs, Medicaid, and Medicare, among
other services. Since HCPCS codes are involved in Medicaid and Medicare, it’s
one of the most important code a medical coder can use.
The HCPCS code set is divided into
two levels. The first of these levels is identical to the CPT codes that we
covered earlier.
Level II is a set of alphanumeric
codes that is divided into 17 sections, each based on an area of specificity,
like Medical and Laboratory or Rehabilitative Services.
Like CPT codes, each HCPCS code
should correspond with a diagnostic code that justifies the medical procedure.
It’s the coders responsibility to make sure whatever outpatient procedure is
detailed in the doctor’s report makes sense with the listed diagnosis,
typically described via an ICD code.
Now that you’ve got a better idea of
what each of these codes is and what they do, let’s start exploring each code
set in a little more detail.
Fatigue
