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  • Medical Coding

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    Raj Dhotre
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    Medical coding involves transforming descriptions of medical diagnoses, procedures, and services into numeric or alphanumeric codes. These codes are used for reimbursement purposes, administrative functions like staffing and scheduling, statistical reporting, clinical research, and marketing. Accurate medical coding allows for standardization and uniformity, avoids issues like upcoding and unbundling, generates clean claims, and minimizes rejections, underpayments, and overpayments. It also helps accelerate reimbursements and prevents fraudulent billing.

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    Medical coding involves transforming descriptions of medical diagnoses, procedures, and services into numeric or alphanumeric codes. These codes are used for reimbursement purposes, administrative functions like staffing and scheduling, statistical reporting, clinical research, and marketing. Accurate medical coding allows for standardization and uniformity, avoids issues like upcoding and unbundling, generates clean claims, and minimizes rejections, underpayments, and overpayments. It also helps accelerate reimbursements and prevents fraudulent billing.

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    600 views7 pages

    Medical Coding

    Uploaded by

    Raj Dhotre
    Medical coding involves transforming descriptions of medical diagnoses, procedures, and services into numeric or alphanumeric codes. These codes are used for reimbursement purposes, administrative functions like staffing and scheduling, statistical reporting, clinical research, and marketing. Accurate medical coding allows for standardization and uniformity, avoids issues like upcoding and unbundling, generates clean claims, and minimizes rejections, underpayments, and overpayments. It also helps accelerate reimbursements and prevents fraudulent billing.

    Copyright:

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    MEDICAL CODING – SYNOPSIS

    MEDICAL CODING
    DEFINITION
    Transformation of narrative descriptions of diseases, injuries and healthcare procedures into
    numeric or alpha numeric designations (codes)

    PURPOSE
     Codes developed to identify all reasons for seeking healthcare

     Codes are detailed in order to accurately describe the diagnoses and the procedures
    performed to test or correct these diagnoses

     Identifying symptoms that must be evaluated and to alert other healthcare professionals to
    life-threatening allergies

     Reporting services performed for reimbursement

     Helping with administrative functions such as staffing, scheduling, and adding or decreasing
    healthcare services

     Comparing facilities and planning for new services in underserved areas


    CODING CLASSIFICATION STANDARDS
    HIPAA names the following code set standards:
    International Classification of Diseases, 9th revision, Clinical Modification ICD-9-CM Volumes 1 & 2
    (diagnosis codes)

    International Classification of Diseases, 9th revision, Clinical Modification ICD-9-CM Volume 3


    (procedure codes)

    Current Procedure Terminology (CPT) (outpatient procedure codes)

    Health Care Common Procedure Coding System (HCPCS)—This code set, established by the Centers for
    Medicare and Medicaid Services (CMS), primarily represents items and supplies and non-physician
    services not covered by the American Medical Association CPT-4 codes.

    International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) is the new
    diagnosis coding system developed as a replacement for ICD-9-CM, Volume 1 & 2.

    International Classification of Diseases, 10th revision, Procedure Coding System (ICD-10-PCS) is the
    new procedure coding system developed as a replacement for ICD-9-CM, volume 3.

    National Drug Code (NDC)—The NDC is a code that identifies the manufacturer, product, and package
    size of all medications recognized by the FDA.
    ADVANTAGES OF MEDICAL CODING
    Standardization
    Medical coding allows for standardization of terms by assigning codes instead of using
    subjective terms. For example, heart attack and myocardial infarction are two words for
    the same thing and are reported with one medical code.

    Uniformity
    Medical codes create uniformity for procedures, services, supplies and other resources
    utilized for reimbursement and reporting. Surgical gauze used at one facility has the same
    medical code as surgical gauze used at another facility. This allows insurance payers to
    reimburse accurately.

    Reimbursement
    Insurance billing claims use medical coding for reimbursement. Medical codes are grouped
    together and assigned an amount based on factors like insurance payer, type of provider
    and location.

    Evaluation of Care
    Medical codes are used to determine scheduling for care. Codes for procedures performed
    frequently are reviewed to plan specialized staff and resources.
    ADVANTAGES OF MEDICAL CODING
    Statistics
    Statistical reporting, both within and outside of health care organizations, is done using
    medical codes. For example, reports for number of injuries caused by motorcycle accidents
    come from medical coding statistics reported to health care agencies.

    Clinical Research
    Medical coding provides important information used in clinical research. Information, like
    cancer codes, is reported to each state to help researchers understand patterns and where to
    concentrate efforts.

    Reporting
    Medical coding helps to meet state and federal reporting requirements. Medical codes are
    used to gather and submit mortality information by healthcare professionals and institutions.
    Additionally, medical codes are used to perform regular internal reporting on topics such as
    hospital-acquired infections, reimbursement and resource usage.

    Marketing
    Medical codes may also be used for marketing of health care services. The health
    care organization uses codes reported for diseases occurring most often to create a
    marketing campaign to educate patients and the community on those diseases.
    ADVANTAGES OF ACCURATE MEDICAL
    CODING
    Avoid Upcoding
    Upcoding is the replacement of the most appropriate code for a service or procedure
    by a code for a more complex service

    Example – A physician codes all established patient outpatient visits with the
    intermediate level CPT code 99213, regardless of the true complexity and work
    involved with each visit. The physician never uses the lower level codes 99211 or
    99212, or the higher level codes 99214 or 99215. This is unfair to patients who have a
    low complexity visit deserving of a 99212 code because their copayment with the
    99213 code may be inappropriately high. The unusual coding pattern for this physician
    (many 99213 services, no 99211, 99212, 99214 or 99215 services) can trigger a HCFA
    audit.

    Avoid Unbundling
    Unbundling is billing of multiple procedure codes for a group of procedures that are
    covered by a single comprehensive code
     Either by Fragmenting one service into component parts and coding each
    component part as if it were a separate service
     Or Reporting separate codes for related services when one comprehensive code
    includes all related services.
    ADVANTAGES OF ACCURATE MEDICAL
    CODING
    Generate Clean Claims

    Minimize Claim Rejections / Denials

    Minimize Underpayment / Overpayment to Healthcare providers

    Reduction in overhead costs for Healthcare providers related to compliance procedures


    in case of incorrect claim amounts / charges mentioned based on medical codes
    assigned on the claim forms

    Accelerate claim reimbursements to Healthcare Providers

    Avoid any fraudulent claims / charges by Healthcare Providers

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