|
 |
| |
 |
|
Coding Training 
|
Mediland recruited a talented pool of resources
on board, gives intense training on Medical Coding conventions,
characteristics, terminology and components of CPT,
ICD-9 and HCPCS codes, modifiers, NCCI Edits, LCD, HIPAA,
Insurance/governmental regulations and Payer-specific
coding requirements.
Keeping in mind that “Transforming descriptions of diseases,
injuries, conditions and procedures into numerical designations
(coding) is a complex activity and should not be undertaken
without proper training and practice”, a trainee is
given an opportunity to learn how to evaluate and interpret
various health records and reports in order to accurately
code the diagnoses and procedures according to the recognized
classification systems. In addition to this, course
work and practical exercises that we conduct include
medical terminology, anatomy, physiology, coding concepts
and operative reports coding. This helps in building
the level of confidence in the employees before they
actually begin live work.
To increase the curiosity of learning and make you feel
comfortable with the subject, let’s look at the Basics
of Coding.
The coding system is classified into procedure coding
“Current Procedural Terminology (CPT)” and diagnosis
coding “International Classifications of Diseases (ICD)”.
|
 |
| |
| Procedure
Coding |
| |
HCPCS has 3 levels of Coding System:
- Level I - CPT
- Level II - HCPCS-National Codes (A through
V)
- Level III - LOCAL codes start with W, X, Y
and Z
|
| |
| HCPCS
LEVEL 1 - CPT (Current Procedural Terminology) |
In
1966 the AMA issued the physicians' CPT. The first
edition was of four-digit numeric coding. In 1977
CPT expanded to five digits. The second edition
expanded CPT to a five-digit coding system with
narratives and included two digit modifiers. In
1983 Medicare's HCPCS system adopted the already
established CPT system for coding. CPT then became
the first level of HCPCS coding system. AMA updates
CPT annually.
|
| |
Basic
steps of CPT coding: |
| |
- Read the guidelines at the
beginning of each CPT section.
- Read carefully each procedure
statement listed on the charge slip, encounter
note, operative report, and laboratory or pathology
report to be coded. Documentation is the key
to the accurate coding. Code what is written,
don't assume about the condition.
- Refer to the index and look
at the main term for the procedure or service
document in the source document. This will include
one of the following: the action, the site,
the condition, the substance, synonyms, eponyms,
or abbreviation.
- Locate necessary sub terms
and follow any cross-reference mentioned in
the index.
- Entries in the CPT index provide
a single, two or more codes or a range of codes.
Any code or codes identified should be considered
tentative until checked in appropriate section
(e.g. medicine, surgery)
- Locate each tentative code
in the appropriate section. If its one code
read its description and makes it sure that
it accurately describes the service or procedure.
When code is within a range, read it carefully
and select the appropriate code as per the description.
- Review the code descriptions
of codes listed for the procedure or service
and any instructional notes.
- Assign the applicable main
code number and any add-on (+) or additional
codes needed to accurately complete the statement
being coded.
- If necessary, assign a modifier
to the code.
- Assign the code.
|
| |
| HCPCS
Level II CODING |
HCPCS codes are referred to National codes
and are published and updated by the CMS. This
coding system includes codes for non-physician
services and specific supplies. In addition
codes are used for the administration of drugs.
National codes consist of one alpha (A -V) and
followed by four digits. HCPCS modifiers are
either of 2 alphas or one alpha and followed
by one digit.
E.g. Codes for non-physician procedures, services,
specific supplies e.g. ambulance services, durable
medical services.
|
| |
|
HCPCS Level III CODING |
|
HCPCS Level 3 codes are "local"
codes assigned and maintained by individual state
Medicare carries. Those codes are also 5-digit
codes that start with a letter (W through Z). |
| Diagnosis
coding |
ICD-9-CM (International Classification
of Disease, Ninth Revision, Clinical Modification),
is a classification system in which diseases and
injuries are arranged in groups of related cases
for statistical purposes. Based on the WHO International
Classification of Diseases, the ICD system has
been revised periodically to meet the needs of
statistical data usage. In the United States,
the system has been expanded and modified (CM)
to meet unique clinical purposes
The responsibility for maintenance of the classification
system is shared between the NCHS (National Center
for Health Statistics) and CMS (Centre for Medicare
and Medicaid Services formerly known as HCFA).
|
| |
Basic
steps of ICD coding:
|
| |
- Identify the reason for the visit (e.g., sign,
symptom, diagnosis, condition to be coded)
- Always consult the Alphabetic Index, Volume
2, before turning to the tabular list.
- Locate the main entry term.
- Read and interpret any notes listed with the
main term.
- Review entries for modifiers.
- Interpret abbreviations, cross-references,
symbols and brackets.
- Choose a tentative code and locate it in the
tabular list.
- Determine whether the code is at the highest
level of specificity. .
- Consult the color-coding and reimbursement
prompts, including the age,sex and Medicare
as secondary payer edits. Refer to the key at
the bottom of the page for definitions of colors
and symbols.
- Assign the code.
|
|
| |
|
|
