Centre for Health Management and Research,
IGMPI
Medical Coding
By Prof.- Dr. Isha Phadke
Centre for Health Management and Research, IGMPI
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Medical Coding
• Medical coding is the transformation of healthcare
diagnosis, procedures, medical services, and
equipment into universal medical alphanumeric codes.
• The diagnoses and procedure codes are taken from
medical record documentation, such as transcription of
physician's notes, laboratory and radiologic results, etc.
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Medical Terminology
- It is the term that is beneficiary to correctly explain the
human body and associated components, conditioned,
processes and procedures in a scientific manner.
- Many of the words used by physicians, surgeons, and
other healthcare providers consist of Greek and Latin root
words that are combined to create a poly-syllabic term
that carries a specific meaning.
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• For Example,
– Hepato – in Greek means, Liver.
– Megaly – Latin word for enlarged
Thus a patient diagnosed with hepatomegaly is
someone who has been found to have an
abnormally large liver
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Importance of Medical Coding
• Medical coding professionals help ensure the codes are applied correctly
during the medical billing process, which includes abstracting the
information from documentation, assigning the appropriate codes, and
creating a claim to be paid by insurance carriers.
• Medical coding systems have a vital role to:-
– play in the collection of general medical statistical data
– medical reimbursement
– hospital payments
– quality review
– benchmarking measurement.
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History of Medical Coding
• In 1948, the World Health Organisation (WHO) took
over the classification system and created the
International Classification of Disease (ICD), which it
updates every 10 years.
• He latest version, ICD-10, is used worldwide except in
the U.S., which will fully adopt it in 2015.
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History of Medical Coding
• Other classification system were created in the U.S. for
domestic purposes. In 1966, the American Medical
Association created the Common Procedural Terminology
(CPT) set, which it updates every year. CPTs describe
medical services and procedures.
• In 1970s, the federal government released the Healthcare
Common Procedure Coding System (HCPCS), which
identified supplies and drugs for Medicare payment.
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Advantages
- Accurate Billing and Reimbursement
- Streamlined Workflow
- Data Analysis and Research
- Insurance Claims Processing
- Compliance with Regulations
- Improved Patient Care
- Facilitates Communication
- Efficient Record-Keeping
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Disadvantages
• Complexity of Coding Systems
• Regular Updates and Revisions
• Potential for Coding Errors
• Increased Administrative Burden
• Training and Certification Costs
• Potential for Fraud and Abuse
• Risk of Data Breaches
• Potential for Over coding or Under coding
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Types of Medical Coding
- ICD is primarily used to code and classify diseases,
conditions, and other health-related problems. It
provides a standardized way of documenting and International
Classification
reporting diseases and health conditions. Disease (ICD)
- CPT is developed and maintained by the American
Medical Association (AMA). It is used to code and
Current
describe medical procedures and services Procedural
Terminology
performed by healthcare providers.
- HCPCS is used for coding procedures, services, and
Healthcare
supplies not covered by CPT. It includes codes for Common
Procedure
durable medical equipment, prosthetics, orthotics, Coding System
(HCPCS)
and supplies, as well as certain medications.
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ICD
- International Classification of Diseases, or ICD codes.
- This code set was established by the World Health Organization (WHO) in the late
1940s.
- These are diagnostic codes that create a uniform vocabulary for describing the
causes of injury, illness and death.
- It's been updated several times in the 60- plus years since it's inception.
- For example, the code that's currently in use in the United States is ICD-10-CM.it
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.
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• To review: the first digit of an ICD-10-CM code is always an alpha the
second digit is always numeric and digits three to seven may be alpha or
numeric.
• Here's a simplified look at ICD-10-CM's format.
