CHAPTER 2 INTRODUCTION TO CODING AND CPT



Chapter 1: Introduction to Diagnostic Coding Learning Outcomes1.1 Explain the purpose of health care coding.1.2 Apply correctly the appropriate steps to coding. 1.3 Incorporate the official guidelines into the determination of the best, most accurate code.1.4 Detect the ethical danger zones that might exist in the workplace.1.5 Know the AHIMA Code of Ethics and AHIMA’s Standards of Ethical Coding.1.6 Employ the AAPC Code of Ethics.Chapter OutlineLearning OutcomesKey TermsThe Purpose of CodingMedical NecessityRisk FactorsSigns and SymptomsProcedures and ServicesSeven Steps to Accurate CodingCoding from Physician’s Notes Official ICD-10-CM Guidelines for Coding and ReportingRules for Ethical and Legal CodingResourcesFoundational KnowledgeOrgan SystemsBody Areas Anatomical PositionsAnatomical DirectionsAnatomical CavitiesThe Abdominopelvic CavityAbbreviations—Do Not UseAmerican Health Information Management Association Code of EthicsAAPC Code of Ethical Standards Chapter SummaryChapter 1 ReviewUsing TerminologyChecking Your UnderstandingApplying Your KnowledgeYou Code It! Practice and ApplicationChapter OverviewThe purpose of coding is to make every effort to ensure clear and concise communication between all parties involved with the health and well-being of the population. In most cases, these parties are the health care providers and the insurance companies (third-party payers). In addition, the government also uses this information to expand research and funding into particular areas of concern. For these and other purposes, including the continuity of care for each and every individual, every health care encounter must be documented in complete detail.When a person goes to see a health care provider, he or she must have a reason—a health-related reason. After all, as much as one might like their physician, a person probably wouldn’t make an appointment, sit in the waiting room, and go through all the paperwork just to say “hello.” Whether the reason is a checkup, a flu shot, or something more serious, there is always a reason why. The reason why is documented by the diagnosis, as written by the health care provider in the notes for this encounter. Information included in this chapter includes additional medical terminology tips to help students discern a diagnostic statement from a procedural statement. This chapter also provides a foundation of anatomy terms and references to begin supporting the connection between medical terminology and the process of coding.Discussion Activities1. Discuss the different uses for diagnosis coding.Learning Outcome: 1.1The purpose of coding is to provide clear and precise communications between all parties that need to know. Multiple parties use these codes, including:--health care facilities (hospitals, doctors’ offices, ASC, SNF, clinics, etc.)--health insurance carriers--the state and federal governmentsChoose one of these organizations and explain how they specifically use ICD-10-CM diagnosis codes.This discussion provides exploration of the many different ways diagnosis codes are used. In addition, this discussion can be used to reinforce the tremendous variety of employment opportunities for these students after graduation. Have some examples of organizations from your local area to reinforce the personal connection between students and using this knowledge for a successful career.[Insurance Billers and Coders (IBC) * Medical Assistants (MA)]Type of FacilityCareer OpportunitiesExamplesHospitalsIBC/MALocal HospitalDoctors’ OfficesIBC/MAYour physicianDentists’ OfficesIBCYour dentistNursing HomesIBC/MAThe MayflowerAssisted LivingIBC/MASavanah CourtMental Health FacilitiesIBC/MALakeside Alternatives; UBCClinicsIBC/MACentraCareRehabilitative CentersIBC/MAAvalon Home Health Care ProvidersIBC/MAVisiting NursesHospiceIBC/MAHospice of the ComforterPharmaceutical CompaniesIBC/MAHoffman LaRoche; MerckPharmaciesIBCWalgreens; CVSInsurance CompaniesIBC/MABlue Cross Blue ShieldHMOsIBC/MAPruCareGovernment AgenciesIBC/MACounty Health DeptSoftware ManufacturersIBCMedisoftHome-based CompanyIBC/MT“My Own Business”2. Accurate CodingLearning Outcome: 1.2Discuss specific examples of the impact of inaccurate coding on:- the patient- the physician and the facilitySome examples that you can cover in your class discussion:The patient may not be able to get the health services they need because the insurance carrier denied the claim due to inaccurate codes. The patient