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Briefing: Coding Is Not Just for Reimbursement Date: 20 March 2007 Time: 1300 - 1350. Objectives. Provide a basic understanding of the coding process Understand the importance of complete, accurate documentation to the coding process Learn the benefits of coding

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briefing coding is not just for reimbursement date 20 march 2007 time 1300 1350
Briefing: Coding Is Not Just

for Reimbursement

Date: 20 March 2007

Time: 1300 - 1350

  • Provide a basic understanding of the coding process
  • Understand the importance of complete, accurate documentation to the coding process
  • Learn the benefits of coding
  • Clarify the connection between data quality and coding
  • Points to Remember
coding process
Coding Process
  • The delivery of quality healthcare depends on the accurate and timely capture of medical data
  • Healthcare professionals are key players in ensuring the collection of medical information
  • What is coding?
    • Numerical representation of diseases and treatment provided
    • Assignment of codes based on care and services received
    • Collection, storage and sharing of data and statistics
  • Originally performed to classify mortality (cause of death) data on death certificates, and morbidity and procedural data
icd 9 cm
  • What is ICD-9-CM coding?
  • ICD-9 is an international disease classification system that groups related disease entities and conditions for the purpose of reporting statistical information
    • Volume 1 tabular list of diagnosis codes
    • Volume 2 alphabetical index
    • Volume 3 contains procedure codes, which are used for billing inpatient hospital stays
cpt 4
  • What is CPT-4?
  • The Current Procedural Terminology coding system describes medical and surgical procedures and services performed by physicians and other health providers
    • Serves a number of purposes
    • Essential to billing for patient care services
    • System used to develop the Resource Based Relative Value System (RBRVS) to assist in determining the amounts paid to doctors and other medical providers for services
    • Uniform codes that translate the same for doctors, hospitals, patients, insurance companies, and other parties
  • If the CPT and HCPCS codes are not identical in meaning or description (i.e., the CPT code is generic and the HCPCS code is more specific), the Level II code should be used
  • Coders should ensure they check for HCPCS codes when a CPT code description contains instructions to include additional information such as:
    • Specific medication
    • Supplies and materials
    • Standardized coding system using alpha numeric codes that are used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office
  • Leveling: Often the same procedure will be coded at two or three levels. The following guideline applies:
    • When both a CPT and HCPCS Level II code have virtually the same meaning or service, use the CPT code
  • Because of the uniqueness of the military’s computer systems, as well as the services/care provided to members, they have devised their own set of coding guidelines
  • These guidelines parallel those of the civilian community. However, some things are unique to the military
    • Services provided by nurses, corpsmen, technicians,

independent duty corpsman (IDC), and independent duty medical technicians

  • Additionally, the DoD Coding guidelines include:
    • DoD Extenders
    • Flight Medicine
    • Nutrition Management
    • Case Management
  • Principal diagnosis:
    • "the diagnosis established after study to be chiefly responsible for occasioning the patient's episode of care in hospital (or attendance at the health care facility)"
  • Secondary Diagnosis:
    • "a condition or complaint either coexisting with the principal diagnosis or arising during the episode of care or attendance at a heath carefacility"
documentation and coding
Documentation and Coding
  • The medical record is the source document for coding
  • Coders rely on the documentation in the record to determine what codes to assign for services provided
  • Responsibility for capturing accurate diagnosis and procedures, in particular, principal diagnosis, lies with the provider, not the coder
  • A joint effort between providers and coders is essential to achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures


documentation and coding1
Documentation and Coding
  • Coders should seek clarification from providers for questions regarding documentation
  • Resolved issues should be documented within the medical record
  • Communication between the coding staff, providers, and other individuals involved in the coding process is vital to ensuring the accuracy of coding
coded data
Coded Data
  • Coded data is:
    • compiled and analyzed to reveal public health patterns and identify ways to better use resources and cut healthcare costs
    • Used on hospital and physician reimbursement claims to describe diagnoses, services, and procedures provided
  • Coded data serves several important functions within healthcare to include:
    • Hospital payments and physician reimbursement
    • Quality review
    • Benchmarking measurements
    • Collection of general medical statistical data
    • Clinical


coded data1
Coded Data
  • Functions of coded data within healthcare
    • Epidemiology
    • Population health
    • Business
    • Research
    • Used for statistical analysis
  • Coded data is used internally by institutions for:
    • Quality management
    • Case-mix management
    • Planning
    • Marketing
    • Other administrative and research activities
documentation errors
Documentation Errors
  • Common provider documentation errors:
    • Inconsistent documentation
    • Incomplete progress notes
    • Undocumented care
    • Missing test results
    • Historical diagnosis documented as current
    • Chronic conditions not documented
    • Post-op complications not listed
    • Illegibility
    • Documentation not completed on time
benefits of coding
Benefits of Coding
  • Coding:
    • Permits the easy retrieval of information according to diagnoses and procedures
    • Provides a consistent method for the collection and retrieval of data
    • Allows healthcare entities to assign codes for the condition treated, and for any procedures rendered by the provider
    • Standardizes diagnoses and procedures into accepted data sets
    • Is used to capture inpatient and outpatient procedures
    • Is the HIPAA-mandated system used for billing all medical services and procedures related to:
      • ICD-9 – diagnoses and procedures
      • CPT-4 – services and procedures
      • HCPCS – drugs, supplies, and services
benefits of coding1
Benefits of Coding
  • Correct code assignment is important and plays a significant role in:
    • Resource utilization
    • APC assignment
    • DRG assignment
    • Reimbursement
  • Correct code assignment permits access to medical records by diagnoses and procedures for use in:
    • Clinical care
    • Research
    • Education
  • Correct code assignment is beneficial to health policy development and planning
data quality
Data Quality

