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Medical Coding Training Online Minicourse
The document outlines the essentials of medical coding, emphasizing the need for trained individuals in the healthcare industry for billing and documentation purposes. It details coding classifications such as ICD-10, CPT, and HCPCS, which are crucial for accurate medical coding and reimbursement processes. Additionally, it highlights the qualities required for medical coders and the significance of precise clinical documentation.
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Dr. Santosh Kumar Guptha introduces the medical coding field, highlighting his certifications and expertise.
There is a growing need for skilled individuals in medical coding and office operations across healthcare sectors.
Medical coding involves converting medical records into codes for diagnoses and procedures using ICD-10 and CPT.
ICD-10 provides reasons for treatments, while CPT identifies the procedures performed on patients.
Essential resources for effective medical coding include various coding manuals for ICD-10 and CPT.
Various titles like Health Information Technician and Coding Specialist represent the role of medical coders.
Key traits for medical coders include attention to detail, accuracy, critical thinking, and commitment to learning.
A core principle in medical coding is that documentation must accurately reflect all services rendered.
ICD-10-CM is the diagnostic classification system used for clinical, epidemiological, and health management.
The WHO is preparing ICD-11, enhancing specificity in patient diagnoses and inpatient procedures.
ICD-10-CM improves reimbursement accuracy, quality of care, disease management, and prevents healthcare fraud.
Thorough clinical documentation is crucial for effective medical coding and impacts healthcare quality.
Detailed guidelines for maintaining complete and precise medical records are essential for coding.
Comprehensive details of patient encounters should be documented to ensure accuracy in care and coding.
ICD-10-CM codes start with an alpha character followed by numeric codes for categorization.
Medical records must be clear and accessible to ensure all relevant information supports patient care.
ICD-10-CM chapters categorize diseases, aiding in easy identification and coding of various conditions.
ICD-10-CM continues to sort diseases and health issues into organized chapters for coding purposes.
Understanding the format and significance of coding characters in ICD-10-CM is crucial.
The 'x' character serves as a placeholder for certain codes requiring expanded details.
The use of characters in ICD-10-CM codes, especially the seventh character for specific categories.
Seventh characters in ICD-10 are used in specific chapters, crucial for categorizing complex cases.
Detailed example of coding open cholecystectomy indicates how to represent surgical procedures.
CPT coding details what procedures were performed and organizes codes into major sections.
CPT codes are developed for concise procedure descriptions, sometimes referencing common sections.
ICD-10-PCS codes consist of seven characters, each having specific meanings related to procedures.
Each character in ICD-10-PCS retains meaning across codes, essential for understanding coding standards.
Explanation of each character's role within ICD-10-PCS codes, facilitating accurate medical coding.
Clarifies the arrangement of characters in ICD-10-PCS codes and their significance in coding procedures.
Samples of ICD-10-PCS coding illustrate the application in hospital procedures.
Information on AAPC and AHIMA board exams focusing on professional coding certifications.
Combined details for both boards aid students in understanding certification requirements and costs.
The presentation concludes with contact details for Medesun Healthcare Solutions, highlighting training.
