for MBA HEALTHCARE AND MHA

1. Presented by
ASIF
Jmc,hcm 4th sem

2.  AAPC describes medical coding as "the
transformation of healthcare diagnosis,
procedures, medical services and equipment
into universal medical alphanumeric codes.“

3.  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.

4. TYPES OF CODE

5. TYPES OF
CODE
ICD
CLASSIFICATION
CPT
HCPCS

6. •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.
ICD
•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.

7. 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

8. Range Topic
A00-B99 Certain infections and parasitic diseases
C00-D49 Neoplasms
D50-D89
Diseases of the blood and blood-forming
organs and certain disorders involving
the immune mechanism
E00-E89
Endocrine, nutritional and metabolic
diseases
F01-F99 Mental, Behavioral and
Neurodevelopmental disorders
G00-G99 Diseases of the nervous system
H00-H59 Diseases of the eye and adnexa
H60-H95 Diseases of the ear and mastoid process
I00-I99 Diseases of the circulatory system
J00-J99 Diseases of the respiratory system
K00-K95 Diseases of the digestive system
L00-L99 Diseases of the skin and subcutaneous
tissue

9. M00-M99
Diseases of the musculoskeletal
system and connective tissue
N00-N99 Diseases of the genitourinary system
O00- O9A
Pregnancy, childbirth, and
puerperium
P00-P96 Certain conditions originating in the
perinatal period
Q00-Q99
Congenital malformations,
deformations and chromosomal
abnormalities
R00-R99
Symptoms, signs, and abnormal
clinical laboratory findings, not
elsewhere classified
S00-T88
Injury, poisoning, and certain other
consequences of external causes
V00-Y99 External causes of morbidity
Z00-Z99
Factors influencing health status and
contact with health services

10. ICD-10-CM
Injury: Closed fracture of distal phalanx of right index finger
S00-T88 – Injury, poisoning and certain other consequences of external causesS60-S69 –
Injuries to the wrist, hand and fingers
 S62 – Fracture at wrist and hand level
o S62.0 – fracture at navicular [scaphoid] bone of wrist
o …
o S62.5 – fracture of thumb
o S62.6 – fracture of other and unspecified finger(s)
 S62.60 – fracture of unspecified phalanx of finger
 S62.61 – displaced fracture of proximal phalanx of finger
 …
 S62.63 – displaced fracture of distal phalanx of finger
 S62.630 – Displaced fracture of distal phalanx of right index finger
 S62.630A – … initial encounter for closed fracture
 S62.630B – … initial encounter for open fracture
 S62.630D – … initial encounter for fracture with routine healing
 Etc.

11. ICD-9-CM CHAPTERS
• Chapter 1: Infectious and Parasitic Diseases (001-139)
• Chapter 2: Neoplasms (140-239)
• Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders
(240-279)
• Chapter 4: Diseases of Blood and Blood Forming Organs (280-289)
• Chapter 5: Mental Disorders (290-319)
• Chapter 6: Diseases of Nervous System and Sense Organs (320-389)
• Chapter 7: Diseases of Circulatory System (390-459)
• Chapter 8: Diseases of Respiratory System (460-519)
• Chapter 9: Diseases of Digestive System (520-579)
• Chapter 10: Diseases of Genitourinary System (580-629)
• Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium (630-679)
• Chapter 12: Diseases Skin and Subcutaneous Tissue (680-709)
• Chapter 13: Diseases of Musculoskeletal and Connective Tissue (710-739)
• Chapter 14: Congenital Anomalies (740-759)
• Chapter 15: Newborn (Perinatal) Guidelines (760-779)
• Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799)
• Chapter 17: Injury and Poisoning (800-999)

12. Types of ICD-9 codes:
Numeric Codes:
• The selection of codes 001.0 through 999.9 is frequently used to describe
the reason for the encounter. These codes are from the section of ICD-9-
CM for the classification of diseases and injuries.
• Alpha-numeric Codes:
• V-codes are used to deal with encounters for circumstances other than a
disease or injury. The Supplementary Classification of factors Influencing
Health Status and Contact with Health Services (V01.0 – V83.89) is
provided to deal with occasions when circumstances other than a disease
or injury are recorded as diagnoses or problems.
• E-codes, from the subsection Supplementary Classification of External
Causes of Injury and Poisoning (E800 – E999) are used to code how an
injury occurred.

