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MIPS Webinar Answers Many Questions
On April 4, the Centers for Medicare & Medicaid Services (CMS) hosted a webinar to provide information on the Advancing Care Information (ACI) performance category of the Merit-based Incentive Payment System (MIPS). The ACI category is just one component of MIPS. For the 2017 performance year, there is also a Quality category and an Improvement […]
AAPC Knowledge Center
From the Trainer: ICD-10 FAQ #1 – If the US is the last to implement, why are there so many unknowns?
For the last year, I’ve traveled across the country providing ICD-10-CM and ICD-10-PCS education to coders and clinical documentation specialists. Our company’s model provides three separate training sessions for our clients: basic, intermediate, and advanced. This means lots of repeat visits to each client, lots of really hard questions, and tons of professional growth for me. I thought it was time to start a new series here on my Coder Coach blog: ICD-10 FAQs. This is a question I’ve been asked a lot lately as we get into advanced trainings and more controversial topics:
If the United States is the last country to implement ICD-10, why are there so many unanswered coding questions and why do we have to wait for Coding Clinic advice?
While it seems logical that someone would have figured out all of this ICD-10 stuff within the last 20 years as we’ve been “messing around” here in the US (please note the sarcasm, because I don’t really think we’ve been messing around; we’ve actually been quite busy), the reality of the situation is that the US version of ICD-10 is different from everyone else’s. The core ICD-10 code set was developed by the World Health Organization (WHO) and classifies causes of morbidity (i.e., diagnoses) and every country has the ability to adapt it further (e.g., ICD-10-CA in Canada, ICD-10-AM in Australia, ICD-10-CM in the US). Two things should have jumped out at you based on this statement:
- ICD-10 diagnosis codes may be different in Canada, Australia, and the US
- The international code set does not include procedures
- The Excludes1/Excludes2 convention, which solves a lot of problems from ICD-9 (and creates a few new ones) is not part of the WHO version
- The use of 7th character extensions for injuries and poisonings is not part of the WHO version
- The expansion of the external cause codes, which are not required for reporting, are not nearly as extensive in the WHO version
- While we have adapted diabetes terminology in the US to Type 1 and Type 2 diabetes, the WHO version still uses the insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) terminology that we’ve worked so hard to banish from our medical record documentation here in the States
So Many Books, So Little Time – Part 1
What’s Your Idea of a Best Seller?
Every once in a while I page through a magazine taking keen interest in the best seller and “must read” book lists that everyone is talking about. I usually tear out the pages for books that are interesting so I can download them later. And then I rarely read them. Or it takes me literally months to finish a book. I love to read, but frankly, after a day of reading code books, and spending a lot of time writing, I just don’t have the eye or mental energy to crack a book for fun.
My idea of a best seller is a string of code books that I use every day. Don’t worry though, I find other ways to have fun that have nothing to do with coding!
The last time I moved, I had lots of friends helping me lug boxes and it didn’t take long for them to zone in on the heaviest ones: they were labeled “code books.” I have code books for various coding systems going back several years and yes, they are heavy. And it’s hard to explain to the layman why I need so many books in such an electronic age. I’ve found it can also be challenging to explain the different code sets to novice coders. But alas, I am going to give it a try in a series of blog posts because you may not be exposed to all coding systems in coding school, but depending on the setting you work in, you may find you have to become familiar with something new.
I Don’t Hate Encoders
Let’s get one thing out of the way first, though. I have no issues with computers or encoders. In fact, I use a computer for almost everything and, like so many people, I am pretty addicted to my iPhone and iPad. But as a coding trainer, I learned by the book and I teach by the book and will always default to the book when I have a question. Encoders are only useful when the user understands the logic behind the program and that logic is based on the book.
In healthcare, we deal with two major planets of coding systems: the International Classification of Diseases (ICD) and the Health Care Common Procedure Coding System (HCPCS). And as if that wasn’t enough, those coding systems are divided into further classifications with different uses. Coding for a physician practice? Then you’d better brush up on different parts of the coding spectrum than what you’d see in a hospital. Coding outpatient services for a hospital? Then you need to know something different than what you would need to know if you were coding hospital inpatient services. Want to know how to code everything? Then it’s time to become familiar with your new best seller list. This post will start with the basic coding system that everyone uses.
ICD-9-CM Volumes 1 and 2: Everyone Does it
You probably aren’t surprised to hear that the government determines which codes we use in the U.S. But you may be surprised to hear that the law that defines those coding systems is a little law called HIPAA. Yes, the same law that addresses privacy and security of medical information also tells us which codes we must use to report healthcare services. This is why some code books boldly state on the cover that they support HIPAA compliance. In order to make health information portable and comparable,the Healthcare Portability and Accountability Act of 1996 (HIPAA) makes sure we’re all speaking a common language, expressed in codes, before we exchange data electronically. The privacy and security provisions are simply byproducts of making sure health care data can be shared electronically.
ICD-9-CM has three volumes. The first two volumes include the diagnosis codes. This includes the tabular (Volume 1) and index (Volume 2). I’ll address volume 3 in part 2 of this series. Bottom line here: every HIPAA-covered entity, which includes hospitals and physicians (and excludes workers’ compensation and car insurers) utilizes ICD-9-CM codes to report diagnoses on a claim.
