This document provides an overview of a medical coding course. The course introduces students to medical coding principles including diagnostic and procedural coding systems. Students will learn medical terminology, how to code diagnoses and procedures, and how to use medical coding software. The goal is to prepare students for entry-level medical coding positions. Key topics covered include ICD, CPT, and HCPCS coding systems, medical terminology, anatomy, coding guidelines, software, and ethical considerations.

1. Coding for Home Health
Medical Coding for Health Professionals Certification

2. Course Objectives
This course is designed to introduce students to the fundamentals of medical coding.
Students will learn the principles of medical coding, including the International
Classification of Diseases (ICD), Current Procedural Terminology (CPT), and
Healthcare Common Procedure Coding System (HCPCS). The course will cover the
basics of diagnostic and procedural coding, medical terminology, and the use of
medical coding software. By the end of the course, students will have a strong
foundation in medical coding and be prepared for entry-level positions in the field.

3. Course Objectives
Understand the role of medical coding in healthcare settings.
Gain proficiency in medical terminology related to coding.
Develop skills in diagnostic and procedural coding using ICD, CPT, and HCPCS
systems.
Learn to navigate and utilize medical coding software.
Prepare for entry-level positions in medical coding or continued education in the field.

4. Introduction To Medical Coding
The Role of Medical Coding in Healthcare
Medical coding is the process of translating medical documentation into standardized
codes that represent diagnoses, procedures, and treatments. These codes are
essential for maintaining accurate health records, facilitating communication between
healthcare providers, ensuring proper reimbursement, and analyzing healthcare data
for research and public health purposes.

5. What is Medical Coding?
Medical coding is the process of assigning standardized codes to diagnoses, procedures, and
treatments. These codes are used to communicate crucial information among healthcare
providers, insurance companies, and government agencies. The primary coding systems used in
the United States are:
1. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM):
Used for diagnosis coding in all healthcare settings.
2. International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-
PCS): Used for inpatient hospital procedure coding.
3. Current Procedural Terminology (CPT): Used for coding medical procedures, services, and
treatments provided by physicians and other healthcare professionals.
4. Healthcare Common Procedure Coding System (HCPCS): Used for coding medical supplies,
equipment, and services not covered by CPT codes.

6. What is Medical Billing?
Medical billing is the process of submitting and following up on claims with health insurance
companies to receive payment for services provided by healthcare providers. The medical billing
process involves several key steps:
1. Patient registration and insurance verification: Gathering patient information and verifying
insurance coverage.
2. Charge entry: Assigning appropriate codes and charges for services provided.
3. Claims submission: Submitting claims to insurance companies for reimbursement.
4. Payment posting: Recording payments received from insurance companies and patients.
5. Denial management and appeals: Addressing denied claims, correcting errors, and re-
submitting claims as necessary.
6. Patient billing and collections: Issuing invoices to patients for their portion of the payment
and managing collections as needed.

7. Overview In Coding Systems
There are three primary coding systems used in medical coding:
1. International Classification of Diseases (ICD): This system is used to code diagnoses and is
maintained by the World Health Organization (WHO). The most recent version, ICD-11, is in use in
many countries, while others continue to use ICD-10.
2. Current Procedural Terminology (CPT): Developed by the American Medical Association (AMA),
CPT codes are used to represent medical procedures, services, and treatments. CPT codes are
updated annually and are the standard for outpatient and office-based services in the United States.
3. Healthcare Common Procedure Coding System (HCPCS): This system is used to code procedures,
supplies, and equipment not covered by CPT codes. HCPCS codes are maintained by the Centers
for Medicare and Medicaid Services (CMS) and are primarily used for billing.

8. Introduction to Medical Terminology
In medical coding, understanding medical terminology is critical. This includes the ability to break
down complex terms into their component parts and recognize common prefixes, suffixes, and
root words. Some examples of medical terminology include:
● Prefixes: These are added to the beginning of a root word to modify its meaning. For
example, the prefix "tachy-" means fast, as in "tachycardia" (fast heartbeat).
● Suffixes: These are added to the end of a root word to modify its meaning. For example, the
suffix "-itis" means inflammation, as in "bronchitis" (inflammation of the bronchi).
● Root words: These are the core components of medical terms and typically describe a body
part or function. For example, the root word "cardio" refers to the heart, as in "cardiology"
(the study of the heart).

9. Learn Your Medical Terminology
Understanding and utilizing medical terminology is a crucial skill for
accurate and efficient medical coding. In the next chapter, we will delve
deeper into medical terminology, exploring the various body systems and
their associated terms, as well as common medical abbreviations.

10. Prefix and Suffix Sample

16. Body Systems and Their Functions
To effectively use medical terminology in coding, it is important to have a basic
understanding of the human body's systems and their functions. Here is an overview of the
major body systems:
Integumentary System: Composed of the skin, hair, nails, and glands, this system
provides protection, regulates body temperature, and facilitates sensation.
Skeletal System: Includes bones, cartilage, and joints, providing support, movement,
and protection for internal organs.
Muscular System: Comprised of muscles and tendons, it enables body movement,
maintains posture, and generates heat.

17. Body Systems and Their Functions Cont.
Nervous System: Consists of the brain, spinal cord, and nerves, and is
responsible for controlling and coordinating body functions, as well as
processing sensory information.
Endocrine System: Composed of glands and hormones, this system
regulates growth, metabolism, and reproduction.
Cardiovascular System: Includes the heart, blood vessels, and blood, and is
responsible for transporting nutrients, oxygen, and waste products
throughout the body.

18. Body Systems and Their Functions Cont.
Respiratory System: Comprised of the lungs, airways, and muscles, this system facilitates
the exchange of oxygen and carbon dioxide.
Digestive System: Consists of the gastrointestinal tract and accessory organs, and is
responsible for breaking down food, absorbing nutrients, and eliminating waste.
Urinary System: Composed of the kidneys, ureters, bladder, and urethra, this system filters
blood and removes waste products in the form of urine.
Reproductive System: Includes the genitals, gonads, and associated glands, and is
responsible for producing offspring and regulating sex-specific functions.