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Medical Coding Training Online Minicourse
- 1. Medical Coding-2017Medical Coding-2017 Dr.Santosh Kumar Guptha Trainer/Author CCS-P, CCS , CPC, COC, CIC, CPC-P, CRC, CCC, CPCO, CANPC, CPB,CPMA, CEMC, CEDC, CIMC, CFPC, CUC, COBGC, CPCD, COSC, CPRC, CPEDC, CHONC, CENTC, CRHC, CGIC, CASCC, CGSC, CSFAC, CCVTC, RMC, RMA, CMBS, CMRS, CSCS, CSBB, FCR, FNR, FOR, CHA, CHL7, AHIMA Approved ICD-10 Trainer, AHIMA ICD-10 Ambassador, India. World Record Holder-42 Certifications
- 2. The medicalindustry is experiencing a high demand for individuals with knowledge of medical office operations, transcription, billing and coding. The business office of every health care provider must submit the proper documentation to a number of insurance companies for reimbursement in order to financially succeed and avoid fraud charges The requirement has created numerous opportunities for trained individuals to be employed in medical offices, clinics, hospitals, insurance companies and do home-based opportunities
- 3. Medical coding meanscoverting medical record to codes. Assigning proper codes for Diagnosis, Procedure and supplies/drugs ICD-10-CM is for Diagnosis ICD-10-PCS is for Hospital Services CPT-4 is for Physician Services HCPCS is for Supplies and Drugs
- 4. ICD-10 representsthe “WHY” it was done Medical Necessity--------- R07.9 (Chest Pain) CPT-4 represents the “WHAT” was done to the patient- Physician Service Procedure------------------- 93010 (EKG) ICD-10-PCS Represents Hospital Service 0DTJ4ZZ Resection of Appendix, Percutaneous Endoscopic Approach HCPCS-is for Supplies and Drugs-Not used in India
- 5. Key medical termsare identified & abstracted from the medical record. Specific codes are assigned to each term. Resources You Need ICD-10-CM Manual-2017 ICD-10-PCS Manual-2017 CPT 2017 HCPCS 2017
- 6. AKA’s of theMedical CoderAKA’s of the Medical Coder Health Information Technician Health Information Coder Medical Record Coder Coder / Abstractor Coding Specialist Insurance Specialist
- 7. Qualities of theMedical CoderQualities of the Medical Coder Knowledge of medical terminology Knowledge of anatomy & physiology Detail oriented Accuracy Critical thinking Willingness to learn Self-motivated • Flexibility • Computer skills
- 8. Principle of MedicalCodingPrinciple of Medical Coding If it’s not documented, it wasn’t done
- 9. ICD-10-CM-2017ICD-10-CM-2017 The International Classificationof Diseases (ICD) is the international standard diagnostic classification for all general epidemiological purposes, many health management purposes, and for clinical use. ICD-10, Clinical Modification (ICD-10-CM) was developed by the U.S. National Center for Health Statistics (NCHS) along with an advisory panel to ensure accuracy and utility in 1993.
- 10. The WHO iscurrently crafting the 11th revision, which is expected to be release in 2018/2019. ICD-10, Clinical Modification (ICD-10-CM) was developed by the U.S. National Center for Health Statistics (NCHS) along with an advisory panel to ensure accuracy and utility in 1993. ICD-10 codes allow for greater specificity and exactness in describing a patient’s diagnosis and in classifying inpatient procedures.
- 11. Benefits to ICD-10-CMBenefitsto ICD-10-CM include but are not limited to the following: •Improving payment systems and reimbursement accuracy •Measuring the quality, safety and efficacy of care •Improve disease management •Conducting research, epidemiogical studies, and clinical trials •Setting health policy •Monitoring resource utilization •Preventing and detecting healthcare fraud and abuse
- 12. Clinical documentation isa vital component that represents the medical condition of the patient and, therefore, has always played a vital role in medical coding. billing, medical research, hospital/physician outcome studies, etc. Complete, accuracy, specific and timely Proper documentation is required
- 13. Medical Record Documentation:-MedicalRecord Documentation:- 1. The medical record should be complete and legible. 2. The documentation of each patient encounter should include: the date; the reason for the encounter; appropriate history and physical exam in relationship to the patient’s chief complaint; review of lab, x-ray data, and other ancillary services, where appropriate; assessment; and a plan for care (including discharge plan, if appropriate) 3. Past and present diagnoses should be accessible to the treating and/or consulting physician. 4. The reasons for—and results of—x-rays, lab tests, and other ancillary services should be documented or included in the medical record.
- 14. Relevant healthrisk factors should be identified. The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient noncompliance, should be documented. The written plan for care should include, when appropriate: treatments and medications, specifying frequency and dosage; any referrals and consultations; patient/family education; and specific instructions for follow-up. The documentation should support the intensity of the patient evaluation and/or treatment, including thorough processes and the complexity of medical decision-making as it relates to the patient’s chief complaint for the encounter. All entries to the medical record should be dated and authenticated.
- 15. ICD-10-CM codes areall alphanumeric, starting with an alpha character
- 16. A medical recordshould be kept clear and legible For the documentation of each patient encounter, the following information should be included: reason for the encounter, date, laboratory and tests data, physical examinations, medical history, assessments, and plan of care. The medical professional should make sure that previous and current diagnoses are always accessible to whomever will handle the case. Ancillary services should be clear, including the results and/or any intervention initiated. All of the following should also be documented regarding patient response: reactions to treatments, changes on the procedures, noncompliance on the part of the patient, and any changes on the diagnosis.
