Medical Coding

CDC

Centers for Disease Control and Prevention

CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.

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NCHS

National Center for Health Statistics

The mission of the National Center for Health Statistics (NCHS) is to provide statistical information that will guide actions and policies to improve the health of the American people. As the Nation’s principal health statistics agency, NCHS leads the way with accurate, relevant, and timely data.

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification

The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) in the United States, has developed a clinical modification of the classification for morbidity purposes. The ICD-10 is used to code and classify mortality data from death certificates, having replaced ICD-9 for this purpose as of January 1, 1999. ICD-10-CM is the replacement for ICD-9-CM, volumes 1 and 2, effective October 1, 2015.

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WHO

World Health Organization

ICD purpose and uses

ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion that allows for:

  • easy storage, retrieval and analysis of health information for evidenced-based decision-making;
  • sharing and comparing health information between hospitals, regions, settings and countries; and
  • data comparisons in the same location across different time periods.

Uses include monitoring of the incidence and prevalence of diseases, observing reimbursements and resource allocation trends, and keeping track of safety and quality guidelines. They also include the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease.

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Student Note: The World Health Organization is currently on the International Classification of Diseases, 11th Revision (ICD-11). 

ICD-10-CM Background

International Classification of Diseases, Tenth Revision, Clinical Modification

World Health Organization (WHO) authorized the publication of the International Classification of Diseases External 10th Revision (ICD-10), which was implemented for mortality coding and classification from death certificates in the U.S. in 1999. The U.S. developed a Clinical Modification (ICD-10-CM) for medical diagnoses based on WHO’s ICD-10 and CMS developed a new Procedure Coding System (ICD-10-PCS) for inpatient procedures. ICD-10-CM replaces ICD-9-CM, volumes 1 and 2, and ICD-10-PCS replaces ICD-9-CM, volume 3.

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American Medical Association

What is a CPT code?

The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.

CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.

The CPT terminology is the most widely accepted medical nomenclature used across the country to report medical, surgical, radiology, laboratory, anesthesiology, genomic sequencing, evaluation and management (E/M) services under public and private health insurance programs.

AMA Article

8 Medical Coding Mistakes That Could Cost You

The article mentions the following mistakes:

  • Unbundling codes
  • Upcoding
  • Failing to check National Correct Coding Initiative (NCCI) edits when reporting multiple codes
  • Failing to append the appropriate modifiers, or appending inappropriate modifiers
  • Overusing modifier 22 (Increased Procedural Services)
  • Improper reporting of the infusion and hydration codes, which are time-based
  • Improper reporting of injection codes
  • Reporting unlisted codes without documentation
  • HCPCS

HCPCS

Healthcare Common Procedure Coding System

Each year, in the United States, health care insurers process over 5 billion claims for payment. For Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II Code Set is one of the standard code sets used for this purpose. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA).

The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. These health care professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs. Decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are republished and updated annually by the AMA. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.

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HCPCS Level II (National Codes)

Healthcare Common Procedure Coding System Level II

The Level II HCPCS codes, which are established by CMS's Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association's Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing.  Level II alphanumeric procedure and modifier codes comprise the A to V range.

CMS

Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services (HHS).

MPFS

Medicare Physician Fee Schedule Look-up Tool

This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS). It provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.).

The Medicare physician fee schedule pricing amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure's relative value unit (i.e., the RVUs for work, practice expense, and malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component.

NCCI

National Correct Coding Initiative

The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.

Read more here.

Medicare NCCI PTP Coding Edits

Since 1996 the Medicare NCCI procedure to procedure (PTP) edits have been assigned to either the Column One/Column Two Correct Coding edit file or the Mutually Exclusive edit file based on the criterion for each edit. The Mutually Exclusive edit file included edits where two procedures could not be performed at the same patient encounter because the two procedures were mutually exclusive based on anatomic, temporal, or gender considerations. All other edits were assigned to the Column One/Column Two Correct Coding edit file. There are important changes to these files described below.

Student Note: The Related Links section at the bottom is where the NCCI PTP Edits live as Excel documents.

Modifier 59 Article

The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. For PTP edits that have a Correct Coding Modifier Indicator (CCMI) of “0,” the codes should never be reported together by the same provider for the same beneficiary on the same date of service.

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MLN

Medicare Learning Networks

Free educational materials for health care professionals on CMS programs, policies, and initiatives.
Get quick access to the information you need.

How to Use NCCI Tools

Learn to navigate the CMS NCCI webpages, work with Medicare code pair edits and medically unlikely edits, and avoid coding and billing errors.

ICD-10-PCS

International Classification of Diseases, 10th Revision, Procedure Coding System

ICD-10-PCS is intended to replace ICD-9 volume 3 for facility reporting of inpatient procedures. Current Procedural Terminology (CPT) is still used for all outpatient procedures. Healthcare Common Procedural Coding System (HCPCS) is still used as before. Common procedures that are not unique to the inpatient setting, such as laboratory tests and educational sessions, were omitted from PCS.

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