19. Medical Prefixes, Suffixes and Roots
A strong grasp of medical prefixes, suffixes, and root words
is crucial for accurate coding. Familiarize yourself with the
following common examples:

20. Medical Prefixes
● Hyper-: Excess, above normal (e.g., hypertension)
● Hypo-: Deficiency, below normal (e.g., hypoglycemia)
● Dys-: Abnormal, difficult (e.g., dyspnea)
● Sub-: Under, below (e.g., subcutaneous)
● Pre-: Before (e.g., prenatal)

21. Medical Suffixes
● ectomy: Surgical removal (e.g., appendectomy)
● -ology: Study of (e.g., cardiology)
● -pathy: Disease (e.g., neuropathy)
● -scopy: Visualization, examination (e.g., endoscopy)
● -plasty: Surgical repair or reconstruction (e.g., rhinoplasty)

22. Medical Roots
● Cardio: Heart (e.g., cardiovascular)
● Gastro: Stomach (e.g., gastrectomy)
● Neuro: Nerve (e.g., neurology)
● Pulmo: Lung (e.g., pulmonary)
● Hemo: Blood (e.g., hematology)

23. Reading Medical Abbreviations
When you are reading the medical records to code, it is very important to know
the medical abbreviations commonly in use.
● BP: Blood pressure
● CBC: Complete blood count
● ECG/EKG: Electrocardiogram
● IV: Intravenous
● PO: By mouth (orally)

24. Applying the Medical Terminology to Coding
Understanding and correctly using medical terminology is essential for
efficient and accurate medical coding. We will explore the International
Classification of Diseases (ICD) coding system, focusing on its structure,
conventions, and diagnostic coding guidelines.

25. Intro to ICD 10/11 Coding
The International Classification of Diseases (ICD) is a standardized
coding system developed and maintained by the World Health
Organization (WHO) to classify diseases, disorders, injuries, and other
health-related conditions. It is used worldwide for morbidity and mortality
statistics, reimbursement systems, and health care management. In this
chapter, we will focus on ICD-11, the most recent version, although some
countries may still use ICD-10.

26. ICD Coding Structure and Conventions
ICD codes are organized hierarchically, starting with broad categories and becoming more
specific as additional characters are added. The ICD-11 coding structure consists of the
following components:
1. Category: The first three characters of the code represent a specific category of
diseases or health conditions.
2. Extension: Additional characters can be added to provide more information about the
severity, location, or other aspects of the condition.
3. Modifiers: Modifiers can be used to further refine the code, indicating details such as
etiology, comorbidities, or other clinical details.

27. ICD Codes
ICD-11 codes are alphanumeric and can include up to seven characters. Some coding
conventions to keep in mind are:
● Placeholder characters: These are used when a code requires additional characters for
specificity but none are available. The placeholder 'X' is used to fill the empty spaces.
● Excludes notes: These indicate when certain conditions should not be coded together,
directing the coder to use a different code instead.
● Inclusion terms: These are additional terms or synonyms that may be used to describe
the same condition but are not part of the code description.

28. Diagnostic Coding Guidelines
When assigning ICD codes, it is important to follow established guidelines to
ensure accurate and consistent coding. Some key diagnostic coding guidelines
include:
Code to the highest level of specificity: Always select the most specific code
available to accurately represent the patient's condition. If necessary, use
placeholder characters to reach the required level of specificity.

29. Diagnostic Coding Guidelines
Follow the conventions of the coding system: Be mindful of the
coding conventions, such as using placeholder characters, following
excludes notes, and considering inclusion terms.
Sequence codes correctly: In cases where multiple codes are used,
list the primary diagnosis first, followed by secondary diagnoses and
comorbidities. The primary diagnosis is the main reason for the
patient's encounter with the healthcare provider.

30. Diagnostic Coding Guidelines
Review the documentation thoroughly: Ensure that the assigned
codes accurately reflect the patient's medical record, including the
physician's notes, diagnostic test results, and other relevant
information.

31. CPT Coding
Current Procedural Terminology (CPT) is a standardized coding system
developed and maintained by the American Medical Association (AMA)
to represent medical procedures, services, and treatments. CPT codes
are widely used in the United States for outpatient and office-based
services and are essential for billing and reimbursement purposes.

32. CPT Coding Cont.
CPT codes are five-digit numeric codes that are organized into three categories:
1. Category I: These are the most commonly used CPT codes and represent procedures and services
performed by healthcare providers. Category I codes are further divided into six main sections:
Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and
Medicine.
2. Category II: These codes are used for performance measurement and quality reporting. They are
not used for billing purposes but can provide additional information on the quality of care provided.
3. Category III: These codes represent temporary codes for emerging technologies, services, and
procedures. They are used for data collection and assessment of new services before they are
assigned a permanent Category I code.

33. CPT Coding Conventions
● Add-on codes: These codes represent additional procedures or services
performed during the same encounter as a primary procedure. They cannot be
used alone and must always be reported with a primary code.
● Modifiers: CPT modifiers are two-digit codes that provide additional information
about a procedure, such as whether it was performed on the right or left side of
the body, or if multiple procedures were performed during the same encounter.
● Parenthetical notes: These notes provide further guidance on the use of specific
CPT codes, such as when certain codes should not be used together or when
additional codes may be necessary.

34. Procedural Coding Guidelines
When assigning CPT codes, it is important to follow established guidelines to ensure accurate and consistent coding.
Some key procedural coding guidelines include:
1. Code to the highest level of specificity: Always select the most specific code available to accurately represent the
procedure or service performed. If necessary, use modifiers to provide additional information.
2. Follow the conventions of the coding system: Be mindful of the coding conventions, such as using add-on codes,
applying modifiers correctly, and adhering to parenthetical notes.
3. Use separate codes for distinct procedures: When multiple procedures are performed during the same encounter,
assign separate codes for each procedure, unless a single code exists that encompasses all of the procedures
performed.
4. Review the documentation thoroughly: Ensure that the assigned codes accurately reflect the patient's medical
record, including the physician's notes, operative reports, and other relevant information.

