introduction to medical coding for payment lawyers

HCCA Clinical Practice Compliance

Conference

October 11-13, 2015

1

Health Care Compliance Association

Clinical Practice Compliance Conference

October 11 - 13, 2015

Philadelphia, PA

Introduction to Medical Coding for Payment Lawyers

Robert A. Pelaia

Deputy General Counsel

University of South Florida

813-974-1675

[email protected]

Introduction to Medical Coding For Payment

Lawyers

DIAGNOSIS CODES

• ICD-9-CM (International Classification of Diseases, 9th

Revision, Clinical Modification)

• ICD-10-CM (International Classification of Diseases, 10th

Revision, Clinical Modification)


Conference

October 11-13, 2015

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Introduction to Medical Coding For Payment

Lawyers

PROCEDURE CODES

• CPT (Current Procedural Terminology, Fourth Edition)

ICD-9-CM – Goodbye!

International

Classification of

Diseases, 9th

Revision,

Clinical

Modification


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October 11-13, 2015

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ICD-10-CM – Hello!

International

Classification of

Diseases, 10th

Revision,

Clinical

Modification

ICD-10 - The Book

Alphabetic Index to Diseases

• Presented first in the book and lists the diseases and

injuries in alphabetical order.


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October 11-13, 2015

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ICD-10 - The Book

Tabular /Numeric List of Diseases

• Presented second in the book and lists the ICD-10

codes in numeric order.

• Tabular List is a chronological list of codes divided

into chapters based on body system or condition.

• 21 Chapters

ICD-10 Implementation Dates

01/16/09 - Original “final” rule was published. Original

compliance date for implementation of ICD-10 was

October 1, 2013.

09/05/12 - New “final” rule was published. Compliance

date for implementation of ICD-10 was moved to

October 1, 2014.

04/01/14 – Law signed by President Obama blocked

ICD-9 Implementation before October 1, 2015.

07/31/14 – CMS officially sets October 1, 2015 as new

ICD-10 compliance deadline.


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October 11-13, 2015

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ICD-10 Structure

X X X X X X

Category Etiology,

Anatomic Site,

Manifestation Extension

ICD-10-CM

• 69,099 diagnosis codes

• Consists of three to seven characters

• 1st character is alpha

• All letters are used except U

• Second character is numeric

• 3rd, 4th, 5th, 6th, & 7th characters can be alpha or numeric

• Decimal is placed after the first three characters

X

ICD-10 Structure

Codes in the ICD-10 code set can have three,

four, five, six, or seven characters.

Many three-character codes are used as

headings for categories of codes

These three-character codes can further

expand to four, five, or six characters to add

more specific details regarding the diagnosis.


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October 11-13, 2015

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S 8 6 0 1 1 D Category Etiology, Anatomic Site, Manifestation Extension

• This ICD-10 code is for the strain of

right Achilles tendon, subsequent

encounter.

ICD-10 Structure

S 8 6 0 1 1 D Category Etiology, Anatomic Site, Manifestation Extension

ICD-10 Structure

S = Injuries, poisoning

and certain other

consequences of external

causes related to single

body regions.

S86 = Injury of muscle,

fascia and tendon of

lower leg

S86.0 = Injury of Achilles

Tendon

S86.01 = Strain of

Achilles Tendon

S86.011 = Strain of right

Achilles Tendon

A= Initial

encounter

D=Subsequent

Encounter

S=Sequela


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• Chapter 1 / A00 - B99

• Certain Infectious / Parasitic Diseases

• Chapter 2 / C00 - D49

• Neoplasms

• Chapter 3 / D50 - D89

• Diseases of Blood / Diseases of Immune System

• Chapter 4 / E00 - E89

• Endocrine, Nutritional and Metabolic Diseases

• Chapter 5 / F01 - F99

• Mental, Behavioral and Neurodevelopmental Disorders

• Chapter 6 / G00 - G99

• Disease of the Nervous System

ICD-10 Chapters

• Chapter 7 / H00 - H59

• Disease of the Eye and Adnexa

• Chapter 8 / H60-H95

• Diseases of the Ear and Mastoid Process

• Chapter 9 / I00 - I99

• Diseases of the Circulatory System

• Chapter 10 / J00 - J99

• Disease of the Respiratory System

• Chapter 11 / K00 - K95

• Disease of the Digestive System

ICD-10 Chapters


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• Chapter 12 / L00 - L99

• Diseases of Skin and Subcutaneous Tissue

• Chapter 13 / M00 - M99

• Diseases of Musculoskeletal System and Connective Tissue

• Chapter 14 / N00 - N99

• Diseases of Genitourinary System

• Chapter 15 / O00 - O9A

• Pregnancy, Childbirth, and the Puerperium

• Chapter 16 / P00 - P96

• Conditions Originating Perinatal Period

ICD-10 Chapters

• Chapter 17 / Q00 - Q99

• Congenital Malformations and Chromosomal Abnormalities

• Chapter 19 / R00 - R99

• Symptoms, Signs, and Abnormal Clinical and Lab Findings

• Chapter 19 / S00 - T88

• Injury, Poisoning, Certain Other External Causes

• Chapter 20 / V00 - Y99

• External Causes of Morbidity

• Chapter 21 / Z00 – Z99

• Factors Influencing Health Status and Contact with Health

Services

ICD-10 Chapters


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Dummy Placeholders

Not every ICD-10 code with a seventh character has a sixth character

- or even a fifth or fourth character for that matter.

