Payment Coding & Place of Service Reporting: A Guide for Healthcare Professionals, Study notes of Medical Records

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MEDICAL CODING

Study Guide

CPC Exam Preparation Outline Required Study Materials

1. Medical Coding Training: CPC® (Current Year)
2. CPT® Professional Edition (Current Year)
3. ICD-10-CM Code Set (Current Year)
4. HCPCS Level II (Current Year) Exam Topics and Focus Areas CPT Code Categories (10,000 – 60,000 Series)  Surgical Procedures:  Integumentary System : Skin repair, lesion removal, grafts.  Musculoskeletal System : Fracture treatments, joint surgeries, musculoskeletal diagnostic procedures.  Digestive System : GI endoscopies, surgical procedures of the digestive tract.  Urinary System : Renal procedures, bladder surgeries.  Nervous System : Spinal surgeries, cranial and peripheral nerve procedures. Evaluation and Management (E/M)  Place of Service (POS) coding.  Preventive medicine services. Anesthesia  Time reporting.  Qualifying circumstances.  Physical status modifiers.  Surgical, diagnostic, and obstetric (OB) anesthesia services. Radiology  Diagnostic radiology (e.g., X-rays, CT scans, MRIs).  Interventional radiology (e.g., vascular procedures). Laboratory/Pathology

 Official ICD-10-CM Coding and Reporting Guidelines.  CPT® parenthetical notes.  Proper use of modifiers. Compliance and Regulatory  Medicare compliance for Parts A, B, C, and D.  Coding’s application to payment policy.  Place of service reporting.  Fraud and abuse prevention.  NCCI edits.  NCD (National Coverage Determinations) and LCD (Local Coverage Determinations).  HIPAA compliance.  Advance Beneficiary Notices (ABNs).  Relative Value Units (RVUs). Medicare Coverage (Parts A, B, C, D) Medicare Part A: o Covers hospital insurance including inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. o Eligibility: Individuals aged 65 and older, or certain disabled individuals, are eligible for Part A if they are U.S. citizens or permanent residents. Medicare Part B: o Covers medical insurance including outpatient care, preventive services, and some home health services. o Eligibility: Generally available to all individuals who have Part A. Medicare Part C (Medicare Advantage): o A private insurance plan that combines Part A and Part B benefits, often with additional benefits such as prescription drug coverage, vision, and dental care. o Eligibility: Available to individuals who are enrolled in both Part A and Part B. Medicare Part D: o Provides prescription drug coverage through private insurance plans approved by Medicare.

o Eligibility: Available to individuals with Medicare who want to add prescription drug coverage. Payment Coding and Place of Service Reporting  Payment Coding: o Healthcare providers must use appropriate codes (e.g., CPT, ICD- 10, HCPCS) to document diagnoses and services provided. o These codes are essential for accurate billing and reimbursement, ensuring that Medicare, Medicaid, and private insurers compensate providers appropriately.  Place of Service Reporting: o Correct Place of Service (POS) codes must be used to indicate the location where a service was provided. Common POS codes include:  11: Office  21: Inpatient Hospital  22: Outpatient Hospital  24: Ambulatory Surgical Center (ASC)  31: Skilled Nursing Facility (SNF) Three main types of codes: ICD codes, CPT codes, and HCPCS codes. These codes help doctors and hospitals explain what is wrong with a patient (diagnosis) and what they did to help the patient (procedures). Here's a simple breakdown: ICD Codes (International Classification of Diseases) ICD codes are like a universal language for describing illnesses, injuries, and causes of death. ICD Category : In ICD codes, the "category" is the first part of the code that explains the main problem, like a disease or injury. Modifier A modifier is an extra code added to a procedure code to give more information. For example, it might explain if a procedure was done on the left or right side of the body, or if the procedure was done more than once.

o Use the ICD-10-CM code that reflects the full description of the disease, including the site, severity, and type (e.g., acute or chronic). o Some codes are specific for conditions like diabetes, hypertension, and cancer and must be documented thoroughly. Codes for Symptoms and Signs : o When a definitive diagnosis has not been made, codes for symptoms or signs can be used (e.g., cough, chest pain). o If a specific condition is diagnosed later, use the appropriate code for the confirmed diagnosis. Combination Codes : o Some conditions are best represented by combination codes, which describe multiple aspects of a disease in one code (e.g., a disease and its associated complication). Sequelae Codes : o Sequelae codes are used to describe the aftereffects of an injury or illness, such as scars or chronic conditions resulting from an earlier disease. Excludes Notes : o Excludes 1 : These conditions are mutually exclusive and cannot be reported together. o Excludes 2 : These conditions may be reported together if they exist together. Laterality : o Many codes specify laterality, which means you need to indicate whether the condition affects the left, right, or bilateral sides of the body (e.g., left or right knee osteoarthritis). Obstetrics Guidelines : o Codes for pregnancy-related conditions should be used only when the patient is pregnant. In certain cases, a pregnancy- related diagnosis may influence the use of additional codes. Injury Codes :