35. Coding Regulations and Guidelines
Medical coding professionals must adhere to various regulations and guidelines to
ensure accurate, consistent, and ethical coding practices. These regulations and
guidelines include:
Health Insurance Portability and Accountability Act (HIPAA): This US legislation
protects patient privacy and sets standards for the electronic transmission of
health information. Medical coders must ensure that patient data is kept
confidential and secure, and that coding practices comply with HIPAA
regulations.

36. Coding Regulations and Guidelines Cont.
Official Coding Guidelines: Each coding system (ICD, CPT, and HCPCS) has
specific guidelines that must be followed when assigning codes. These
guidelines help ensure accurate and consistent coding across healthcare
providers and facilities.
Payer-specific guidelines: Insurance companies and government payers (such as
Medicare and Medicaid) may have their own coding guidelines and requirements.
Medical coders must be familiar with these guidelines to ensure proper
reimbursement and avoid claim denials or audits.

37. Importance of Coding Accuracy
Accurate coding is crucial for several reasons:
1. Patient care: Correct coding ensures that patients receive appropriate care and that their
medical records accurately reflect their diagnoses and treatments.
2. Reimbursement: Accurate coding is essential for healthcare providers to receive proper
reimbursement for the services they provide. Undercoding or overcoding can result in claim
denials, payment delays, or potential fraud investigations.
3. Data analysis and research: Medical coding provides valuable data for healthcare research,
public health surveillance, and healthcare management. Accurate coding is essential for
generating reliable statistics and insights into healthcare trends and outcomes.

38. Ethical Considerations in Medical Coding
Ethical behavior is a fundamental aspect of medical coding. Some ethical considerations include:
1. Confidentiality: Medical coders must maintain patient confidentiality and follow HIPAA
regulations when handling patient information.
2. Integrity: Coders should always strive for accurate and honest coding, avoiding any
practices that could be considered fraudulent or misleading.
3. Professionalism: Medical coders should stay up-to-date with coding guidelines, regulations,
and industry standards, and participate in ongoing education and professional development.
4. Compliance: Coders should adhere to their organization's coding policies and procedures,
and work closely with compliance officers to ensure that coding practices are in line with
regulatory requirements.

39. Medical Coding Software and Tools
Medical coding software and tools can streamline the coding process, improve
accuracy, and reduce the likelihood of errors. These programs often include
features such as code lookup, code validation, claim scrubbing, and reporting
capabilities, making them invaluable resources for medical coders and
healthcare organizations.
Several medical coding software options are available, each with its own unique
features and capabilities. Some popular options include:

40. 1. 3M Codefinder: This comprehensive coding software covers ICD, CPT, and
HCPCS codes, and provides features such as code lookup, code validation, and
compliance checks.
2. Optum EncoderPro: EncoderPro offers a robust code lookup tool for ICD, CPT,
and HCPCS codes, along with code validation, compliance checks, and
reimbursement calculation features.
3. AAPC Coder: Developed by the American Academy of Professional Coders
(AAPC), this software includes code lookup, code validation, and compliance
tools, as well as access to industry news and updates.
4. Find-A-Code: Find-A-Code offers an easy-to-use interface for searching ICD, CPT,
and HCPCS codes, along with code validation, compliance checks, and access to
coding guidelines and payer-specific policies.

41. Navigating Medical Coding Software
To effectively use medical coding software, consider the following tips and best practices:
Familiarize yourself with the software interface: Each software option will have its unique interface,
so take the time to explore and understand the layout, features, and functionality.
Use code lookup tools: Medical coding software often includes code lookup tools that can help you
find the correct codes quickly and efficiently. Be sure to use these tools to improve your coding
accuracy and productivity.
Validate codes and check for compliance: Many coding software options include code validation
and compliance checking features that can help you identify potential errors or inconsistencies
before submitting claims. Utilize these features to reduce claim denials and improve overall coding
accuracy.

42. Continued
To effectively use medical coding software, consider the following tips and best practices:
Stay up-to-date with coding changes: Many medical coding software programs offer
updates and resources to help you stay current with coding guidelines, industry news,
and regulatory changes. Regularly access these resources to ensure that your coding
knowledge remains up-to-date.
Customize software settings: Some coding software allows for customization, such as
creating favorites lists, custom reports, or personalized settings. Take advantage of
these features to tailor the software to your specific needs and preferences.

43. ICD 10/11 Coding Basics
The International Classification of Diseases, Tenth Revision (ICD-10) is a coding
system used to classify and report diagnoses and reasons for patient encounters.
Developed by the World Health Organization (WHO), ICD-10 is used worldwide for
morbidity and mortality statistics, epidemiology, health management, and clinical
research.
In the United States, ICD-10 has two components: ICD-10-CM (Clinical Modification)
for diagnosis coding and ICD-10-PCS (Procedure Coding System) for inpatient
hospital procedure coding. This chapter focuses on ICD-10-CM diagnosis coding.

44. Structure of ICD Codes
ICD-10/11-CM codes are alphanumeric, containing three to seven characters. The
code structure consists of:
1. Category: The first three characters represent the category of the disease or
condition.
2. Subcategory: The fourth, fifth, and sixth characters provide additional specificity,
such as the location, severity, or etiology of the condition.
3. Extension: The seventh character, if applicable, provides even more information,
such as the episode of care or other clinical details.

45. Coding Conventions to Keep in Mind
Some coding conventions to keep in mind when using ICD-10-CM codes are:
● Placeholder character: When a code requires a seventh character but has fewer
than six characters, a placeholder "X" is used to fill the empty characters.
● Excludes1 and Excludes2 notes: Excludes1 notes indicate that the conditions
listed cannot be coded together, while Excludes2 notes indicate that the
conditions listed can be coded together if the patient has both conditions.
● Includes and Inclusion notes: These notes provide examples or further
explanations of the conditions included in a specific category or subcategory.

