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WELCOME MEDICAl C0DING
INDEX Introduction Brief History Types of Code Basics Steps in Coding Skill Required BY Coder Reference
Introduction Medical coding is defined as the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alpha-numeric codes. It standardizes the language and presentation of all these elements so they can be easily understood, tracked, and modified. Importance · Collection of general medical statistical data · Medical reimbursement · Hospital payment · Quality review · Benchmarking measurement
Brief History · Originated in England during the 17th century. · Statistical data was collected from a system called the London Bills of Mortality, and the data was organized into numerical codes. · The codes were then used to estimate the most recurrent causes of death. · Statistical examination of the mortality rate was then organized into “International list of causes of death.” · WHO used this list in tracking the mortality rates and international health developments. · The list was later developed into the International Classification of Diseases, its 10th edition is ICD-10- CM. · In 1997, the global medical community accepted the ICD system, which compelled the NCHS to extend ICD by including cause of death and clinical diagnosis. · This way to catalog medical records makes medical evaluations quick and easier.
Types of Coding Three main types of Medical Coding 2. 1. ICD CPT 3. HCPCS
ICD 1. · Originated in England during the 17th century. · Statistical data was collected from a system called the London Bills of Mortality, and the data was organized into numerical codes. · The codes were then used to estimate the most recurrent causes of death. · Statistical examination of the mortality rate was then organized into “International list of causes of death.” · WHO used this list in tracking the mortality rates and international health developments. · The list was later developed into the International Classification of Diseases, its 10th edition is ICD-10-CM. · In 1997, the global medical community accepted the ICD system, which compelled the NCHS to extend ICD by including cause of death and clinical diagnosis. · This way to catalog medical records makes medical evaluations quick and easier.
CPT (Current Procedure Terminology) 2. Used to document the majority of medical procedures performed in a physician’s office. Published and maintained by American Medical Association (AMA). CPT codes are 5-digit numeric codes divided into 3 categories: Category 1: Used most often, divided into 6 ranges corresponding to 6 major medical fields. Category 2: Performance measurement, laboratory, or radiology test results. Category 3: Emerging medical technology.
HCPCS (Healthcare Common Procedure Coding System) 3. Developed by CMS (Centers for Medicare & Medicaid Services), maintained by AMA. Corresponds to services, procedures, and equipment not covered by CPT. Official code set for outpatient hospital care, chemotherapy drugs, and other services. Divided into 2 levels: Level 1: Identical to CPT. Level 2: Alphanumeric codes, divided into 17 sections (medical, lab, rehab, etc.).
BASIC STEPS IN CODING Review the health record. Identify the principal diagnoses and procedures to be coded. Identify the main terms in the alphabetic index. Review any sub-terms under the main term in the index. Follow cross-reference instructions (e.g., “see also”). Verify in the tabular list the codes selected from the index. Refer to instructional notation in the tabular column. Assign codes to the highest level of specificity. Assign codes to diagnoses and procedures, reporting all applicable codes and sequences in accordance with the guidelines.
SKILLS Medical terminology Anatomy and physiology basics ICD-9, ICD-10, CPT, and HCPCScoding LCD and NCCI guidelines REQUIRED BY A CODER HIPAA compliance Medical billing concepts Detail-oriented and self- motivated
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