o When coding for injuries, the nature of the injury and the site of the injury should be reported separately. o Use activity codes (e.g., playing football) when applicable to help describe the cause of injury. Code Assignment for Specific Conditions : o Follow the guidelines for specific conditions such as infections, injuries, or neoplasms to accurately assign codes. 7th Characters and Placeholder 'X' 7th Character: Some codes require a 7th character, especially those involving injuries or certain types of diseases.  Placeholder 'X': If the code is less than 6 characters but requires a 7th character, use 'X' as a placeholder to maintain the correct number of characters. Coding Conventions in ICD-10-CM Brackets []: Synonyms, alternative words. Parentheses (): Nonessential modifiers. “Includes” : Further definition of a category. “Code First”: Indicates the need to sequence a specific code first. Extensions: Added as the 7th character for encounter types (e.g., "A" for initial, "D" for subsequent, "S" for sequela). Placeholder 'X' : Used to fill empty characters when an extension is required but not all preceding characters are present. ICD-10-CM Manual Organization Divided into three volumes :

1. Volume I : Tabular index.
2. Volume II : Alphabetical index.

Topic Range External causes of morbidity V00-Y Health status and contact factors Z00-Z ICD-10-CM Coding Conventions and Structure Main Terms and Coding Conventions Alphabetic Index: The Alphabetic Index lists conditions and their corresponding codes in alphabetical order for quick reference. Tabular List: The Tabular List organizes codes numerically with detailed descriptions and guidelines to ensure accurate code assignment. Structure and Organization of ICD-10-CM Chapters: ICD-10-CM is divided into 22 chapters based on body systems or conditions. For example: Chapter 1: Certain Infectious and Parasitic Diseases Chapter 2: Neoplasms Chapter 7: Diseases of the Eye and Adnexa Each chapter includes codes and guidelines relevant to specific conditions. Section II: Guidelines for the selection of the principal diagnosis in inpatient settings. 7th Characters and Placeholder 'X' 7th Character: Some codes require a 7th character, especially those involving injuries or certain types of diseases.

 Placeholder 'X': If the code is less than 6 characters but requires a 7th character, use 'X' as a placeholder to maintain the correct number of characters. Nonessential Modifiers Definition: Nonessential modifiers are supplementary descriptive terms enclosed in parentheses after the main term. These words do not change the meaning or the coding of the condition. Purpose: To provide additional details about the condition without affecting the choice of code. Example: In the term "Appendicitis (acute)," the word "acute" is a nonessential modifier. The code for appendicitis remains the same whether "acute" is included or not in the diagnostic statement. Instructional Notes and Guidelines Includes Notes: Purpose: These notes provide further explanation or examples to define the content of a category.  Example: An Includes Note might clarify what conditions are covered by a particular category or provide specific examples. Excludes Notes: Excludes1: This indicates that the listed condition should not be coded together with the condition above the note. These conditions are mutually exclusive. o Example: "Congenital tuberculosis" and "Acquired tuberculosis" cannot be coded together. Excludes2: This means that while the condition listed is not included in the category, it

o Example: A manifestation code for diabetic retinopathy would be used only after coding for diabetes. Code Also Notes: o Purpose: Indicate that multiple codes may be needed to fully describe a condition. The sequence in which codes are listed depends on the severity or reason for the encounter. o Example: A Code Also note might suggest that both the underlying disease and its complication be coded to provide a complete picture of the patient's condition. Abbreviations in ICD-10-CM NEC (Not Elsewhere Classifiable): o Purpose: Used when a specific condition doesn't have a dedicated code within the ICD-10-CM system. The condition fits into a broader category but lacks a precise code. o Example: If a provider describes a condition without a more specific classification, NEC is used to indicate that it falls under a general category. NOS (Not Otherwise Specified): o Purpose: Applied when the clinical information is insufficient to assign a more specific code. o Example: If a diagnosis is made with insufficient detail, NOS is used to indicate the condition is unspecified. Punctuation Marks in ICD-10-CM Parentheses () o Purpose: Enclose supplementary terms that provide additional detail but do not affect the assigned code. o Example: Appendicitis (acute) – The word "acute" is a modifier that does not change the main diagnosis code. Brackets []

o Purpose: Enclose synonyms, alternative wording, or explanatory phrases. These are typically used in the Tabular List and for manifestation codes in the Alphabetic Index. o Example: Arthritis [osteoarthritis] – A synonym to aid coders in understanding the relationship between terms. Colons (:) o Purpose: Indicate that the description following a code is incomplete and additional terms are required to fully specify the condition. o Example: A description such as Diabetes mellitus : type 2 requires further information to specify the condition completely. Dashes (--) o Purpose: Indicate that a code requires additional characters to complete it. o Example: A code like M79-- for soft tissue conditions would require additional characters to complete the code. Relational Terms in ICD-10-CM "And" o Meaning: In ICD-10-CM, "and" means both "and" or "or" depending on the context. o Example: Hypertension and diabetes could refer to both conditions present simultaneously or just one, depending on the clinical documentation. "With" o Meaning: Implies a relationship between two conditions, where one condition is associated with or due to the other. o Example: Asthma with pneumonia suggests that the pneumonia is related to the asthma. "In" o Meaning: Indicates that one condition is present within another.