46. Coding Guidelines and Examples
When assigning ICD-10-CM codes, it is important to follow established guidelines to ensure accurate
and consistent coding. Some key guidelines include:
1. Code to the highest level of specificity: Select the most specific code available to accurately
represent the patient's diagnosis. If necessary, use the placeholder character "X" to complete the
code.
2. Follow the conventions of the coding system: Be mindful of coding conventions, such as using
placeholder characters, adhering to Excludes1 and Excludes2 notes, and considering Includes and
Inclusion notes.
3. Sequence codes correctly: The primary or first-listed diagnosis should reflect the main reason for
the patient encounter, while additional diagnoses should be listed in order of significance.

47. Example 1
Example 1:
A patient is diagnosed with Type 2 diabetes mellitus without complications.
ICD-10-CM code: E11.9 - Type 2 diabetes mellitus without complications

48. Example 2
Example 2:
A patient has acute bronchitis due to the influenza A virus.
ICD-10-CM codes:
● J09.X1 - Influenza due to identified novel influenza A virus with pneumonia
(primary diagnosis)
● J20.9 - Acute bronchitis, unspecified (additional diagnosis)

49. Example 3
Example 3:
A patient presents with a fracture of the distal end of the left radius, initial
encounter for closed fracture.
ICD-10-CM code: S52.525A - Displaced fracture of the distal end of the left
radius, initial encounter for closed fracture

50. The ICD Coding Book
The ICD--CM coding book is a valuable resource for medical coders, providing comprehensive
information on ICD-10-CM diagnosis codes, coding guidelines, conventions, and official coding
advice. This chapter will guide you through the process of using the ICD-CM coding book to look
up and assign codes accurately.
The ICD-CM coding book is divided into three main sections:
Tabular List
Alphabetic Index
Appendix and Guidelines

51. Tabular List
Tabular List: The Tabular List is organized by chapters, each
representing a body system or disease category. It contains a
hierarchical listing of ICD-10-CM codes, along with their descriptions,
instructional notes, and coding guidelines.

52. Alphabetic Index
Alphabetic Index: The Alphabetic Index is an alphabetical listing
of terms and their corresponding ICD-10-CM codes. It serves as a
starting point for locating the appropriate codes for diagnoses,
signs, symptoms, and other reasons for patient encounters.

53. Appendixes and Guidelines
Appendixes and Guidelines: The appendixes and guidelines
section includes the Official ICD-10-CM Coding Guidelines,
which provide instructions on code selection, sequencing, and
reporting, as well as information on conventions,
abbreviations, and specific coding situations.

54. Steps to Code Using the ICD Coding Book
Step 1: Locate the term in the Alphabetic Index
1. Begin by looking up the main term in the Alphabetic Index. The main term
represents the disease, condition, or symptom you are coding for.
2. Once you locate the main term, review any subterms listed below it. Subterms
provide additional specificity, such as the body site, etiology, or clinical details.
3. Identify the appropriate code or range of codes listed next to the main term or
subterm. These codes will guide you to the correct section in the Tabular List.

55. Steps to Code Using the ICD Coding Book
Step 2: Verify the code in the Tabular List
1. Navigate to the Tabular List, using the code or code range identified in the Alphabetic Index.
2. Locate the appropriate code in the Tabular List, ensuring it matches the diagnosis,
condition, or symptom you are coding for.
3. Review any coding notes, such as Excludes1, Excludes 2, Includes, or Inclusion notes, as
well as any instructional notes specific to the code.
4. Make sure the code is complete and accurate. If the code requires additional characters,
review the available options, and select the most specific code.

56. Steps to Code Using the ICD Coding Book
Step 3: Follow the Official ICD-10-CM Coding Guidelines
Consult the Official ICD-10-CM Coding Guidelines to ensure you are
following the correct rules for code selection, sequencing, and reporting.
Pay close attention to any guidelines specific to the disease or condition
you are coding for, as well as general coding principles and conventions.

57. Steps to Code Using the ICD Coding Book, Cont.
Practice looking up codes regularly to build your familiarity and confidence with the coding process.
Stay up-to-date with coding changes, updates, and errata by consulting the official sources, such as
the Centers for Disease Control and Prevention (CDC) or the National Center for Health Statistics
(NCHS) websites. This will ensure that you are using the most current codes and guidelines.
Participate in coding workshops, seminars, or webinars to reinforce your coding skills and
stay informed about industry updates and best practices.
Consult official coding advice, such as the American Hospital Association's (AHA) Coding
Clinic, for clarification on complex coding situations or scenarios not explicitly addressed in
the coding book.

58. Gain Deep Understanding
By understanding the structure and organization of the ICD-10-CM
coding book, following a systematic process for code lookup, and
adhering to the official coding guidelines, you will be well-equipped to
assign ICD-10-CM codes accurately and efficiently. As you gain
experience and continue to refine your coding skills, you will become
more proficient in using the coding book and navigating the
complexities of the ICD-10-CM coding system.

59. Quiz Question 1
What does ICD-10-CM stand for?
a. International Classification of Diseases, 10th Edition, Clinical Modification
b. International Coding and Diagnosis, 10th Edition, Clinical Management
c. Internal Classification of Diseases, 10th Revision, Clinical Modification
d. International Classification of Diseases, 10th Revision, Clinical Measurement

60. Quiz Question 2
What is the primary purpose of the ICD-10-CM coding system?
a. To classify and report diagnoses and reasons for patient encounters
b. To classify and report medical procedures and services
c. To classify and report medical supplies and equipment
d. To classify and report healthcare personnel

61. Quiz Question 3
How many characters can an ICD-10-CM code have?
a. 3-5
b. 3-7
c. 4-6
d. 5-8

62. Quiz Question 4
What is the purpose of a placeholder "X" in ICD-10-CM codes?
a. To indicate an unspecified diagnosis
b. To fill empty characters when a code requires a seventh character but has
fewer than six characters
c. To indicate that a code has been deleted or replaced
d. To represent an unspecified location or body part

63. Quiz Question 5
Which of the following notes indicate that the conditions listed cannot be
coded together?
a. Excludes1
b. Excludes 2
c. Includes
d. Inclusion notes