- 17. A &B = Certain Infectious and Parasitic Diseases C & D = Neoplasms D = Diseases of the Blood and Blood-forming Organs E = Endocrine Nutritional and Metabolic Diseases F = Mental, Behavioral, Neurodevelopmental Disorders G = Diseases of the Nervous System H = Diseases of the Eye and Adnexa H = Diseases of the Ear and Mastoid Process I = Diseases of the Circulatory System J = Diseases of the Respiratory System K= Diseases of the Digestive System L = Diseases of the Skin and Subcutaneous Tissue M = Diseases of the Musculoskeletal System ICD-10-CM ChaptersICD-10-CM Chapters
- 18. N =Diseases of the Genitourinary System O = Pregnancy, Childbirth and the Puerperium P = Certain Conditions Originating in the Perinatal Period Q = Congenital Malformations, Deformations and Chromosomal Abnormalities R = Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified S & T = Injury, Poisoning and Certain Other Consequences of External Causes V = Transport accidents - External Causes of Morbidity W = Other External Causes of Accidental Injury X = Exposure to smoke, fire and flames X - Y = Assault Z = Factors Influencing Health Status and Contact With Health Services Medical coding training hyderabad
- 19. XX XX XXXX Category . Etiology, anatomic site, severity Added 7th character for obstetrics, injuries, and external causes of injury ICD-10-CM Coding CharactersICD-10-CM Coding Characters XX XX XXAAMMSS 00 22 66. 55 xx AA Additional Characters Alpha (Except U) 2 Numeric 3-7 Numeric or Alpha 3–7 Characters
- 20. 55thth Character “x”Character “x” Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter; and T15.02xD – Foreign body in cornea, left eye, subsequent encounter.
- 21. XX XX XXXX Category . Etiology, anatomic site, severity Added 7th character for obstetrics, injuries, and external causes of injury Coding and Seventh CharacterCoding and Seventh Character XX XX XXAAMMSS 00 22 66. 55 xx AA Additional Characters Alpha (Except U) 2 Numeric 3-7 Numeric or Alpha 3–7 Characters
- 22. CODING AND USEOF SEVENTH CHARACTERCODING AND USE OF SEVENTH CHARACTER •Used in these chapters: • Obstetrics • Injury • External cause • Musculoskelet al •Either alpha or numeric •Placeholder X •Meanings vary
- 23. Surgeon performs anopen cholecystectomy for acute cholecystitis with cholelithiasis. K80.00 Calculus of gallbladder with acute cholecystitis, without obstruction 0FT40ZZ Open resection of gallbladder
- 25. Introduction to CPTCodingIntroduction to CPT Coding CPT-4 represents the “WHAT” was done to the patient Procedure------------------- 93010 (EKG)-5 Digit Code Text organized in 6 major sections Evaluation and Management (99201 - 99499) Anesthesiology (00100 - 01999, 99100 - 99140) Surgery (10040 - 69990) Radiology (70010 - 79999) Pathology and Laboratory (80049 - 89399) Medicine (90281 - 99199)
- 26. CPT CodesCPT Codes Developed as a stand-alone descriptions of the procedures To conserve space, some are not printed in their entirety but refer back to a common portion listed in a preceding entry** Example: 25100-arthrotomy, wrist joint; for biopsy 25105 for synovectomy
- 27. Seven Character AlphanumericCode ◦ AllAll procedure codes will be seven characters long ◦ “II” and “OO” (letters) are never used 34 possible values for each character ◦ Digits 0 – 9 ◦ Letters A-H, J-N, P-Z 27 ICD-10-PCS: Code StructureICD-10-PCS: Code Structure
- 28. A charactercharacter isa stable, standardized code component ◦ Holds a fixed place in the code ◦ Retains its meaning across a range of codes A valuevalue is an individual unit defined for each character 28 ICD-10-PCS StructureICD-10-PCS Structure (Characters and Values)(Characters and Values)
- 29. 1st character = SSection 2nd character= BBody System 3rd character = RRoot Operation 4th character = BBody Part 5th character = AApproach 6th character = DDevice 7th character = QQualifier SSusieusie BBuysuys RRootoot BBeereer AAtt DDairyairy QQueenueen 29
