procedurediagnosis code overview. participants will interpret basic medical codes and assess how to...
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PROCEDURE DIAGNOSIS
CODE OVERVIEW
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Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations.
Learning Objective
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Medical coding is a uniform language that allows a reliable means of communication among physicians, patients and third parties.
Medical “Code Speak”
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ICD means International Statistical Classifications of Diseases.
ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.
ICD-9 and ICD-10 Codes.
The Diagnosis
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HCPCS Codes
Healthcare Common Procedure Coding System (HCPCS) is maintained by the Centers for Medicare and Medicaid Services (CMS).
Provide a system for reporting the medical services provided to Medicare beneficiaries.
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HCPCS Code RangesA-codes: Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental
B-codes: Enteral and Parenteral Therapy
C-codes: Temporary Hospital Outpatient Prospective Payment System
D-codes: Dental Procedures
E-codes: Durable Medical Equipment
G-codes: Temporary Procedures & Professional Services
H-codes: Rehabilitative Services
J-codes: Drugs Administered Other Than Oral Method, Chemotherapy Drugs
K-codes: Temporary Codes for Durable Medical Equipment Regional Carriers
L-codes: Orthotic/Prosthetic Procedures
M-codes: Medical Services
P-codes: Pathology and Laboratory
Q-codes: Temporary Codes
R-codes: Diagnostic Radiology Services
S-codes: Private Payer Codes
T-codes: State Medicaid Agency Codes
V-codes: Vision/Hearing Services
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CPT codes enable healthcare providers to effectively and efficiently communicate with government or private insurance companies about medical, surgical and diagnostic services rendered to a patient.
The CPT Coding System
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The Current Procedural Terminology (CPT) is a five digit coding system first published by the American Medical Association (AMA) in 1996.
The Procedure / Service
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1
ToFrom
Medicine90281 9699997001 9779998925 99199
Surgery 10021 69999
Radiology 70010 79999
Pathology 80002 89399
Evaluation & Management 99201 99499
Hospital DRG Code DRG-001 DRG-999
Anesthesia 00100 0199999100 99142
CPT Code Ranges
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Health InsuranceClaim Form 1500
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Claim Form 1500Page 2
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Medical Record Documentation
Cycle
DOL/OWCP Review Claim
Documents are Coded &
Submitted to DOL/OWCP
Doctor Examines Claimant
Doctor Renders
Treatment & Documents Diagnosis
Claimant Goes to Doctor
PaymentSent
Most provider offices use
“superbills” for billing purposes.