64. Quiz Question 6
In the ICD-10-CM coding book, what section is an alphabetical listing of
terms and their corresponding ICD-10-CM codes?
a. Tabular List
b. Alphabetic Index
c. Appendixes
d. Official ICD-10-CM Coding Guidelines

65. Quiz Question 7
What is the first step in using the ICD-10-CM coding book to look up a code?
a. Locate the term in the Tabular List
b. Verify the code in the Alphabetic Index
c. Locate the term in the Alphabetic Index
d. Consult the Official ICD-10-CM Coding Guidelines

66. Quiz Question 8
When assigning ICD-10-CM codes, you should always:
a. Code to the highest level of specificity
b. Use the shortest possible code
c. Use a combination of unrelated codes to describe the condition
d. Use the same code for all conditions in the same body system

67. Quiz Answers
1. a. International Classification of Diseases, 10th Edition, Clinical Modification
2. a. To classify and report diagnoses and reasons for patient encounters
3. b. 3-7
4. b. To fill empty characters when a code requires a seventh character but has
fewer than six characters
5. a. Excludes1
6. b. Alphabetic Index
7. c. Locate the term in the Alphabetic Index
8. a. Code to the highest level of specificity

68. EHRs or Electronic Health Records
Electronic Health Records (EHRs) are digital versions of patients'
medical records, containing comprehensive information about a
patient's medical history, diagnoses, treatments, medications,
allergies, immunizations, and other relevant data. EHRs have
transformed the healthcare industry by enhancing the efficiency,
accuracy, and accessibility of medical records, improving patient
care and reducing errors.

69. Benefits of EHRs
Improved Patient Care: EHRs provide healthcare providers with instant access to a patient's
medical history, enabling more informed decision-making and reducing the likelihood of
errors. EHRs can also facilitate coordination among different healthcare providers, ensuring
that patients receive appropriate and timely care.
Increased Efficiency: EHRs streamline administrative tasks, such as recordkeeping, billing,
and appointment scheduling. They can also automate certain functions, such as
prescription refills and lab result notifications, saving time for both providers and patients.
Enhanced Security and Privacy: EHRs offer advanced security features to protect sensitive
patient information. Healthcare providers must comply with the Health Insurance Portability
and Accountability Act (HIPAA), which sets strict standards for the protection of electronic
protected health information (ePHI).

70. Benefits of EHRs Continued
Improved Data Analytics and Population Health Management: EHRs enable
healthcare organizations to collect, analyze, and use data more effectively. This
can help identify trends, track the effectiveness of treatments, and improve
population health management efforts.
Financial Incentives: In the United States, the federal government has established
programs, such as the Medicare and Medicaid EHR Incentive Programs, to
encourage the adoption and meaningful use of EHRs among healthcare
providers.

71. Challenges of EHR Implementation
High Costs: EHR implementation and maintenance can be expensive, particularly for
smaller practices and rural healthcare facilities.
Training and Adoption: Healthcare providers and staff may require extensive training
to effectively use EHR systems, and some may be resistant to change.
Interoperability: EHR systems from different vendors may not communicate
seamlessly, which can hinder information exchange and care coordination.
Data Privacy and Security: Ensuring the privacy and security of sensitive patient
information is crucial, and healthcare providers must continually invest in
safeguarding their EHR systems against data breaches and cyber threats.

72. ICD-10 Coding Basics and Scenarios
The International Classification of Diseases, Tenth Revision (ICD-10)
is a globally recognized coding system used to classify and report
diseases, injuries, and health conditions. The Clinical Modification
(ICD-10-CM) is the United States' adaptation of ICD-10 for diagnosis
coding. ICD-10-CM is used by healthcare providers, insurance
companies, and government agencies to ensure accurate
documentation, communication, and reimbursement for healthcare
services.

73. ICD-10 Code Structure
ICD-10-CM codes consist of three to seven characters, with each character representing
specific information about the diagnosis:
1. First character: A letter indicating the category of the diagnosis (e.g., A for certain
infectious and parasitic diseases, C for neoplasms).
2. Second character: A numeric digit representing the general subcategory of the
diagnosis.
3. Third character: A numeric digit further specifying the subcategory.
4. Fourth to sixth characters (optional): A combination of letters and digits providing
additional details about the diagnosis, such as anatomical site, severity, or other
clinical information.
5. Seventh character (optional): A letter or digit used as an extension to provide even
more specific information, such as the encounter type, healing status, or laterality.

74. ICD-10 Coding Conventions
Placeholder "X": When a code requires a seventh character but has fewer than six
characters, a placeholder "X" is used to fill the empty characters, ensuring the seventh
character is in the correct position.
Excludes1 and Excludes2 notes: These notes indicate that certain conditions should
not be coded together. Excludes1 means the conditions are mutually exclusive, while
Excludes2 means that the conditions may coexist but should be coded separately.
Includes notes: These notes provide additional information or examples of conditions
included in a specific category or subcategory.
Inclusion terms: Inclusion terms are listed below certain codes to provide examples of
conditions that the code may represent.

75. Alphabetic Index and Tabular List
The ICD-10-CM coding book consists of two main sections: the Alphabetic Index
and the Tabular List. To look up a code, follow these steps:
1. Locate the term in the Alphabetic Index: Search for the main term or
diagnosis, followed by any subterms or modifiers.
2. Verify the code in the Tabular List: Once you have identified a code in the
Alphabetic Index, verify it in the Tabular List, ensuring it accurately
represents the diagnosis and adheres to any applicable coding guidelines.
3. Assign the most specific code: Always code to the highest level of
specificity, using as many characters as needed to describe the diagnosis
accurately.

76. Importance of Proper Coding
ICD-10-CM is a vital component of the healthcare system, ensuring
accurate documentation and communication of diagnoses.
Understanding the structure, conventions, and guidelines of ICD-10-CM
coding is crucial for healthcare providers, medical coders, and billers to
maintain the financial health of medical practices and institutions. As the
field of medical coding continues to evolve, staying up to date on ICD-10-
CM coding practices is essential for professionals in the healthcare
industry.

