Level II – This is a standard coding system used by physicians and other health care professionals to bill to Medicare and Medicaid for medical services performed. This level coding system is used primarily to identify any products, supplies, and services that are not provided in the CPT codes of level one. These services include ambulance services, durable medical equipment, prosthetics, orthotics, and supplies that are used in a physician’s office. Level II codes are alpha-numeric codes. They consist of one alphabetical letter followed by four numeric digits.
Volume 1 (provides tabular lists containing cause-of-death titles and codes and inclusion and exclusion terms for cause-of-death titles.)
Volume 2 (Contains descriptions, guidelines, and coding rules.)
Volume 3 (Contains an alphabetical index to diseases and nature of injury, external causes of injury, table of drugs and chemicals.)
2. It establishes whether there is a medical emergency or necessity of some kind, regarding the services and procedures provided by physicians.
3. It determines the level of health care being provided by the physician.
A3 is Use of codes for reporting purposes
A4 is Placeholder character
A5 is 7th Characters
Volume 2 (Contains descriptions, guidelines, and coding rules.)
Volume 3 (Contains an alphabetical index to diseases and nature of injury, external causes of injury, table of drugs and chemicals.)
G Codes: G codes are used to identify procedures and services, that have no codes listed in the CPT.
Q Codes: These codes are used to identify services, whose codes are not listed in the CPT. Q codes include drugs, biologicals, and other types of medical equipment. They are necessary for claims processing purposes.
K Codes: These codes were established by the DME MACs (Durable Medical Equipment Medicare Administrative Contractors). The K codes are used when the permanent national codes don’t have any codes to implement a DME MAC medical review policy. For example, if certain regional medical review coverage policies are needed, the K codes would be used for such purposes of identifying product categories and supplies for such coverage policies.
S Codes: Private insurers use S codes to report drugs, services, and supplies where no national codes exist. The S codes are used to assist such private insurers when they are engaged in implementing policies, programs, and claims processing. Medicaid also uses these codes. Medicare doesn’t.
H Codes: H codes are used by Medicaid, when separate codes are required for identifying mental health services including alcohol and drug treatment services.
T Codes: T codes are used by the Medicaid office when there are no permanent national codes available, and a code is required to satisfy the Medicaid program. Medicare doesn’t use T codes.
Dental Codes: This category is separate from the national codes. The American Dental Association (ADA) releases a publication called The Current Dental Terminology (CDT). This publication list codes that dentists use in billing for procedures and supplies. Although, the CDT codes are a part of the HCPCS Level II codes, they maintained by the ADA, who also makes decisions on what codes to add, delete, and revise.
Miscellaneous Codes: These are codes that are not classified. These codes are used when a healthcare provider submits a bill for an item or service, where no code exist for it. Such a code can include a new drug that the Food and Drug Administration approved, but there is no code for it yet. This way the healthcare provider can bill for the drug without waiting for the code to be created for it. When a claim is filed and it includes a miscellaneous code, the item or service the service provider is billing for, has to be described precisely. The pricing information also has to be included, along with a reason why the item or service was needed.
Temporary National Codes: Temporary codes are used when a national program operational need is not met by an existing national code. Temporary codes can change every year, depending on if a permanent code is created, to replace the temporary code. If no permanent code is created, the temporary code doesn’t have an expiration date.
Anesthesiology (00100 – 01999, 99100 – 99140)
Surgery (10040 – 69990)
Radiology (70010 – 79999)
Pathology and Laboratory (80049 – 89399)
Medicine (90281 – 99199)
plus- code is adding on
Revised – changes have been done
dot – symbolizes the code is new
sideway triangles – words or content has changed
additional pointer – AMA published references
exemptions to use of modifier – tells you modifier 51 is nt allowed
conscious sedation – 2005 symbol tells you it was used
Relevant history of the patient;
Physical examination results;
Any prior diagnostic test results;
Assessment of the visit including tests results or diagnosis;
The medical plan the patient has;
Date of service and identify of patient.