The letter “X” serves as a dummy placeholder when a code contains

fewer than six characters and a seventh character applies.

When selecting ICD-10-CM codes, coders must add a placeholder so

the seventh character is in the correct position.

EXAMPLE: T15.12XA

Foreign body in conjunctival sac, left eye, initial encounter.

ICD-10 Examples

S and 5 Z and 2 I and 1 O and 0

• I Codes – Diseases of Circulatory System

• I63.011 – Cerebral infarction due to thrombosis of right

vertebral artery

• O Codes – Pregnancy/Childbirth

• O24.013 - Pre-existing diabetes mellitus, type 1, in

pregnancy, third trimester


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October 11-13, 2015

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ICD-10 Examples - Laterality

“Laterality” (side of the body affected) is a new coding

convention added to relevant ICD-10 codes to increase

specificity. Designated codes for conditions such as

fractures, burns, ulcers, and certain neoplasms will require

documentation of the side/region of the body where the

condition occurs.


In ICD-10, laterality code descriptions include

right, left, bilateral, or unspecified designations:

• The right side = character 1

• The left side = character 2

• Bilateral = character 3

• Unspecified side/region = character 0 or 9

(depending on whether it is a 5th or 6th

character).


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October 11-13, 2015

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ICD-9

• 370.03 - Central Corneal Ulcer

1. Completely review all medical record documentation.

2. Abstract the medical conditions that should be coded.

3. Identify the main term for each diagnosis.

4. Locate the main term in the Alphabetic Index.

5. Verify the code in the Tabular List by reading the notes & following the

guidelines.

Assigning ICD-10 Codes


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Step 1

• Completely review all medical record documentation in order

to properly identify the terms that best describe the patient’s

diagnosis.


Step 2

• Abstract the medical conditions that should be coded.


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Step 3 • Identify the main term for each diagnosis reflected in the

medical record. Main terms identify the diseases, injury or

conditions.

Diseases • Influenza

• Bronchitis

Conditions • Fatigue

• Fracture

• Injury

Nouns or Adjectives • Disease, disturbance, syndrome

• Aberrant, abnormal, enlarged


Step 4

• Look up the main term that best describe the patient’s

diagnosis in the alphabetic index and identify the ICD-10 code

that appears to best matches the diagnosis.


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Step 5

• Look up the selected code in the tabular/numerical list to

make the code selection. Careful attention should be paid to

“includes” and “excludes” notes and other instructions.

• Code to the highest level of specificity.


It is essential to use both the Index and the Tabular

List when selecting a code. Selection of the full code,

including laterality and any applicable 7th character,

can only be done in the Tabular list.

A dash (-) at the end of an Index entry means that

additional characters are required.

Even if a dash isn’t present, you must refer to the

Tabular list to verify that no 7th character is required.


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October 11-13, 2015

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Mini ICD-10 Quiz

Roger suffers from paralysis of his upper

right arm. He is left-handed.

Mini ICD-10 Quiz

Melissa presents with a boil in the

external ear of the left side.


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October 11-13, 2015

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Mini ICD-10 Quiz

A 79 year old with osteoporosis presents

with a new pathological fracture of the

right femur.

Mini ICD-10 Quiz

Rhonda was treated at her dermatologist

for basal cell carcinoma of the skin of the

chin.


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CPT

Current Procedural

Terminology,

Fourth Edition

CPT

Background CPT was developed and published in 1966 by the American Medical

Association. The current version, CPT 2008, is referred to as “CPT-4”

because it is the fourth edition of CPT. Annual updates of CPT are not

considered new editions.

Application CPT is used for reporting physician (professional) services and technical

services provided with the professional services.


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CPT

Updating

CPT Codes are updated through a deliberative process of adding,

deleting, and revising codes.

CPT codes are updated and revised by the AMA’s CPT Editorial Panel

on an annual basis.

CPT Organization

CPT is divided into six sections, followed by six appendices and

an alphabetic index. The CPT codes are listed in numeric order

within sections and subsections.

Evaluation and Management (99201 – 99499)

Anesthesia (00100 – 01999)

Surgery (10021 – 69990)

Radiology (70010 – 79999)

Pathology and Laboratory (80047 – 89356)

Medicine (90281 – 99607)


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CPT Organization

• Section guidelines appear at the beginning of each of the six

CPT sections.

• Subsection guidelines appear at the beginning of many of the

subsections.

• The guidelines provide definitions and additional information

to assist in the proper selection of CPT codes within the

corresponding section or subsection.

CPT Evaluation and Management Codes

Key Components

• History

• Exam

• Medical Decision Making

New Patient vs. Established Patient


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SELECTING LEVEL OF E&M CODES

History - Levels and Types


Select an E&M

Code in 7 Easy

Steps!