– A01 - {Disease}
– A01.0 {Disease] of the lungs
• A01.01... simple
• A01.02... complex
– A01.020... affecting the trachea
• A01.021 ... affecting the cardiopulmonary system
– A01.021A... initial encounter
• A01.021D ... subsequent encounter
• A01.021S... sequela
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ICD – 10 : Chapters
The following table lists the chapter number (using Roman numerals), the code range of each
chapter, and the chapter's title from the international version of the ICD-10
Chapter Block Title
Certain infectious and parasitic
I A00–B99
diseases
II C00–D48 Neoplasms
Diseases of the blood and
blood-forming organs and
III D50–D89
certain disorders involving the
immune mechanism
Endocrine, nutritional and
IV E00–E90
metabolic diseases
Mental and behavioural
V F00–F99
disorders
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Chapter Block Title
VI G00–G99 Diseases of the nervous system
VII H00–H59 Diseases of the eye and adnexa
VIII H60–H95 Diseases of the ear and mastoid process
IX I00–I99 Diseases of the circulatory system
X J00–J99 Diseases of the respiratory system
XI K00–K93 Diseases of the digestive system
Diseases of the skin and subcutaneous
XII L00–L99
tissue
Diseases of the musculoskeletal system
XIII M00–M99
and connective tissue
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XIV N00–N99 Diseases of the genitourinary system
XV O00–O99 Pregnancy, childbirth and the puerperium
Certain conditions originating in the perinatal
XVI P00–P96
period
Congenital malformations, deformations and
XVII Q00–Q99
chromosomal abnormalities
Symptoms, signs and abnormal clinical and
XVIII R00–R99
laboratory findings, not elsewhere classified
Injury, poisoning and certain other
XIX S00–T98
consequences of external causes
XX V01–Y98 External causes of morbidity and mortality
Factors influencing health status and contact
XXI Z00–Z99
with health services
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CPT
Current Procedure Terminology
CPT 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.
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CPT
- New editions are released each October, with CPT 2021 being in use since
October 2021. It is available in both a standard edition and a professional
edition.
- The CPT code set describes medical, surgical, and diagnostic services and is
designed to communicate uniform information about medical services and
procedures among physicians, coders, patients, accreditation organizations,
and payers for administrative, financial, and analytical purposes
- 99214 can be used for an office visit.
- 99397 can be used for a preventive exam if you are over age 65.
- 90658 can be used for the administration of a flu shot.
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Categories
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
• The third category of CPT codes corresponds to emerging medical
technology.
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Category I - CPT
The six sections of the CPT codebook are, in order:
- Evaluation and Management
- Anesthesiology
- Surgery
- Radiology
- Pathology and Laboratory
- Medicine
Here's a quick look at the sections of Category I CPT codes, as arranged by
their numerical range.
- Evaluation and Management: 99201 - 99499
- Anesthesia: 00100 - 01999; 99100 - 99140
- Surgery: 10021 - 69990
- Radiology: 70010 - 79999
- Pathology and Laboratory: 80047 - 89398
- Medicine: 90281 - 99199; 99500 - 99607
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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 (Center for Medicare and Medicaid Services - 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.
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Levels of HCPCS
- The HCPCS code set is divided into three levels.
- Level I consists of the American Medical Association's Current Procedural Terminology
(CPT) and is numeric.
- Level II codes are alphanumeric and primarily include non-physician services such as
ambulance services and prosthetic devices, and represent items and supplies and non-
physician services, not covered by CPT-4 codes (Level I).
- Level III codes, also called local codes, were developed by state Medicaid agencies,
Medicare contractors, and private insurers for use in specific programs and jurisdictions.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) instructed CMS
to adopt a standard coding systems for reporting medical transactions. The use of Level
III codes was discontinued on December 31, 2003, in order to adhere to consistent
coding standards.
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BASIC STEPS IN CODING
- Review the health record.
- Identify the diagnoses and procedures to be coded.
- Identify the principal diagnosis and the principal procedure.
- Identify main term(s) in the Alphabetic Index.
- Review any sub terms under the main term in the Index.
- Verify in the Tabular List the code(s) selected from the Index.
- Refer to any instructional notation in the Tabular.
- Assign codes to the highest level of specificity.
- Assign codes to the diagnoses and procedures, reporting all applicable codes and
sequence in accordance with the guidelines.
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Suppose a patient visits a healthcare provider for a
comprehensive physical examination, and the provider
diagnoses the patient with hypertension.
• ICD Code for Hypertension:
– Use the ICD-10 code for hypertension, such as I10 (essential
primary hypertension), based on the documentation.
• CPT Code for Comprehensive Physical Examination:
– Use the appropriate CPT code for the comprehensive physical
examination, such as 99386 (an intricate preventive evaluation
and management (E/M))
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Thank you
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