- 30. ICD-10-PCS Code FormatICD-10-PCSCode Format S 3 2 0 1 0 A Section Body System Root Operation Body Part Approac h Device Qualifie r
- 31. ICD-10 ProcedureCode 0DN90ZZ Release of duodenum, open approach 0FB03ZX Excision of liver, percutaneous approach, diagnostic 02PS0CZ Removal, extraluminal device from pulmonary vein, right, open
- 32. Board Exams-USA (AAPCandBoard Exams-USA (AAPC and AHIMA)AHIMA) AAPC: American Academy of Professional Coders-USA Exam-CPC: Certified Professional Coder Fees: 500 USD, 2 attempts Exam Center- Delhi, Mumbai, Chennai, Bangalore, Hyderabad Required minimum 200 hours of training to clear the exam. Should learn Coding conventions, HIPAA complaince, Medical Billing Medesun Healthcare Solutions-
- 33. Board Exam-USABoard Exam-USA AHIMA:American Health Information Management Association Exam-CCS: Certified Coding Specialist Fees: 299 USD, 1 attempt Exam Center- Delhi, Mumbai, Chennai, Bangalore, Hyderabad Required minimum 250 hours of training to clear the exam. Should learn Coding conventions, HIPAA compliance, Hospital Coding and Medical Billing Medesun Healthcare Solutions-AHIMA Ambassador India.
- 34.
- 35. Thank you!Thank you! ContactInformation: MEDESUN HEALTHCARE SOLUTIONS PLOT 6, ROAD 1, DOCTORS COLONY SAROORNAGAR-HYDERABAD Phone-9966933693, 040-65266444 Email: info@medesun.com http://www.medesunglobal.com
Editor's Notes
- #18 Instructor/Speaker: YOU may want to become familiar with the first character of each possible chapter code…….. For example: F = Mental and behavioral disorders; K= Diseases of the digestive system, and the like. THESE alpha characters will always remain the same. (PAUSE AND MOVE TO NEXT SLIDE)
- #20 Instructor/Speaker: (Read the Slide) …….Understanding the Coding Character, yes CHARACTER NOT DIGITS as IN ICD-9. Let’s review this slide (INSTRUCTOR………walk through the slide, left to right….) (PAUSE and move to next slide)
- #21 INSTRUCTOR/SPEAKER: ………… Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter; and T15.02xD – Foreign body in cornea, left eye, subsequent encounter. ANY QUESTIONS?(PAUSE……….move to next slide)
- #22 Instructor/Speaker: Again look at the characters. The seventh character extenders are usually a letter, and are used to identify the encounter type. The most common seventh character extenders used in ICD-10-CM are: A – Initial encounter D – Subsequent encounter S – Sequela The 7th character is used in several chapters and the meaning is different depending on the chapter. (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters (PAUSE and …………NEXT SLIDE)
- #23 Instructor/Speaker: The seventh character is required for all codes within the category, or as stated by the tabular list instructions. In ICD-10-CM, in order to allow the seventh character to remain the seventh character, a dummy placeholder “x” must be used to fill in any empty character(s)………..FOR INJURY AND EXTENRAL CAUSE THE 7th CHARACTER IN THE CODE IDENTIFIES THE INJURY encounter and sequela information AND also for FRACTURE CODES this 7th character identifies the initial encounter, subsequent and sequela……..open you code books to page 803 and look at code S02………. (PAUSE and ……..NEXT SLIDE)
- #26 INSTRUCTOR/SPEAKER: ………… Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter; and T15.02xD – Foreign body in cornea, left eye, subsequent encounter. ANY QUESTIONS?(PAUSE……….move to next slide)
- #27 INSTRUCTOR/SPEAKER: ………… Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter; and T15.02xD – Foreign body in cornea, left eye, subsequent encounter. ANY QUESTIONS?(PAUSE……….move to next slide)
- #32 INSTRUCTOR/SPEAKER: ………… Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter; and T15.02xD – Foreign body in cornea, left eye, subsequent encounter. ANY QUESTIONS?(PAUSE……….move to next slide)