Hello this is Cindy. Today we're going
to talk about Chapter 1, which is
really just an overview of the
introduction to clinical coding. It's
really important that you understand
the information that's on this slide. It is
also in your textbook. You will see test
questions about it because it is what is
involved in reimbursement in our country,
for how we get reimbursed for our medical
care. ICD-10-CM, as you can see, is used to
report "diagnosis" in any setting, physician
office, hospital outpatient, hospital
inpatient and that would include
ambulatory surgery. ICD10 is the code set
that is the diagnosis that explains why
a patient is seeking care. Every
procedure code has to have a diagnosis
code that provides medical necessity for
the procedure. So a claim for a CPT code
must have at least one ICD-10-CM code
with it and then the outpatient and
inpatient breaks out the way you see it
here. It's really important that you know
this. The way we teach these codes in our
school, the diagnosis coding is HIT220/221
CPT is HIT241 and HIT231 is
ICD-10-PCS. Let me say that again. In our school
ICD-10-CM is taught in HIT220/221,ICD-10-PCS is taught inHIT231
and CPT is taught in HIT241.
We don't teach HCPCS, the Level 2
HCPCS as a separate book because
it's so rare you as a coder are going
to be selecting those codes. They are
usually hard coded, meaning they are set
up in the reimbursement system so that
someone just pushes the button and that
code gets assigned. Whenever you are
looking at prosthetics
or
specific services that are not covered
in the CPT book. Things you need to know
about CPT-it is published by the
American Medical Association and updated
annually and all these changes are
effective January first of each year. You
may recall from ICD-10-CM that the ICD
excuse me the ICD codes are updated
October first of every year. The CPT code
book has three categories. Category I
has six main sections, the majority of
our CPT codes are in the Surgery section
but there is also Categories II and
III and the Modifiers. Those are
considered supplementary. Category II
codes are used in performance assessment
and quality improvement even though they
are used primarily to track quality
improvement activities. Some payers
actually require them so it may be that
you would be assigning them on a claim.
The example given in the textbook is that a
specific payer might require that the
body mass index is reported whenever
submitting a CPT code for any
nutritional therapy, so you really have
to know your payers and know what their
requirements are. Category III codes
include temporary codes that represent
emerging medical technologies. These are
things that have not been approved by
the FDA yet so they don't have a CPT
code but for good reason, it wants to be
tracked who's using them especially
in research, Modifiers, we will study a lot
more in Chapter 3, but these are used to
report additional information about any
unusual circumstances. It doesn't change
the basic definition of a CPT code but
it gives information about other
things that happened while that
procedure was being performed.
Sometimes HCPCS gets confusing because CPT is
really HCPCS level I; we just don't
call it that. We call it CPT and HCPCS
level II, we call HCPCS, for
whatever reason. But what's the important
thing for you to remember is that two
different entities
developed these code sets. AMA developed
and maintained CPT and CMS developed
and maintains HCPCS and for that
reason, if CMS disagrees with anything in
the CPT codes they can't change the CPT
codes. Only AMA cany change CPT codes so
what CMS would do then is establish a
guideline or a rule or something for
a Medicare patient, (the coders) they're going to do
this, this, or this. So even though they
don't they can't control one another's
code sets, they do control reimbursement
by having guidelines that people have to
have to follow to get paid.This is just
reiterating HCPCS level 1 is CPT
and HCPCS level 2 (also called the National
codes) All insurance companies use
the HCPCS codes, not just CMS. Even
though CMS developed them. Medicare
Medicaid and the private insurers use
HCPCS codes and modifiers in the
claims processing. CMS 1500 (forms)
are used for a physician office for the
physician's payment. CMS 1450 (form) also
known as the UB04 form, used for hospital
inpatient and outpatient services. There
are good examples in your textbook of
what these claims forms look like.
NCDs and LCDs are
national and local coverage
determinations. This comes into play
because Medicare policies include two
types of coverage. You have your national
coverage and your local coverage. There
are contracts between CMS and private
insurance companies that are known as
"carriers". There's also contracts with
intermediaries and with contractors who
actually process the Medicare claims in
local regions. I believe the
processor for Medicare in Colorado is
Novatas. I'm not positive about that
but I'm pretty sure that's right. I'm not
quite at Medicare yet so I don't know
for sure but I think that's right and
the only other thing I would say about
that, in general, the national
coverage determinations are what's
followed and the only time a local (coverage determination) comes
up is when there isn't a national
coverage determination and
then the insurance companies might have
a local coverage determination. That's
short and sweet for this Chapter 1. It's
really just an overview of the coding
systems that are required under the law,
that would be the Medicare law as well
as HIPAA, requires that we use these code
sets the way that I mentioned earlier. If
you have any other questions about
Chapter 1, let me know. We will be
doing Chapter 2 very soon.