The risks should be explained to the patient
The patient’s progress needs to be reported including response to treatment, changes in a treatment, or a revision of the diagnosis;
All diagnosis and treatment codes placed on the claim form must be supported by the documentation in the medical record.
2. Minor: The physician sees patient and gives a good prognosis with a good treatment plan that will cure problem.
3. Low severity: Physician sees patient but realizes problem is not severe enough to warrant giving any type of treatment. The patient is expected to recover fully.
4. Moderate severity: Physician diagnosis shows patient with a terminal illness. As such, physician cannot give a clear prognosis.
5. High severity: Physician agrees that patient has a long-term illness that will just about cripple the patient. The chance of the patient surviving is small.
Ears, nose, mouth, and throat
2. Amount and/or complexity of data
3. Risk of significant complications, morbidity, and/or mortality
and Date of service and identify of patient
2. Technically speaking anesthesia refers to as suppressing the ________ by using drugs.
3. In the CPT book, there is a section with codes for anesthesia. These codes cover preoperative and postoperative visits by the anesthesiologist, along with care during the procedure, watching the patient’s vital signs, and what else.
4. You may already know what the respiratory system is. If you don’t this involves the left and right lungs, as well as nose, nasal cavity, nasopharynx, oropharynx, laryngopharynx, and larynx. True or False.
5.The cardiovascular system involves the heart along with what else.
The blood vessels
6. The hemic involves the spleen and bone marrow, while the lymphatic system involves the lymph nodes and the __________ channels.
2. The proper coding system to use in most cases would be what ______ looks on as the proper type.
3. If you use the CPT book instead of ICD-10-CM, you will find the integumentary system procedures listed in a subsection of the Surgery section and will fall in the code range of 10065-18456. True or False.
4. If there was any type of incision or drainage associated with surgery, the codes that may be used would start with is _______.
5. Debridement is a procedure where the physician removes foreign material from an infected lesion or wound. For this type of procedure, the coder would use codes that start with ________.
6. The code for doing a flap starts at code _________, and goes to _____, depending on the location of the body.
Or, Q68.1 Congenital deformity of finger(s) and hand or Q74.3 Arthrogryposis multiplex congenital.
2. Pathological dislocations use code M24.30, Pathological dislocation of unspecified joint. This type of dislocation may be the result of an underlying disease that caused the affected bone to become weak enough to break.
3. Recurrent dislocations use code M24.40 Recurrent dislocation, unspecified joint. This type of dislocation seems to occur most often in a major joint.
Rheumatoid arthritis is different. You would use the subcategory M06.9 Rheumatoid arthritis. Rheumatoid arthritis is classified as a chronic, systemic, inflammatory connective tissue disease. The reason a distinction has to be made between the two conditions is that they both inflammation and are listed under arthropathy.
When using ICD-10-CM you may find other procedures associated with arthropathy. These will be found in categories M02. The procedures are extra terms you may not see as often, but will be used from time to time. These terms are:
Arthrotomy: This involves an incision into a joint.
Arthroscopy: This involves using an endoscope to view a joint.
Biopsy: This involves the removal of tissue so it can be examined.
Arthrodesis: This is a process of making the joint immobile by binding it together.
Arthroplasty: This involves an operation to fix or mend a joint.
Replacement: This involves removing of diseased tissue in the joint and replacing the tissue with something artificial.
Revision: This involves doing surgery on a joint that already had surgery done to it.
Myelopathy: This is pathology of the spinal cord. This problem occurs because the vertebrae develop arthritis in places.
Cervical: This term refers to the seven cervical vertebrae.
Thoracic: This term refers to the twelve thoracic vertebrae.
Lumbar: This term refers to the five lumbar vertebrae.
Sacral: This term refers to a single fused bone that has five segments attached to it.
Coccyx: This term refers to a single fused bone that is located at the end of the spinal column. This bone is made up of three to five segments.
Lumbosacral: This term refers to one or more lumbar vertebrae along with the sacrum.
Enthesopathy: This term refers to pathology occurring at the site where muscle tendons and ligaments attach to bones.
There are other conditions where orthopedics do a diagnosis and use procedures. Two of these conditions are malunion and nonunion of factures, and bone infections.
