Presenter – Krishna Sai

Madhur
- C.P.C, CCs, CPMA
 What is 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. 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 happens every time you see a healthcare provider. The
healthcare provider reviews your complaint and medical history, makes an expert
assessment of what’s wrong and how to treat you, and documents your visit.
That documentation is not only the patient’s ongoing record, it’s how the
healthcare provider gets paid.
 What Does A Medical Coder Do?
• Uses knowledge of medical terminology, anatomy and physiology,
diseases and classification systems to assign a diagnostic or procedural
code to a patient’s medical record.
• Reviews medical documentation to assign medical codes and ensure the
physician practices and hospitals get reimbursed from insurance
companies.
• Communicates with other healthcare personnel to clarify diagnoses or
obtain additional information.
• Enables insurance companies to account for money they reimburse to
physicians and practices, to help prevent fraudulent medical claims or
errors in payment.
 Medical Coding
Entry-Level Titles
Job listings include
Medical Coder
Outpatient Medical Coder
Entry-Level Coding Specialist
Coder I
Medical Coding Associate
CCA Cer tified Medical Coder
Health Information Technician
and more
 Medical Coder Cer tifications
• Two professional organizations, the American Health Information
Management Association (AHIMA), and the American Academy of
Professional Coders (AAPC), offer nationally recognized medical
coding certification exams.
• The Medical Coder Certificate program provides an opportunity for
students to take the AHIMA Certified Coding Associate (CCA) exam
in HITT 2246. The cost of the CCA certification exam is included in
the leaning materials for this course. If they choose to sit for the
exam, students can have the CCA coding certification upon
completion of the program.
• Successful completion of the program also provides a foundation for
students to prepare for the Certified Coding Specialist (CCS) and the
AAPC Certified Professional Coder (CPC) exam.
Note: Exams are administered by the credentialing organization at a testing center.
 Medical coders translate documentation into
standardized codes that tell payers the
following:
• Patient's diagnosis
• Medical necessity for treatments, services, or supplies the patient
received
• Treatments, services, and supplies provided to the patient
• Any unusual circumstances or medical condition that affected those
treatments and services
 Why is medical coding needed?
• The healthcare revenue stream is based on the documentation of what was learned,
decided, and performed.
• A patient's diagnosis, test results, and treatment must be documented, not only for
reimbursement but to guarantee high quality care in future visits. A patient's personal
health information follows them through subsequent complaints and treatments, and
they must be easily understood. This is especially important considering the hundreds
of millions of visits, procedures, and hospitalizations annually in the United States.
• The challenge, however, is that there are thousands of conditions, diseases, injuries, and
causes of death. There are also thousands of services performed by providers and an
equal number of injectable drugs and supplies to be tracked. Medical coding classifies
these for easier reporting and tracking. And in healthcare, there are multiple descriptions,
acronyms, names, and eponyms for each disease, procedure, and tool. Medical coding
standardizes the language and presentation of all these elements so they can be more
easily understood, tracked, and modified.
• This common language, mandated by the Health Information Portability and
Accountability Act (HIPAA), allows hospitals, providers, and payers to communicate
easily and consistently. Nearly all private health information is kept digitally and rests on
the codes being assigned.
 Types of codes used
• ICD-10-CM (International Classification of Diseases, 10th Edition, Clinically
Modified)
• ICD-10-CM includes codes for anything that can make you sick, hurt you, or kill
you. The 69,000-code set is made up of codes for conditions and disease,
poisons, neoplasms, injuries, causes of injuries, and activities being performed
when the injuries were incurred. Codes are “smart codes” of up to seven
alphanumeric characters that specifically describe the patient’s complaint.
ICD-10-CM is used to establish medical necessity for services and for tracking.
It also makes up the foundation of the MS-DRG system below.
• CPT (Current Procedure Terminology)
®

• This code set, owned and maintained by the American Medical Association,
includes more than 8,000 five-character alphanumeric codes describing
services provided to patients by physicians, paraprofessionals, therapists, and
others. Most outpatient services are reported using the CPT system.
®

Physicians also use it to report services they perform in inpatient facilities.

Here's a little behind the scene on the making of CPT codes.
®
•
T y p e s o f c o d e s u s e d
ICD-10-CM (International Classification of Diseases, 10th Edition, Clinically Modified)
• ICD-10-CM includes codes for anything that can make you sick, hur t you, or kill you. The 69,000-
code set is made up of codes for conditions and disease, poisons, neoplasms, injuries, causes of
injuries, and activities being performed when the injuries were incurred. Codes are “smar t codes” of
up to seven alphanumeric characters that specifically describe the patient’s complaint.
ICD-10-CM is used to establish medical necessity for services and for tracking. It also makes up the
foundation of the MS-DRG system below.
• CPT® (Current Procedure Terminology)
• This code set, owned and maintained by the American Medical Association, includes more than
8,000 five-character alphanumeric codes describing services provided to patients by physicians,
paraprofessionals, therapists, and others. Most outpatient services are repor ted using the CPT®
system. Physicians also use it to repor t services they perform in inpatient facilities. Here's a little
behind the scene on the making of CPT® codes.

• ICD-10-PCS (International Classification of Diseases, 10th Edition, Procedural Coding System)

• ICD-10-PCS is a 130,000 alphanumeric code set used by hospitals to describe surgical procedures
performed in operating, emergency depar tment, and other settings. Don’t let the procedural coding
intimidate you by taking the right approach to ICD-10-PCS coding.
• HCPCS Level II (Health Care Procedural Coding System, Level II)
• Developed originally for use by Medicare, Medicaid, Blue Cross/Blue Shield, and other providers to
repor t procedures and bill for supplies, HCPCS Level II’s 7,000-plus alphanumeric codes are used
for many more purposes, such as quality measure tracking, outpatient surgery billing, and academic
studies.
• CDT® (Code on D ental Procedures and Nomenclature)
• CDT® codes are owned and maintained by the American D ental Association (ADA). The five-character codes
start with the letter D and used to be the dental section of HCPCS Level II. Most dental and oral procedures
are billed using CDT® codes.
• ND C (National D rug Codes)
• The Federal D rug Administration's (FDA) code set is used to track and report all packages of drugs. The 10
-13 alphanumeric character smart codes allow providers, suppliers, and federal agencies to identify drugs
prescribed, sold, and used.
• Modifiers
• CPT® and HCPCS Level II codes use hundreds of alphanumeric two-character modifier codes to add clarity.
They may indicate the status of the patient, the part of the body on which a service is being performed, a
payment instruction, an occurrence that changed the service the code describes, or a quality element.
• MS -D RG and APC
• Two federal code sets used to facilitate payment deriving from those above systems are MS -D RG and
APCs. They rely on existing codes sets but indicate the resources consumed by the facility to perform the
service.
• MS -D RG (Medical S everity D iagnosis Related Groups)
• MS -D RGs are reported by a hospital to be reimbursed for a patient’s stay. The MS -D RG is based on the ICD
-10-CM and ICD -10-PCS codes reported. They are defined by a particular set of patient attributes which
include principal diagnosis, specific secondary diagnoses, procedures, sex, and discharge status. The
Centers for Medicare & Medicaid S ervices (CMS ) work with 3M HIS to maintain this data set.
• APC (Ambulatory Payment Categories)
• APCs are maintained by the Centers for Medicare & Medicaid S ervices (CMS ) to support the Hospital
Outpatient Prospective Payment S ystem (OPPS ). S ome outpatient services in a hospital, such as minor
surgery and other treatments, are reimbursed through this system.