13.  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.
CPT

14.  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.

15. 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
The six sections of the CPT codebook are, in order:
 Evaluation and Management
 Anesthesiology
 Surgery
 Radiology
 Pathology and Laboratory
 Medicine

16.  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.
 The HCPCS code set is divided into two levels. The first of
these levels is identical to the CPT codes that we covered
earlier.
 Level II is a set of alphanumeric codes that is divided into
17 sections, each based on an area of specificity, like
Medical and Laboratory or Rehabilitative Services.
HCPCS

17. THREE LEVELS OF HCPCS:
 Level 1 – CPT codes
 5 digit numeric codes contained in CPT-4 published by the AMA.
 describes physician and hospital outpatient procedures and services.
 Level 2 – National Codes
 Alphanumeric codes assigned by CMS.
 These 5 digit codes begin with an alphabetical character, A to V and
are use to report services or supplies that include ambulance,
dental, medical & other unique services, supplies (DME, orthotics,
prosthetic), drugs, or procedures not included in CPT-4.
 Include codes for non-physician procedures, such as ambulance
services, durable medial equipment, specific supplies, and
administration of injectable drugs

18.  Level 3 – Local Codes
 Alphanumeric codes developed & assigned by the
local Medicare carrier or fiscal intermediary.
 Local codes are five-digit, alphanumeric codes
using the letters S, and W through Z.
 Local codes are used to denote new procedures
or specific supplies for which there is no national
code.

19. Other Types of Coding Systems :
• Diagnostic Codes
– Are used to determine diseases, disorders, and symptoms
– Can be used to measure morbidity and mortality
– Examples: ICD-9-CM, ICD-10
• Procedural codes
– They are numbers or alphanumeric codes used to identify
specific health interventions taken by medical professionals.
– Examples: ICPM, ICHI
• Pharmaceutical codes
– Are used to identify medications
– Examples: AT, NDC
• Topographical codes
– Are codes that indicate a specific location in the body
– Examples :ICD-O, SNOMED

20.  The purpose of coding guidelines is to provide timely
directions for accuracy and consistency in coding and
to promote uniformity among hospitals in reporting
ICD-9- CM coded clinical information. The task of
reexamining coding guidelines to ensure that they are
clear and complete and of developing additional
guidelines where they are needed has been assigned
to a subcommittee of the Coding Clinic for ICD-9-CM
Editorial Advisory Board. The 7 coding guidelines
appearing in this issue have been reviewed by the
Editorial Advisory Board and have been approved by
all members of the cooperating parties (American
Medical Record Association, Health care Financing
Administration, National Center for Health Statistics,
and the American Hospital Association) to the Central
Office on ICD-9-CM maintained by the American
Hospital Association.

21.  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 subterms under the main term in the Index.
 Follow any cross-reference instructions, such as “see
also”
 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.

22.  Medical Terminology.
 Anatomy & Physiology Basics .
 Analytical skills.
 ICD-9,ICD-10, CPT & HCPCS coding.
 LCD & NCCI Guidelines.
 HIPAA Compliance.
 Medical Billing concepts.
 Detail oriented & Self motivated.

23.  Any Medical , Paramedical & Science
graduates & Post graduates.
 MBBS, BAMS, BHMS, BDS,BUMS,Pharmacy ,
Nursing, Physiotherapy.
 Biotechnology, Microbiology, Biochemistry ,
Zoology, Anatomy, Physiology ,Bioinformatics,
Health education, Chemistry, Biomedical.

24. The AAPC and the AHIMA are two of the
top professional organizations granting
medical coding and billing certification. Read
on to learn more about each organization
and the types of medical coding certification
available.