Malunion and Nonunion of Fractures
These conditions are used when a patient visits his physician and the physician notices the bones are not healing properly. At that time, the physician will take the required steps to ensure the bone heals properly. The proper codes to use for this situation would be S42 – S82 depending on add-ons and S02-S12 depending on add-ons.
2. A fracture is considered a break in an organ or _______.
3. A dislocation is disarrangement of __________.
Two or more bones
4. It is because there is so many and they overlap, arthropathy has been not termed as a general condition of the joint. True or False.
5. Osteoarthritis is known principally as a __________________.
A degenerative joint disease
6. When the physician surgically repairs a fracture, the code use will be ______.
2. What book is the Hypertension Table located?
3. What series of codes are often used for cardiology in the CPT codebook? The 30000 series is one of them. Name two others.
70000 and 90000
4. Codes 93724, 93279-93281, 93288, 93293, 93294, and 93296 deal with pacemakers, while 93282-93284, 93289, 93295 and 93296 deal with cardioverter-defibrillator systems. True or false.
5. The basic codes you will find in the 30000 series will be based on surgeries to correct an illness or disease of the ________
1-a, 2-b, 3-c, 4-a, 5-c.
If the visit shows an impending or threatened condition, you would use the codes in chapter Chapter 15 O98.7- and Z2: Pregnancy, Childbirth, and the Puerperium. If HIV was involved in some way, use chapter 15 codes. This chapter relates to HIV cases and codes. If the patient is going to an OB/GYN as a routine visit and no complications are present, you would use code Z33.1, but if there are complications, you would go with codes in chapter 15. The most used code for complications is Code O94.
Basically, there are hundreds of different diagnoses and procedures done for a patient who is pregnant and for one who is not pregnant. If you do coding for this specialty, you must understand what the terms are, what the diagnosis is, and what procedures the OB/GYN used. You will also have to know exactly what the patient’s complaint was. All of this should be listed on the medical record. Read it over. If you do not understand what is said, seek the OB/GYN for clarification.
If the labor went fine with no complications, you would look in the CPT codebook and use code 59400, which deals with routine obstetric care including antepartum care (time of pregnancy from conception to onset of delivery), vaginal delivery, and postpartum care. If you use ICD-9-CM, the code to use would be 650, meaning normal delivery, as well as code V27.0, that indicates the outcome of delivery was a single live baby.
If a cesarean delivery had to be made, you would use code 59510 in the CPT codebook. If there should be multiple births involved, the code for this would be P01.5 Newborn (suspected to be) affected by multiple pregnancy in the ICD-10-CM codebook. If there should be a problem with fertilization where the egg attaches to the fallopian tube instead of the uterus, you would use the CPT codebook and look for codes 59120-59151.
If the patient is pregnant and wants an abortion, you can find the codes for this in the CPT codebook using codes 59812 to 59870. The code used will depend on the type of abortion requested.
Other problems that may occur could be related to delivery. If the baby comes out the wrong way, which results in complications, you would have to use ICD-10-CM codes to list this. The category O33.0 is most commonly used.
Or Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings.
2. When working with an OB/GYN, you will find patients are private with their doctors. Therefore, when verifying documents, you have to do what.
Observe patient confidentiality at all times
3. In the reproductive system, the ovaries are considered the _______ organs.
4. When using the ICD-10-CM codebook, you will notice that _________ covers pregnancy.
5. The OB provides _____ what for the patient.
6. The main job of a GYN is to take care of _______.
2. Diagnostic Ultrasound
3. Radiation Oncology
4. Nuclear Medicine
M-mode: This is when one dimension is used but also with trace movement. This trace movement is used to record amplitude and velocity of moving echo-producing structures.
B-scan: This is a two-dimensional scan with a two-dimensional display.
Real-Time Scan: This is a two-dimensional scan that includes a display of two-dimensional structure and motion with time.
The most common radioactive materials used are radium-226, cobalt-60, cesium-137, and iodine-125. The codes used for radiation therapy are normally 77401-77416.