Data Quality



data quality1
Data Quality
  • Documentation in the medical record must be of highest quality
  • Incomplete or missing data could:
    • Compromise patient care
    • Contribute to incorrect assumptions made by policy makers
    • Result in inaccurate research findings
data quality2
Data Quality
  • Data accuracy
    • Shared responsibility between the coder and the provider
    • Collaborative effort between the two
  • Data accessibility
    • Complete, accurate, legible, and timely documentation
  • Purpose of audits
    • Allows for examination of the documentation within the medical record to ensure the accuracy of the codes assigned and that no codes have been missed
    • Ensures the standards of correct coding are adhered to as provided in the:
      • DoD Coding Guidelines
      • Official Coding Guidelines
      • Standards of Ethical Coding
    • Ensures the appropriate reimbursement for care provided to patients
    • Assesses the quality of coding by individuals (i.e., coders, providers, and other healthcare professionals), and highlight areas needing further education
  • Medical necessity
    • The need for an item or service to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member
      • Treatment and services should be linked to an appropriate diagnosis, symptom or complaint
      • Up to four ICD-9 codes can be linked to a CPT code
  • Fraud and abuse prevention
    • Overcoding/upcoding – Assigning a code specifically for the purpose of obtaining a higher level of payment
    • Undercoding – Failure to assign codes to based on the care that was provided
      • Example:
        • Undercoding results inlost revenue of 3%-15% per encounter
        • Difference between two codes - 99212 for $29 and 99213 for $55
        • However,


$55 - $29 = $26

$26 twice a week


48 weeks


3 doctors in a physician practice

= $7,488

    • Unbundling – use of multiple codes describing individual components of a procedure rather than an appropriate single code that describes all steps of the procedure performed
    • Billing for services not provided
    • Performance of unnecessary medical services
  • Misuse:
    • Level 4 (99214) visits most overused
  • New vs. established patients
  • Inaccuracies in coding can lead to a variety of problems
    • Denials for reimbursement
    • Compliance issues
    • Staffing inefficiencies
    • Decreased productivity
    • Erroneous statistics
points to remember
Points to Remember

Points to Remember

do s and don ts
Do’s and Don’ts
  • Do’s:
    • Do use both the Alphabetic Index and Tabular List
    • Doassign codes to highest level of detail
    • Doassign residual codes as appropriate:NEC and NOS
    • Do assign combination codes when available
    • Do code both acute and chronic conditions when they exist concurrently and are documented within the medical record


do s and don ts1
Do’s and Don’ts
  • Do code unconfirmed diagnoses as if established (inpatient setting)
  • Do question the provider when two or more diagnoses equally meet the criteria for principal diagnosis If no further information is available code the first mentioned diagnosis as the principal diagnosis
  • Do avoid indiscriminate multiple coding
    • Irrelevant information (i.e. signs and symptoms integral to the diagnosis)
    • Diagnostic tests ( i.e. laboratory, x-ray, or electrocardiographic tests), unless diagnosis confirmed by physician
do s and don ts2
Do’s and Don’ts
  • Don’ts:
    • Don’t assign an unspecified code when a more specific code can be assigned
    • Don’t assign a code for conditions that fail to meet UHDDS criteria for reporting
    • Don’t make diagnostic decisions when reviewing the medical record
    • Don’t code symptoms as the principal diagnosis when a related definitive diagnosis has been established
  • Coding
    • Coding allows healthcare providers to collect, store, and share important medical data and statistical information regarding the care provided to an individual using a common language
    • While it is important for hospitals, providers, and other healthcare entities who provide care to be reimbursed for the resources they expend, coding is important for more than reimbursement
      • Research
      • Population health
      • Benchmarking
      • Quality review
  • Documentation
    • The medical record is the major source document for coding and reporting of diagnoses and procedures
    • Coding and documentation should be integrated into the process of providing care
    • Seek clarification from providers for questions regarding documentation
    • Responsibility for the capture of accurate diagnoses and procedures lies with the provider, not the coder
    • Teamwork is essential between providers and coders
    • Quality care is a principal measure
    • Process must work for providers
    • Remember” “Not documented, Not coded”
  • Data Quality and Compliance
    • Documentation must be complete and accurate
    • Incomplete data can:
      • Compromise patient care
      • Contribute to incorrect assumptions by policymakers
      • Lead to inaccurate research findings
    • Data accuracy is a shared responsibility between coder and the provider
    • Ensure codes assigned meet requirements for medical necessity
    • Treatment and services should be linked to an appropriate diagnosis, symptom, or complaint
    • Address issues of overcoding, undercoding, and unbundling
  •, (200). Improve Your ICD-9 Coding Accuracy.
  •, (2005). Full Payments. Full Control.
  •, (2006). What is Medical Coding?
  •, 2006. Coding.
  •, (2006). The Importance of Accurate Medical Records.
  • Bibbins, B., (2006). Soliciting Physician Documentation of Medical Necessity.
  •, (2006, Mar). ICD-9 Coding System Explained.
  •, (2003). General Information.
  •, (2006). Questions on the Use of Level II HCPCS.
  •, (2006, Oct). Medical Coding – The Numerical Representation.
  • Johns, M., 2007. Health Information Management Technology an Applied Approach. Chicago, Illinois: AHIMA (pgs 36-37)
  • Levinson, S., 2006. Practical E/M: Documentation and Coding Solutions for Clinical Care. Chicago, Illinois: AMA (pgs xvii – xviii)
  •, (2006, Nov). Clinical Coding.
  •, (200). What Is CPT Coding?