25.  By far the largest organization of coders is the American
Association of Professional Coders (AAPC). The AAPC offers
general and specialized medical coding and billing certification.
 A general certification is the best place to start as a new medical
coder. The AAPC’s Certified Professional Coder (CPC)
exam remains the most popular certification in the field.
 The American Association of Professional Coders recommends
that all persons interested in the CPC exam have an associate
degree.
 This general certification covers several different aspects of the
coding profession, including diagnostic codes, procedure codes
for over a dozen specific fields, coding guidelines, medical
terminology and more. The AAPC also offers four other core
certification options, including Certified Outpatient
Coding (COC™), Certified Inpatient Coder (CIC™), Certified Risk
Adjustment Coder (CRC™), and Certified Professional Coder-
Payer (CPC-P®).

26.  The American Health Information
Management Association, or AHIMA, is
another large professional organization for
coders. Like the AAPC, AHIMA offers a
number of medical coding and billing
certification options, including the Certified
Coding Assistant (CCA), Certified Coding
Specialist (CCS), and Certified Coding
Specialist – Physician-based (CCS-P)

27.  The AMBA is a professional organization
dedicated entirely to the medical billing
field. The AMBA has been certifying medical
billing professionals through their Certified
Medical Reimbursement Specialist (CMRS)
exam for over a decade.
AMBA (American Medical Billing Association)

28.  This exam, much like the CPC exam is a large,
comprehensive exam that tests individuals on all
phases of the medical billing process. Students
must be a member of AMBA to take the exam.
Membership in AMBA costs $99 annually.
 The exam is comprised of 16 sections, covering:
•CMS 1500 Claim Form
•Insurance
•Insurance Carriers
•Acronyms/Terms in
Healthcare Use
•Compliance and HIPPA
•Fraud and Abuse
•Managed Care
•General
•Case Studies
•Medical Terminology
•Anatomy and Physiology
•Information Technology
and Computers
•Web and Information
Technology
•ICD-10-CM Coding
•CPT Coding
•EDI Transactions and
Clearinghouses

29.  As the largest organization of health
information professionals, the American
Association of Professional Coders focuses
mainly on medical coding, but they do offer
a medical billing certification.
 This certification, which is earned upon the
completion of the Certified Professional
Biller (CPB™) exam, tests the medical biller
on every facet of the billing profession. Like
the CPC™ discussed in Course 1-4, this
certification is a rigorous but well-respected
benchmark for professionals in the health
information field.
AAPC

30. The CPB™ exam takes five hours and 40
minutes to complete, and consists of 200
questions focused on:
 Types of insurance
 Billing regulations
 HIPAA and compliance
 Reimbursement and collections
 Billing
 Coding
 Case Studies

31.  Certified Professional Coder (CPC)
 Certified Professional Coder – Outpatient
Hospital (CPC-H)
 Certified Professional Coder – Payer (CPC-P)
 Certified Interventional Radiology
Cardiovascular Coder (CIRCC)
 Certified Professional Medical Auditor (CPMA)

32.  • Certified Coders are in high demand
throughout the healthcare industry.
 • Healthcare/IT companies (KPO,BPO)
 • Hospitals/Clinics.
 • Insurance Firms.
 • Medical Coding Executive
 • Coding specialist
 • Coding Supervisor
 • Coding consultant
 • Compliance audit specialist
 • Compliance officer
 • Medical records supervisor
 • Insurance Specialist

33.  ASC – Ambulatory Surgical Center
 CMS – Centers for Medicare & Medicaid
 CPT-4 – Current Procedural Terminology, 4th Edition
 DRG – Diagnosis Related Groups
 ESRD – End Stage Renal Disease
 HCPCS – Healthcare Common Procedure Coding System
 ICD9-CM – International Classification Of Diseases, Vol. 9,
Clinical Modification
 RVU – Relative Value Unit
 LCD – Local Coverage Determination
 LMRP – Local Medical Review Policy
 RBRVS – Resource-Based Relative Value Unit
 NEC : “Not elsewhere classifiable” or other specified code
 NOS : “Not otherwise specified” or unspecified