77. Coding For Home Health Agencies
Home health agencies provide healthcare services to patients in their homes,
including nursing care, physical therapy, occupational therapy, speech
therapy, and medical social services. Accurate ICD-10 coding is crucial for
home health agencies to ensure appropriate documentation, communication,
reimbursement, and quality measurement. The ICD-10 coding system for
home health agencies is the same as for other healthcare settings, but with
some unique considerations and guidelines specific to home care.

78. The Primary Diagnosis
Primary Diagnosis: The primary diagnosis, also known as the principal diagnosis,
is the main reason for the home health services. It should be coded first and
should reflect the primary focus of the home care plan. Home health agencies
should also code any comorbidities, secondary diagnoses, or complications that
impact the care provided, patient's response to treatment, or the need for
additional services. The primary diagnosis is typically found in the Face to Face
or Discharge documentations that is submitted to the agency by the referral
source.

79. Timing of Diagnoses
Timing of Diagnoses: Home health agencies should code the diagnoses that
are active and relevant during the episode of care. Diagnoses that have
resolved or are not relevant to the current care plan should not be coded.
When assessing the diagnoses provided, always look at the medical note,
and judge which ones were the most relevant during the visit or the
inpatient/SNF stay.

80. Coding From Documentation
Coding from Documentation: Home health agencies should code
diagnoses based on the documentation provided by the certifying
physician or other authorized healthcare professionals involved in the
patient's care. The home health agency staff should not assign codes for
diagnoses that are not documented or confirmed by the appropriate
healthcare professionals. It is very important that the Home Health
Agency Codes match the physicians notes.

81. Sequencing of Codes
Sequencing of Codes: In addition to the primary diagnosis, home
health agencies should code and sequence any additional diagnoses
according to the ICD-10-CM guidelines. The order of the additional
codes should reflect the severity of each condition and its impact on
the patient's care. The severity ranges from 1-3.

82. Oasis Assessments and ICD-10 Coding
OASIS Assessments and ICD-10 Coding: Home health agencies are required
to complete the Outcome and Assessment Information Set (OASIS)
assessments for Medicare and Medicaid patients. The diagnoses
documented in the OASIS assessment should be consistent with the ICD-10
codes reported on the home health agency claims. The data set in the OASIS
has to reflect and support the codes.

83. Medicare Payment
Coding for Medicare Home Health Payment: For Medicare patients,
home health agencies must also consider the Patient-Driven Groupings
Model (PDGM), which is a payment system that groups patients into
categories based on their diagnoses, functional status, and other
factors. The primary diagnosis should be selected from the "acceptable
diagnoses" list for PDGM to ensure appropriate payment.

84. Comprehensive Assessment and Care Planning
Comprehensive Assessment and Care Planning: Home health agencies are
required to perform a comprehensive assessment of each patient, including
a review of the patient's medical history, current health conditions,
medications, and functional status. This assessment forms the basis of an
individualized care plan, which should include the ICD-10 codes for all
relevant diagnoses. Proper coding ensures that the care plan accurately
reflects the patient's needs and enables effective communication among the
home health agency staff and other healthcare providers.

85. Importance of Detailed Documentation
Importance of Detailed Documentation: Clear and thorough
documentation by the certifying physician and other healthcare
professionals is essential for accurate ICD-10 coding in home health
care. The documentation should provide enough information for the
home health agency to assign the most specific codes possible,
reflecting the patient's current health status and needs.

86. Collaboration with Physicians
Collaboration with Physicians and Other Healthcare Providers: Home
health agencies must collaborate closely with the certifying physician
and other healthcare providers involved in the patient's care to ensure
that the diagnoses are accurately documented and coded. This
collaboration may involve regular communication, sharing of medical
records, and participation in care conferences to discuss the patient's
progress and any changes in their health status.

87. Updating Diagnoses and Codes
Updating Diagnoses and Codes: Home health care is an ongoing
process, and patients' conditions may change over time. Home health
agencies should continually review and update the ICD-10 codes as
needed to accurately reflect the patient's current health status and
needs. This may involve updating the OASIS assessment, care plan, and
claim submissions to ensure that the codes are consistent across all
documentation.

88. Coding Quality and Compliance
Coding Quality and Compliance: Home health agencies must adhere to the
ICD-10-CM coding guidelines and comply with the regulatory requirements
set forth by the Centers for Medicare and Medicaid Services (CMS) and other
payers. This includes maintaining up-to-date knowledge of coding
conventions, guidelines, and changes in the ICD-10-CM code set. Periodic
coding audits and reviews can help identify potential coding errors or areas
for improvement, ensuring that the agency maintains high-quality coding
practices and reduces the risk of claim denials or penalties.

89. Training and Education
Training and Education: Ongoing training and education are essential
for home health agency staff responsible for ICD-10 coding,
including nurses, therapists, and medical coders. This training should
cover the latest coding guidelines, coding updates, and any changes
in the regulatory requirements for home health care. Regular training
and education can help ensure that the agency's coding practices
remain accurate, efficient, and compliant.

90. ICD-10 coding is a critical component of home health care, affecting the
quality of care, documentation, communication, and reimbursement. By
understanding and adhering to the specific guidelines and considerations for
home health care, home health agencies can ensure accurate coding
practices and maintain compliance with regulatory requirements. Investing in
ongoing training and education for staff and fostering collaboration among
healthcare providers will further enhance the agency's ability to provide high-
quality, patient-centered care.

91. Patient Driven Groupings Model (PDGM)
The Patient-Driven Groupings Model (PDGM) is a payment system
implemented by the Centers for Medicare and Medicaid Services (CMS) for
home health services provided under Medicare. It took effect on January 1,
2020, replacing the previous Home Health Prospective Payment System (HH
PPS). PDGM aims to improve the payment accuracy and incentives for home
health agencies by focusing on patient needs and characteristics rather than
the volume of services provided. Accurate ICD-10 coding plays a crucial role
in determining the appropriate reimbursement under PDGM.