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HISTORY (new patient)

Step 1 - Determine the “name” level of the

History component, which will be either…

Problem-focused,

Expanded problem-focused,

Detailed, or

Comprehensive.


HISTORY (new patient)

Step 2 - Convert this “name” level of history into

a “number” level.

Problem-focused = Level 1

Expanded problem-focused = Level 2

Detailed = Level 3

Comprehensive = Levels 4 & 5


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EXAM (new patient)

Step 3 - Determine the “name” level of the Exam

component, which will be either…

Problem-focused,

Expanded problem-focused,

Detailed, or

Comprehensive.


EXAM (new patient)

Step 4 - Convert this “name” level of exam into a

“number” level.

Problem-focused = Level 1

Expanded problem-focused = Level 2

Detailed = Level 3

Comprehensive = Levels 4 & 5


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MEDICAL DECISION MAKING (new patient)

Step 5 - Determine the “name” level of the

Medical Decision Making component, which will

be either…

Straightforward,

Low complexity,

Moderate complexity, or

High Complexity.


MEDICAL DECISION MAKING (new patient)

Step 6 - Convert this “name” level of Medical

Decision Making into a “number” level.

Straightforward = Levels 1 & 2

Low complexity = Level 3

Moderate complexity = Level 4

High Complexity = Level 5


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October 11-13, 2015

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Putting It All Together

NOTE: The same “name” level of an element may

result in a different “number” level depending on the

type of service being

For instance, a Detailed history translates to a Level 3

when looking at the NEW Patient Office Visit range of

codes (99203).

HOWEVER, a Detailed history translates to a Level 4

when looking at the ESTABLISHED Patient Office

Visit range of codes (99214).



In cases where a “name” level is associated with TWO

number levels, credit the higher number level.

For example: in the NEW Patient Office Visit subcategory, a

Comprehensive level of history is associated with both the

Level 4 and Level 5 codes within that category, so the

Comprehensive history would be converted to a (number)

Level 5 history in this category.


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In cases where a “name” level is associated with TWO

number levels, credit the higher number level.

Another example: in the NEW Patient Office Visit

subcategory, a Straightforward level of MDM is associated

with both the Level 1 and Level 2 codes within that category,

so the Straightforward MDM should always be converted to

a (number) Level 2 MDM in this category.



Step 7 - With a “number” level in hand for each of the

three key components, determine whether you must now

apply the “3/3 rule” or “2/3 rule” to arrive at the final

code level for the category in question.

3/3: When using the 3/3 rule, the LOWEST of the three

individual component levels IS the final visit level.

2/3: When using the 2/3 rule, the NEXT-TO-LOWEST

component level IS the final visit level.


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Mini E&M Quiz

• New Patient Visit (3/3 rule)

• Level 3 History (detailed)

• Level 3 Exam (detailed)

• Level 2 MDM (straightforward)



Mini E&M Quiz

• New Patient Visit (3/3 rule)

• Level 5 History (comprehensive)

• Level 4 Exam (comprehensive)

• Level 3 MDM (low complexity)


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Mini E&M Quiz

• Established Patient Visit (2/3 rule)

• Level 4 History (detailed)

• Level 3 Exam (expanded problem focused)

• Level 2 MDM (straightforward)



Mini E&M Quiz

• Established Patient Visit (2/3 rule)

• Level 2 History (problem-focused)

• Level 2 Exam (problem-focused)

• Level 3 MDM (low complexity)


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Assigning CPT Codes

Step 1

Review the medical record documentation in order to properly

identify the terms that best describe the service.

Assigning CPT Codes

Step 2

Look up the terms that best describe the service in the CPT index

and identify the CPT code that best matches the service.


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Assigning CPT Codes

Step 3

Look up the selected code in the main section of CPT to make the

code selection. Careful attention should be paid to use of

modifiers.

Mini CPT Quiz

• Soft Tissue Shoulder Biopsy

• ____________

• Removal of Foreign Body, External Eye; Conjunctival

Superficial

• ____________

• Electrolyte Panel - Pathology

• ______________


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CPT Modifier Examples

Modifier 25 - Significant, Separately Identifiable E&M Service by the

Same Physician on the Same Day of the Procedure or Other Service.

Modifier 25 is used to describe separate, distinctly identifiable services from

other services or procedures rendered during the same visit. Always attach

the modifier to the evaluation and management code.

Modifier 57 - Decision for Surgery.

Modifier 57 is used when an evaluation and management (E&M) service

resulted in the initial decision to perform surgery. Major surgical procedure is

defined by CMS as a procedure having a 90-day global period assigned by

CMS. The global period includes the 1-day prior to surgery.

Top 10 Takeaways

1. ICD-10 Codes are Diagnosis Codes

2. ICD-10 was Effective October 1, 2015

3. ICD-10 Index / Alphabetic

4. ICD-10 Tabular / Numeric

5. CPT Codes are Procedure Codes


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Top 10 Takeaways

6. E&M Codes Have 3 Key Components

7. History / Exam / MDM

8. New Patient E/M = 3 Key Components

9. Established E/M = 2 Key Components

10. Code to Highest Level of Specificity

Questions & Answers

introduction to medical coding for payment lawyers

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