o Meaning: Recommends looking up the condition’s main term for the correct code assignment. o Example: See condition fracture directs to the relevant fracture codes. Summary of Key Points

1. Main Terms are listed in bold in the Alphabetic Index for easy reference.
2. The Tabular List provides detailed descriptions and guidelines for the proper use of codes.
3. 7th Character and Placeholder 'X' ensure correct formatting when codes require additional characters. 4. Nonessential Modifiers provide extra descriptive information but do not change the coding.
4. Excludes Notes clarify which conditions should be coded together or separately, indicating whether conditions can coexist or are mutually exclusive.
5. Includes Notes give further detail and examples for a category.
6. Code First/Use Additional Code Notes guide the correct sequencing of codes when one condition leads to another. CPT Codes (Current Procedure Terminology) CPT codes explain the medical treatments or services a patient received. CPT codes come in three categories: Category I: Most common medical procedures like surgeries, x-rays, and doctor visits. Category II: Tracks performance (optional codes). Category III: For new or experimental treatments. Some CPT codes need extra details, like whether the procedure was done on the left or right side. These extra details are called modifiers. Modifier Exempt (CPT) Some procedure codes cannot have modifiers added to them. These are a small group of codes, and they are listed in the CPT manual.

Pathology and Laboratory (CPT) This section of CPT codes covers tests that help doctors figure out what disease or illness a patient has. This includes blood tests, biopsies, and lab work. HCPCS Codes (Healthcare Common Procedure Coding System) HCPCS (pronounced "hick-picks") codes are used for things not covered by CPT codes. Who uses them: Medicaid, Medicare, and insurance companies use HCPCS codes for billing. HCPCS has two levels: Level I: Same as CPT codes. Level II : Extra codes for things like medical equipment or supplies. The Healthcare Common Procedure Coding System (HCPCS) is a vital coding system in medical billing and coding, particularly for Medicare, Medicaid, and other third-party payers. Here's a summary of the key points: What Is HCPCS?  Purpose : Developed by CMS to report medical services and supplies not fully covered by CPT.  Structure : Composed of three levels:

1. Level I : CPT codes (identical to AMA's CPT codes, used when billing Medicare or Medicaid).
2. Level II : Codes for non-physician services, durable medical equipment (DME), and drugs.
3. Level III : Local codes (phased out after HIPAA standardization). Level II HCPCS Codes  Represent services/products that CPT doesn't fully address.  Examples : Ambulance rides, prosthetics, orthotics, medical equipment, and non-oral drugs.

o CPT code : Describes the procedure. o HCPCS Level II code (J0135) : Captures the drug administered. Documentation and Updates  HCPCS manuals: o Feature symbols similar to CPT (e.g., a circle for new codes, a triangle for revised ones). o Include detailed drug tables for accuracy in coding medications.  CMS frequently updates HCPCS codes, and coders must stay current with guidelines. HCPCS Level II: Focus on Modifiers, Supplies, Medications, and Professional Services for Medicare Patients Structure and Format : o Always two characters long. o Can contain letters , numbers , or a combination of both. o Added to the end of HCPCS or CPT codes with a hyphen. Differentiating HCPCS and CPT Modifiers : o HCPCS modifiers : Contain at least one letter (e.g., -RT, -LT, - F1 ). o CPT modifiers : Numeric only (e.g., -50, -53 ). Purpose : o Provide additional functionality or information to the primary service/procedure. o Examples:  Indicating the location on the body (e.g., -LT, -RT ).

 Clarifying a specific scenario (e.g., -QM for ambulance services).  Modifying reimbursement claims (e.g., -GA for waiver of liability). Functional vs. Informational Modifiers Functional Modifiers : o Directly impact reimbursement. o Examples: -LT (left side), -RT (right side), -53 (discontinued procedure). Informational Modifiers : o Provide additional context but do not change payment. o Examples: -E1 (upper left eyelid), -F5 (right hand, thumb). Modifiers in HCPCS Level II Modifiers provide additional information about the service or supply provided, ensuring claims are accurately processed and reimbursed. They can be "informational" or "functional," depending on their purpose. Examples of HCPCS Level II Modifiers:  LT/RT : Left side (LT) or right side (RT) to specify the side of the body where a procedure was performed.  E1–E4 : Indicate which eyelid was treated: o E1 : Upper left. o E2 : Lower left. o E3 : Upper right. o E4 : Lower right.  GA : Indicates a waiver of liability (e.g., Advance Beneficiary Notice signed by the patient).  KX : Confirms specific requirements have been met for Medicare claims.  NU : New equipment (used for durable medical equipment).