ICD-9-CM codes have 3-5 digits with a decimal point after the first three digits. All codes are numeric except for V codes, which start with a V and then have two numeric digits and may have up to two more digits after the decimal point; and E codes, which start with an E and have three numeric digits and may have an additional digit after a decimal point. E and V codes are actually “supplementary” codes that are not included in the main part of the ICD-9-CM volumes 1 and 2 code set.
Here are some examples of ICD-9-CM codes:
- 486, Pneumonia, organism unspecified
- 401.9, Essential hypertension, unspecified
- 250.00, Diabetes mellitus without mention of complication, Type II or unspecified type, not stated as uncontrolled
Examples of supplementary codes:
- V08, Asymptomatic HIV infection status
- V27.0, Outcome of delivery, single liveborn
- V76.51, Screening for malignant neoplasm of colon
- E961, Assault by corrosive or caustic substance, except poisoning
- E885.3, Fall from skis
So Many Books, So Little Time- Part 2
Here’s another critical tip: if you are buying ICD-9-CM code books, it can be super confusing because there are various publishers and lots of code books with different-yet-similar titles. If you purchase an ICD-9-CM code book for physicians, it will have only volumes 1 and 2. If you buy ICD-9-CM for hospitals, you get all three volumes, or the complete ICD-9-CM code set.
- 47.0, Appendectomy
- 36.97, Insertion of drug-eluting coronary artery stent(s)
- CCA (Certified Coding Associate) from AHIMA
- CCS (Certified Coding Specialist) from AHIMA
- CIC (Certified Inpatient Coder) from AAPC (new)
So Many Books, So Little Time – Part 3
Yes, it’s true. There are so many books and so little time, I haven’t even had time to blog for the last two weeks because I had my nose in two of them. Thank God for smartphones and long waits at the car wash, or who knows how much longer it would been before I posted again!
Three Levels of HCPCS
The Healthcare Common Procedure Coding System (HCPCS) has three different levels and just to make things more interesting, Level I is not usually called HCPCS, it’s called CPT. The Current Procedural Terminology (CPT) was developed and is maintained by the American Medical Association (AMA).
By Physicians for Physicians
What makes CPT so unique is that it is the only coding system in the HIPAA-approved code sets that is developed by physicians for physicians. The codes you see in the CPT code book are the result of various medical and surgical societies coming together with the AMA to decide which procedures deserve their very own CPT codes. Every year at the AMA’s CPT Symposium, coders from around the country gather in Chicago to listen to these physicians present the coding updates for the coming year. It’s an expensive but valuable conference that I think every coder should experience at least once.
CPT codes are primarily used by physicians to report procedures and services performed in every possible setting where a physician – or qualified health practitioner – may see a patient: his office, the hospital, a clinic, a nursing home, etc. But it doesn’t stop there. CPT is also used to report hospital outpatient procedures. Of course, since there are still a lot of procedures that are performed solely as inpatient, hospital coders use a small number of CPT codes in comparison to pro-fee (physician) coders.
Three within Three
- The procedure must have FDA approval
- The procedure must be commonly performed by practitioners nationwide
- The procedure must have proven efficacy
- Evaluation and Management (E/M) (codes beginning with 9)
- Anesthesia (codes beginning with 0)
- Surgery (codes beginning with 1-6)
- Radiology (codes beginning with 7)
- Pathology and Laboratory
- Medicine (the rest of the codes beginning with 9)
- 99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity
- 12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6cm to 7.5cm
- 75625, Aortography, abdominal, by serialography, radiological supervision and interpretation
- 1040F, DSM-5 criteria for major depressive disorder documented at the initial evaluation (MDD, MDD ADOL)1
- 3775F, Adenoma(s) or other neoplasm detected during screening colonoscopy (SCADR)12
- 0387T, Transcatheter insertion or replacement of permanent lead less pacemaker, ventricular
- 0274T, Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic
By the way, the errata is on the list of approved materials for the AAPC exams. The year I took the CIRCC exam (Certified Interventional Radiology and Cardiology Coder), there were a lot of errors in the electrophysiology code notes and the errata was something I really needed. Be sure to check it out!
I also really can’t talk about CPT without bringing up a little tiny thing from the hospital side called a charge description master (CDM), or as it’s more commonly called, the charge master. It’s as masterful as it sounds: a line-item listing of everything a hospital department charges for. Each line item has a description of the charge, charge amount, and sometimes a CPT code. One of the most difficult transitions I see in pro-fee coders crossing over to the hospital side is not understanding that the coder doesn’t code everything. There are many codes that are assigned automatically by the charge master when a charge is applied to the bill. This is the case when the CPT code doesn’t require a lot of subjective reasoning (e.g., lab test or x-ray). For those procedures and services, such as operative procedures, that require subjective reasoning, a real-live coder will assign the code. It may sound counter intuitive, but this actually increases the amount of coding-related jobs in a hospital. The charge master analyst requires coding knowledge as he/she works with hospital departments to set up charges, research appropriate CPT codes for the procedure or service, and determine if it will be hard coded (by the charge master) or soft coded (by a person in coding).
CPT Made (Too?) Simple
This posting really oversimplifies the CPT code set (that’s right, it gets more complex!), but it’s a start if you’re still finding your way in the coding field. I have a love-hate relationship with CPT because I find it both challenging (love!) but also frustrating when I hear conflicting coding advice between CMS, the AMA, and medical/surgical societies (hate!). If you find that you love all aspects of CPT, then you can have a very lucrative career in either the pro-fee or facility coding arenas.
Stay tuned to this series… Next up is HCPCS Level II.