may have to pay for a procedure or service out of pocket, over and above their insurance premiums, when the insurance company should have paid for the procedure but won’t because the codes are not correct. The patient may have difficulty getting health insurance in the future because his or her chart states a condition this person never had. For example, John goes to get a test to rule out HIV. If the coder reported that John was HIV positive, this might cause John unfair problems with health care treatment and coverage in the future.The physician’s reimbursement, as well as that for the facility, may be negatively impacted. When a claim for a procedure that was provided is denied because the diagnosis code shown did not support medical necessity means that the physician or the facility (or both) does not get the money he or she rightfully earned by providing the procedure or service. Consistent errors in coding may result in fines, penalties, and prison if found to be fraudulent behavior (Human errors are expected to be corrected over time. When the same mistake keeps happening, there is reason to suspect fraud). When a claim is improperly denied, the physician must spend money and additional staff time to appeal the denial. In addition, the physician (and the facility) must deal with not having the money, reducing the funds available for payroll, rent, utilities, equipment, etc.3. What code would you use?Learning Outcome: 1.3Read this scenario then determine what diagnosis code or codes you would use. Explain why you chose this code(s).PATIENT: VAN DYKE, OLIVIAACCOUNT/EHR #: VANDOL001 DATE: 09/16/18ATTENDING PHYSICIAN: Suzanne R. Taylor, MDS: Pt is a 25-year-old female who has had a sore throat for the past week. She states that she has felt feverish for the last 2 days, and had a temperature of 100.5 degrees last night.O: Ht 5’5” Wt. 159 lbs. R 16. T 99. BP 110/85 Pharynx is inspected and there is obvious purulent material in the left posterior pharynx. Neck: supple, no nodes. Chest: clear. A: Acute pharyngitisP: 1. Send pt for test to rule/out Strep. 2. Recommend patient gargle with warm salt water and use OTC lozenges to keep throat moist. 3. Will write Rx once results of Strep test come back. 4. Return in 3 weeks for follow-up.Suzanne R. Taylor, MDSRT/pw D: 9/16/18 09:50:16 T: 9/18/18 12:55:01Answer: J02.9 Acute pharyngitis, unspecifiedThe test for strep has not been done yet, so this diagnosis has not yet been confirmed. If strep throat is confirmed by pathology, the code would change to J02.0 Streptococcal pharyngitis The patient’s sore throat, fever, and the purulent material in the pharynx are component signs and symptoms of acute pharyngitis, and therefore, not coded separately.Additional ResourcesGrey’s Anatomy Online: ’s Medical Dictionary: Medical Encyclopedia: Medical Association: Hospital Association: Health Information Management Association: : ICD-10-PCS: No 2017 Updates or NotesNo 2018 updates or notesChapter 1 Review Answer KeyUsing TerminologyPart ILearning Outcomes: 1.1 and 1.4BDGIFEJHCKAPart IILearning Outcome: 1.4HIEDCABGFPart IIILearning Outcome: 1.2ACDEBFChecking Your UnderstandingLearning Outcomes: 1.1, 1.2, 1.3, and 1.4DBCDADBCBBACDDDApplying Your KnowledgeLearning Outcomes: 1.1, 1.2, 1.4 and 1.5What does a diagnosis or diagnostic statement tell us? Comment: (given as feedback)The diagnosis or diagnostic statement, in the encounter notes will explain why the patient was seen and treated. Why is it important to tell the "whole story" of the encounter?Comment: (given as feedback)It is the responsible of the professional coder to tell the whole story about this patient’s condition. Omitting a detail may seem like no big deal; however, that detail may be the portion of the story that is the key to supporting the medical necessity for the physician’s decisions about treatment. Explain what a preexisting condition is and why it is important to the professional ment: (given as feedback)Pre-existing conditions, known as personal history, may also require additional codes to report the complete story of this patient’s condition. Professional coders must discern from the documentation when the pre-existing condition(s) warrants additional coding. List the seven steps to accurate ment: (given as feedback) Read through the superbill and the physician's notes for the encounter, from beginning to end Reread the physician's notes and highlight key words regarding diagnoses and procedures directly relating to the