HI 205 Chapter10.4ed rev6 6-18

1. Chapter 10
Introduction to
Coding and
Reimbursement

2. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 2
Nomenclatures &
Classification Systems
• Medical nomenclature
• Coding/classification system

3. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 3
Nomenclatures
• Basle Nomina Anatomica
• Standardized Nomenclature of Disease
(SND)
• Standardized Nomenclature of Diseases and
Operations (SNDO)
• Systematized Nomenclature of Pathology
(SNOP)
(Continues)

4. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 4
Nomenclatures (Continued)
• Systematized Nomenclature of Medicine
(SNOMED)
• Current Medical Information and
Terminology (CMIT)
• Unified Medical Language System (UMLS)

5. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 5
Medical Classification &
Coding Systems
• London Bills of Mortality
• Nosologia Methodica
• Bertillon International Statistical
Classification of Causes of Death
• Manual of the International Statistical
Classification of Diseases, Injuries, and
Cause of Death (ICD-6)
(Continues)

6. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 6
Medical Classification &
Coding Systems (Continued 1)
• International Classification of Diseases
adapted for use in US (ICDA)
• Diagnostic and Statistical Manual of Mental
Disorders (DSM)
• Current Procedural Terminology (CPT)
• International Classification of Diseases for
Oncology, third edition (ICD-0-3)
(Continues)

7. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 7
Medical Classification &
Coding Systems (Continued 2)
• International Classification of Injuries,
Disabilities, and Handicaps (ICIDH)
• HCPCS Level II (national codes)
• Current Dental Terminology (CDT)
• National Drug Codes (NDC)
• Alternative Billing Codes (ABCcodes™)

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accessible website, in whole or in part. 8
Third-Party Payers
• Blue Cross and Blue Shield (BCBS)
• Commercial payers
• Employer self-insurance plans
• Government-sponsored programs
• Managed care
• Workers’ compensation

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accessible website, in whole or in part. 9
Health Care Reimbursement
Systems
• Medicare Severity DRGs (MS-DRGs)
• Resource Utilization Groups (RUG)
• Home Health Resource Groups (HHRG)
• Ambulatory Payment Classifications (APC)
• Inpatient Rehabilitation Facility Prospective
Payment System (IRF PPS)
(Continues)

10. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 10
Health Care Reimbursement
Systems (Continued 1)
• Long-Term Care Diagnosis-Related
Groups (LTC DRG)
• Clinical Laboratory Fee Schedule
• Durable Medical Equipment, Prosthetics/
Orthotics, and Supplies (DMEPOS)
fee schedule
• Resource Based Relative Value Scale (RBRVS)
(Continues)

11. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 11
Health Care Reimbursement
Systems (Continued 2)
• Ambulatory Surgical Center Payments (ASCs)
• Ambulance Fee Schedule
• End-Stage Renal Disease Composite
Payment Rate System

12. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 12
Case Mix Analysis & Severity
of Illness Systems
• Case mix: types and categories of patients
• Case mix index: indicates the average weight
of a hospital’s diagnosis-related groups
• Severity of illness physiologic complexity of
extent and interaction of patient’s disease
• Critical pathways

13. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 13
Processing Insurance Claims
• Chargemaster and encounter form
• CMS-1450 (or UB-04) and CMS-1500
• Electronic data interchange (EDI)

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accessible website, in whole or in part. 14
Fraud & Abuse
• Medical necessity
• Medicare Fraudulent practices regulated by
– The Civil Monetary Penalties Act
– Department of Health and Human Services
– Office of the Inspector General
– The National Correct Coding Initiative
• Never Events
• Hospital-Acquired conditions and Present on
Admission Indicator Reporting