Heart scans are done mainly to detect possible heart attacks. They also use scans during stress testing. Lung scans are done to detect lung diseases like emphysema. Kidney or renal scans are done typically to check and evaluate the overall function of the kidneys. Thyroid scans are done to see if there are any nodules present.
2. In the CPT codebook, there is a section on radiology. In this section will be four subsections. Diagnostic Radiology or Diagnostic Imaging is one of them. Name one more.
3. If you happen to work with a radiologist who does an ultrasound procedure, you may see one of four types of codes. One is A-mode. Name three more.
M-mod, B-scan, and Real-Time Scan
4. Radiation oncology is a practice where radiation is used to treat psychosis. True or False.
5. Nuclear medicine is a practice of where ________ are administered to patients with the idea of diagnosing the disease.
1-a, 2-c, 3-d, 4-b, 5-c.
Immunizations: Beginning with the January 1, 2011 CPT codebook, codes 90465-90468 were deleted. The new codes are 90460-90461. These are mainly for pediatric-specific immunizations. The codes 90471-90474 remain the same.
Infusions: The code to use for this would be 96360-96361.
Psychiatric Services: When it comes to psychiatric services, many times the patient is administered to the hospital. If this is the case, there is a psychiatry series of codes you would use that are in combination with E/M codes. The physician could do an evaluation, therapy, or both. Make sure to read the medical record carefully, for it will tell you which options are used. This way you will know what code to find.
Dialysis: Dialysis involves removing waste from the kidneys when the kidney failed. This removal process is done by some type of medical equipment like a catheter. Kidney failure is referred to as End Stage Renal Disease (ESRD). When you look up this term in the CPT codebook, you will find the codes are divided up into categories to deal with ESRD. When selecting the code for ESRD, if the patient is an outpatient only, you will do it for one time only. The code will include the beginning of dialysis, E/M outpatient care, and telephone calls that need to be made. If the patient is admitted to the hospital, you will need to select additional E/M codes. The dialysis that is done at the hospital will also need different codes. If the dialysis is on a per day basis, you will need to use code series 90922.
Ophthalmology: An ophthalmologist is an eye doctor who does testing services as well as surgical treatments. When the ophthalmology does his job, he may perform one of three types of services: ophthalmological services only, ophthalmological services in combination with an evaluation or E/M service, or E/M service only using the E/M guidelines as set forth in the 1995 and 1997 guidelines, with an additional code for any ophthalmological services he may perform. When looking in the CPT codebook, you may find codes that can be used in conjunction with E/M codes. If the ophthalmologist provides a combination of services, he will do so at one of two levels: intermediate and comprehensive. The code you use will depend on what level is used. If contact lenses are prescribed, an additional code will be used. If eyeglasses are prescribed, the code series used would be 92340.
Cardiovascular: When discussing the pulmonary part of the cardiovascular system, the codes will also include laboratory procedures. The code for medication is not listed. You will find the codes for medication in the HCPCs Level II codebook. For most other codes involving this topic, see lesson 9 – Cardiology and the Cardiovascular System.
Health and Behavior Assessment: If a physician were to provide psychiatric services, you are a coder would select an E/M code, not the code listed in the chapter on medicine in the CPT codebook. If a psychiatrist were to perform the services, the codes to use would be in the 96150 series.
Chemotherapy: If chemotherapy is used, the codes selected would be for the administration of the medication only. If any other treatment options are used, additional coding would be required.
Physical Medicine and Rehabilitation: if the patient has to undergo some kind of rehab services, or needs to see a physical therapist, the code series you would use is 97001.
Acupuncture: If there is a situation, where the patient needs to have acupuncture done to treat an illness, the code series 97810 would be used. Service is counted in 15 minutes intervals. Usually within 15 minutes the acupuncture has worked. By the way, the time required for the needles to remain inserted does not count. There are two types of acupuncture: electrical and nonelectrical. Therefore, you will need to find which procedure was used, and code it accordingly.
Home Health Procedures: If at any time, a patient is at home and a home health aide visits him, or a physician has to make a house call, the proper code to record this would be in the 99500 series of codes.