encounterMake a list of any questions you have regarding unclear or missing information necessary to code the encounter; query the care provider Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounterCode each procedure as stated in the notes describing what the provider did for the patient Link each procedure code to at least one diagnosis code to verify medical necessity Double-check your codesExplain what is meant by ment: (given as feedback)Unbundling is coding the individual parts of a specific diagnosis or procedure rather than one combination or bundle that includes all of those components. Summarize the AHIMA Standards of Ethical Coding. Comment: (given as feedback)AHIMA STANDARDS OF ETHICAL CODINGCoding professionals should:1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.8. Advance coding knowledge and practice through continuing education.9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.You Code It! Practice and ApplicationLearning Outcomes: 1.3, 1.4, 1.5 and 1.6Case study 1: Patient: HAVERLAND, JULIANNAFeedback: Empathy is very nice; however, breaking the law is never a proper thing to do. Coders are legally and ethically responsible to use codes that report the absolute truth. In addition, future procedures or services may be helpful to Julianna’s condition that would be medically necessary for the diagnosis of ‘expressive language disorder, developmental aphasia’ that is not a standard of care for ‘sensory hearing losses. Therefore, reporting the wrong code might benefit them now, but be detrimental in the future. Lastly, if the ‘sensory hearing loss’ diagnosis is reported and something occurs with Julianna’s condition in the future this may result in Dr. Victors being sued for malpractice because the developmental aphasia was not diagnosed properly at this early stage. This, of course, would be unfair to Dr. Victors because she did do her job properly and she did make the correct diagnosis at this time.Case study 2: Patient DARDEN, CONNERFeedback: It is part of a professional coding specialist’s legal and ethical responsibility to assure that the documentation in the patient’s file supports all codes reported on the claim form. Therefore the coder must make certain that the patient’s chart includes the information from the attending physician that supports the ‘deviated septum’ diagnosis (signs, symptoms, and physician examination results noted during previous visits). This can be a sensitive situation for the coder because it is the coder’s responsibility to determine the codes based on the documentation from the attending physician. Case study 3: Patient: MAHONEY, BARTFeedback: Great example of why coders need to know anatomy and physiology, along with medical terminology. Bart is diagnosed with an upper respiratory infection due to unidentified influenza virus and the test performed is an urinanalysis (UA). This is not part of the standard of care as a diagnostic test for a respiratory infection. Perhaps the wrong diagnosis was checked off on the superbill? Perhaps the wrong procedure was marked off on the superbill? Perhaps a second diagnosis was mistakenly not checked off – one that would support the provision of a UA? Go back into the patient’s chart and read the complete physician’s notes for the encounter to identify what information is needed to correct this situation because a claim submitted with this diagnosis code (J11.1) and this procedure code (81000) will be denied due to lack of medical necessity. Query the physician about this, if the missing information is not included in the notes. Case study 4: Patient: FROMAGE, LILLIANFeedback: The coder can help the situation without participating in this fraud known as “coding for coverage”, such as educating the physician on the legal implications of this behavior (the physician may not know what they are doing is illegal and unethical).Case study 5: Patient: KIRREN, CHARLESFeedback:Understand the difference between congenital and acquired conditions as well as understand the importance of coding accuracy; the statement in the notes “the basic problem is still the same either way” not necessarily. The standard of care for congenital talipes cavus may not be the same as the standard of care for acquired talipes cavus either now or in the future. Again, using the wrong code now may appear to help the family at this time, but have unknown negative impact in years to come. ................
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