92. Components of PDGM
PDGM categorizes home health episodes into distinct payment groups based on five key
components:
Admission Source: Determines whether the patient is admitted to home health
services from an institutional setting (e.g., hospital, skilled nursing facility) or a
community setting (e.g., physician's office, self-referral).
Timing of the Home Health Episode: Categorizes the episode as either "early" (the
first 30-day episode) or "late" (subsequent 30-day episodes).
Clinical Grouping: Based on the primary diagnosis code, the patient is assigned to
one of 12 clinical groupings that represent the primary reason for home health
services.

93. Components of PDGM Cont.
Functional Impairment Level: Assesses the patient's functional status based on
the responses to specific questions in the Outcome and Assessment Information
Set (OASIS) assessment. Patients are categorized into low, medium, or high
functional impairment levels.
Comorbidity Adjustment: Evaluates the presence of secondary diagnoses that
may impact the patient's care needs and resource utilization. Patients may
receive a low, medium, or high comorbidity adjustment based on specific ICD-10
codes and combinations.

94. Importance of Accurate Coding with PDGM
ICD-10 coding is critical in determining the appropriate payment for
home health services under PDGM, as it directly impacts the clinical
grouping and comorbidity adjustment components. Accurate and
specific coding ensures that the home health agency is fairly
compensated for the care provided to the patient.

95. Key Considerations of Coding Under PDGM
Primary Diagnosis Code: The primary diagnosis code should represent the
primary reason for home health services and be selected from the
"acceptable diagnoses" list for PDGM. Inaccurate or non-specific primary
diagnosis codes may result in lower reimbursement rates or claim denials.
Secondary Diagnosis Codes: Home health agencies should report all relevant
secondary diagnoses that impact the patient's care needs or resource
utilization. These codes contribute to the comorbidity adjustment under
PDGM, potentially increasing the reimbursement rate for patients with
complex needs.

96. Key Considerations of Coding Under PDGM Cont.
Coding to the Highest Level of Specificity: To ensure accurate payment under
PDGM, home health agencies should code diagnoses to the highest level of
specificity, using as many characters as needed to describe the patient's
condition accurately.
Ongoing Monitoring and Updates: Home health agencies should regularly review
and update the ICD-10 codes as the patient's condition changes or new
information becomes available. This helps ensure that the clinical grouping and
comorbidity adjustment remain accurate throughout the patient's episode of
care.

97. The Patient-Driven Groupings Model (PDGM) emphasizes the importance of
accurate ICD-10 coding for home health agencies, as it directly impacts the
reimbursement for services provided. By understanding the key components of
PDGM and following best practices for ICD-10 coding, home health agencies can
ensure appropriate payment and maintain compliance with CMS requirements.
Ongoing education and training for staff involved in coding and documentation
are essential for success under PDGM.

98. Reimbursements Under PDGM
Under the Patient-Driven Groupings Model (PDGM), the reimbursement for home
health services provided to Medicare beneficiaries is determined by the patient's
characteristics and needs, rather than the volume of services provided. This payment
system aims to improve payment accuracy and create incentives for home health
agencies to deliver patient-centered, high-quality care. In this context, understanding
the factors that influence reimbursement under PDGM is crucial for home health
agencies to ensure appropriate compensation for their services.

99. Calculation of Reimbursement PDGM
Reimbursement for home health services under PDGM is based on a 30-day episode
of care, known as a payment period. The payment for each 30-day period is
determined by considering the following factors:
1) Base Payment Rate
2) Case-Mix Adjustment
3) Wage-Index Adjustment
4) Budget Neutrality Factor
5) Rural Add-on Payment
6) LUPA (Low Utilization Payment Adjustment)

100. Base Payment Rate
CMS establishes a base payment rate for home health services, which is annually
adjusted to account for inflation, changes in the cost of providing care, and other
factors. This base rate is then divided by the national average case-mix weight to
calculate the standardized 30-day payment rate. You will see two 30-day payment
rates per 60 days certification period.

101. Case-Mix Adjustment
Each 30-day payment period is assigned a case-mix weight based on the
patient's PDGM grouping, which takes into account the admission source,
timing of the episode, clinical grouping, functional impairment level, and
comorbidity adjustment. The case-mix weight is designed to reflect the
relative resource utilization and intensity of care for each payment group.

102. Wage Index Adjustment
The payment rate is further adjusted based on the home health agency's
geographic location using the wage index. This adjustment accounts for
regional differences in labor costs, ensuring that agencies in areas with
higher labor costs receive higher reimbursement rates.

103. Budget Neutrality Factor
Budget Neutrality Factor: CMS applies a budget neutrality factor to the
payment rate to ensure that the overall expenditures for home health
services do not increase or decrease solely as a result of the implementation
of PDGM. This factor is calculated based on the estimated change in the
national average case-mix weight due to PDGM.

104. Rural Add-On Payment
Home health agencies serving patients in rural areas may be eligible for an
additional payment known as the rural add-on. This payment is designed to
support access to home health services in rural communities, where the cost
of providing care may be higher due to factors such as travel time and
distance.

105. LUPA
In cases where the patient receives a low number of visits during the 30-day
payment period, the reimbursement may be adjusted based on the Low Utilization
Payment Adjustment (LUPA). Instead of the PDGM case-mix adjusted rate, the
home health agency receives a per-visit payment for each service provided
during the LUPA episode. If the Lupa is 4, that means at least 4 visits have to be
made between all disciplines involved in the case to receive full payment for the
30 days.

106. Reimbursement under the Patient-Driven Groupings Model (PDGM) is
determined by a combination of factors that reflect the patient's
characteristics, needs, and the home health agency's location. By
understanding the components of the PDGM reimbursement
calculation, home health agencies can optimize their care delivery,
documentation, and coding practices to ensure appropriate
compensation for their services. As the healthcare landscape
continues to evolve, staying up to date on PDGM and other payment
models is crucial for home health agencies to maintain financial
stability and deliver high-quality, patient-centered care.