2. Immune globulin is an __________ with similar antibody activity as regular antibiotics.
3. ______ is where a medicine is fed to the patient intravenously by means of a bag or bottle, over a period of time.
4. Dialysis involves removing waste from the ________.
The state of the community economically
The experience of the physician
The medical specialty
Typical charges by other doctors
The cost of the service or treatment
2. Most registration forms contain basic information like the patient’s name, address, birth date, social security number, and marital status. Name two more items that may be found on the form.
Telephone numbers and Insurance info
3. When considering fees, the physician is billed based on his _______, his diagnoses, and the services he provides.
4. The medical staff is also obligated to inform the person of the cost of the visit before any medical procedures are done. True or False.
5. When is it usually the time to engage in a collection agency?
This means that when they get to the medical facility they will have to fill out a health insurance claim form. These health insurance plans are provided by employers, health maintenance organizations, Medicare, Medicaid, individual policies, TRICARE/CHAMPVA, or worker’s compensation.
When filling out claim forms, they can be done electronically or done by filling out an actual form. The form you will use is referred to as the CMS-1500.
When you look at a claim form, you will notice there 33 items or Blocks that need to be filled out. There will be certain blocks that need to be filled out corresponding to the type of health insurance the patient has. Other blocks are standard but are required to be filled in. The forms are in red to help with scanning. This is the procedure in most medical facilities.
In order to fill out the form, most data is found on the patient’s registration form. Before entering the data into the claim form, make sure the patient has signed the release of some kind of medical information statement.
2. What is the form that will be filled out and submitted for reimbursement?
3. The CMS-1500 claim form has how many blocks.
4. Of all the blocks in the form, only one block has to be filled out by hand. Which block is that?
The signature block
5. In 1965, Congress passed Title 19 of the Social Security Act. What program was established form this act?
6. What is Tricare for?
To treat families of military personnel
7. In dealing with Worker’s Compensation, there are five types of benefits provided. One is for medical treatment. Name one more.
The payment cycle actually begins when the patient arrives for his/her appointment. If it is a hospital visit where inpatient care is involved, the payment cycle starts when the patient arrives at the emergency room.
To make sure the payment cycle is successfully completed, proper information has to be gathered and verified. This information includes the patient’s current name, address, insurance company ID, and so forth.
When filling out the claim form, all data entered has to be accurate. Inaccurate information is what causes many rejections from insurance companies, and eventually audits. If a claim is rejected, at that time the medical practice and file an appeal. The medical practice must know the appeal process before engaging it.
If an audit were to occur, the first form of contact should be with the firm’s attorney. It is important to use an attorney because they know how to handle auditors and the decisions they make.
2. When medical facilities submit claim information, it is a requirement by law that each field in the claim form be accurate. What three codebooks are used when filling out the CMS-1500 claim form?
CPT, ICD-10-CM, HCPCS Level II
3. If the claim form has been denied or rejected, what is the first step to take?
File an appeal with the insurance company
4. If a medical practice firm were to get a notice that an audit is to be done, what is the first action required by the practice.
Seek an attorney
As a coder, you will be responsible for learning ICD-10-CM coding. You will discover that ICD-10-CM has multiple coding guidelines. You will see these guidelines in the coding manual. You can also get them from the American Hospital Association (AHA).
DRGs are built upon a group of major diagnostic categories (MDCs), which are grouped by body system. Currently, there are 25 separate MDCs under PPS. These initial groups are based on broad categories with each category broken down even further into 500 DRGs. Each DRG is based on the hospital base rate and relative weight. The hospital base rate is established by CMS and is determined by type of hospital, the location, and services provided. The relative weight is a value that is assigned by Medicare.
2. When working as an inpatient coder, you will use ICD-10-CM. What Volumes will be looked at for the right codes?
Volume 1, Volume 2, Volume 3
3. Who provides the coding guidelines for the ICD-10-CM?
4. Most hospitals use several ways to be paid for their services. One way is to charge per diem. What are two other ways?
Using contract rate and Based on diagnosis related group (DRG)