107. Which PDGM Groupings Pay More?
It is essential to understand that the Patient-Driven Groupings Model (PDGM) aims to
promote value-based, patient-centered care rather than encouraging home health agencies
to pursue specific groupings for higher reimbursement rates. The PDGM reimbursement
model is designed to more accurately reflect the patients' needs and required resources,
which means that the most appropriate and highest quality care should be the priority for
home health agencies.
However, certain PDGM groupings may result in higher reimbursement rates due to the
complexities of the patient population or the resources needed to provide care. These may
include:

108. Complex Clinical Groupings
Complex clinical groupings: Patients with more complex conditions or
higher acuity levels may require more intensive care and resources,
leading to a higher reimbursement rate. Examples of such clinical
groupings include extensive wound care, complex nursing interventions,
or significant therapy needs.

109. Higher Functional Impairment Methods
Higher functional impairment levels: Patients with higher functional
impairment levels often require more assistance and resources to
manage their daily activities and care needs. As a result, higher
functional impairment levels can contribute to increased reimbursement
rates.

110. Higher Comorbidity Adjustments
Higher comorbidity adjustments: Patients with multiple comorbidities or
specific combinations of secondary diagnoses that significantly impact
their care needs may receive higher reimbursement rates due to
increased resource utilization.

111. Institutional Admission Source
Institutional admission source: Patients admitted to home health
services from an institutional setting, such as a hospital or skilled
nursing facility, typically have more complex care needs than those
admitted from a community setting. This can result in higher
reimbursement rates for institutional admission source groupings.

112. Early Home Health Episodes
Early home health episodes: The timing of the home health episode also
influences reimbursement rates, with early episodes (the first 30-day
episode) generally receiving higher payments compared to late episodes
(subsequent 30-day episodes).

113. Highest Quality Care
It is important to emphasize that home health agencies should focus on
providing the most appropriate and highest quality care for their patients,
rather than targeting specific PDGM groupings for higher reimbursement
rates. Proper documentation, accurate ICD-10 coding, and regular
communication with physicians and other healthcare providers are crucial in
ensuring that the care provided aligns with the patients' needs and results in
appropriate reimbursement under the PDGM model.

114. Coding Example 1
In this example, let's consider a patient who is receiving home health services following a hospitalization due to congestive heart
failure (CHF). The patient also has type 2 diabetes mellitus and hypertension. Here's how ICD-10 coding would be applied in this
scenario:
Primary Diagnosis:
The primary diagnosis should represent the main reason for home health services. In this case, the primary diagnosis is
congestive heart failure, which is coded as:
I50.9 - Congestive heart failure, unspecified
Secondary Diagnoses:
Secondary diagnoses are additional conditions that impact the patient's care needs and resource utilization. In this example, the
patient has type 2 diabetes mellitus and hypertension. These conditions are coded as:
E11.9 - Type 2 diabetes mellitus without complications
I10 - Essential (primary) hypertension

115. Coding Example 1 Cont.
As a home health agency, you would report the primary and secondary diagnoses in
your documentation and billing submissions, ensuring that the ICD-10 codes are
accurate and specific. This information is crucial for determining the appropriate
PDGM grouping and reimbursement rate, as well as for communication with other
healthcare providers involved in the patient's care.
Remember that accurate coding is essential for appropriate reimbursement and
compliance with regulations. Home health agencies should ensure that their staff is
trained and updated on ICD-10 coding guidelines and best practices, as well as any
changes in the code set.

116. Coding Example 2
In this example, let's consider a complicated case where a patient is receiving home health services after a hospitalization due to a stroke.
The patient has multiple comorbidities, including atrial fibrillation, chronic kidney disease (CKD) stage 3, and a history of deep vein
thrombosis (DVT). The patient also has difficulty walking and requires assistance with activities of daily living (ADLs).
Primary Diagnosis:
The primary diagnosis should represent the main reason for home health services. In this case, the primary diagnosis is the stroke, which is
coded as:
I63.9 - Cerebral infarction, unspecified
Secondary Diagnoses:
Secondary diagnoses are additional conditions that impact the patient's care needs and resource utilization. In this example, the patient has
atrial fibrillation, chronic kidney disease stage 3, and a history of deep vein thrombosis. These conditions are coded as:
I48.91 - Unspecified atrial fibrillation
N18.3 - Chronic kidney disease, stage 3 (moderate)
Z86.718 - Personal history of other venous thrombosis and embolism

117. Coding Example 2 Cont.
Additionally, the patient's functional limitations and assistance required for ADLs should be
documented and coded, if applicable.
As a home health agency, you would report the primary and secondary diagnoses in your
documentation and billing submissions, ensuring that the ICD-10 codes are accurate and specific.
This information is crucial for determining the appropriate PDGM grouping and reimbursement
rate, as well as for communication with other healthcare providers involved in the patient's care.
In more complex cases like this, it is particularly important to ensure accurate and complete
documentation of all relevant diagnoses, as well as any changes in the patient's condition or care
needs over time. Home health agencies should invest in ongoing training and education for staff
involved in ICD-10 coding and documentation to ensure compliance with guidelines and best
practices.

118. Coding Software
Encoder Software: Encoder software is a comprehensive coding tool that
helps medical coders find the correct codes for diagnoses and procedures
based on the clinical documentation. These software programs often come
with built-in code libraries, such as ICD-10, CPT, and HCPCS, along with
guidelines and coding rules. Encoders can help identify coding errors,
provide suggestions for more specific codes, and offer references to coding
guidelines or medical literature to support the selected codes.
Examples: 3M Encoder, Optum360 EncoderPro, TruCode Encoder

119. Coding Software Cont.
Computer-Assisted Coding (CAC) Software: Computer-assisted coding software
uses natural language processing (NLP) technology to analyze clinical
documentation and automatically generate suggested codes for diagnoses and
procedures. CAC software helps streamline the coding process and reduces
manual work, while also improving coding accuracy and consistency. However,
medical coders still need to review and validate the suggested codes to ensure
their accuracy and compliance with coding guidelines.
Examples: Dolbey Fusion CAC, Nuance Clintegrity, 3M 360 Encompass