Connection Between Coding Systems, Settings and Billing

To complete the following assignment, use your existing coding knowledge and the attached Lesson Content
mod_9_worksheet.docx

mod_9_lesson_content.docx

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HIM3304, Module 9 Assignment
Connection Between Coding Systems, Settings and Billing
As the manager of Coding at LiveWell, you have been asked to prepare a presentation for a group of resident physicians
on coding and coding systems in the USA. The resident physicians must leave with a clear understanding of the types of
coding used in the US, the corresponding medical settings for each system, as well as the connection to medical billing.
You prepare the following sheet for your presentation which needs to be completed prior to the resident’s arrival.
__________________________________________________________________________________________
To complete the following assignment, use your existing coding knowledge as well as the information found on the
Lesson Content page for this module.
A: Of the major coding systems in the United States, the following outlines the purpose of three common
systems. The coding system described in questions 1, 2 and 3 is
(Identify the letter – either A, B, C or D)
A. ICD-10 CM
B. ICD-10 PCS
C. CPT
D. HCPCS
1. This system is also known as CPT Level II and is used for durable medical goods and medications, for example.
Answer 1: ________
2. This system is used to code procedures and surgeries in the inpatient setting only.
Answer 2: __________
3. This system codes diagnoses and is used in the inpatient, outpatient and physician office setting.
Answer 3: ___________
Answer 4.
B: Coding systems have unique but similar purposes. They assign
codes, consisting of (4.)__________________ and/or letters, that
identify a (5.) ____________, procedure or service. They also
function significantly in the medical (6.)_____________process.
Answer 5.
Answer 6.
C: Account Example – Patient LaSheka
LaSheka goes to TESTME, an MRI standalone facility, because she is experiencing back pain. The MRI is
completed and read by a radiologist employed by TESTME.
Which coding system would be used to code the following from account example LaSheka
(Identify the letter – either A, B, C or D)
A. ICD-10 CM
B. ICD-10 PCS
C. CPT
D. HCPCS
7. Physician services, the radiologist.
8. Outpatient test, the MRI
9. Diagnosis, back pain.
Answer 7:
Answer 8:
Answer 9:
D: Account Example – Patient Walter
Walter is in a car accident and is transported to an Emergency Room at LiveWell Hospital. Walter is evaluated by
an ED physician, has a x-ray, is diagnosed with a fracture of the medial malleolus of left ankle. Walter leaves
with a follow-up appointment with an orthopedic surgeon and a pair of crutches.
Which coding system would be used to code the following from account example Walter
(Identify the letter – either A, B, C or D)
A. ICD-10 CM
B. ICD-10 PCS
C. CPT
D. HCPCS
10. Emergency transport, the ambulance.
11. ED Physician services.
12. Medial malleolus fracture
13. Crutches.
Answer 10:
Answer 11:
Answer 12:
Answer 13:
E: Account Example – Patient Halima
Halima is admitted to LiveWell hospital directly from a local physician office, not associated with LiveWell, and
is diagnosed with esophageal reflux, hiatal hernia and esophageal dysmotility via a swallowing study test.
Which coding system would be used to code the following from account example Halima
(Identify the letter – either A, B, C or D)
14. Esophageal reflux
15. Swallowing Study
A. ICD-10 CM
B. ICD-10 PCS
C. CPT
D. HCPCS
Answer 14:
Answer 15:
On October 11, 2014, medical coding in U.S. healthcare settings changed from ICD-9 to ICD-10. The
transition required business and systems changes throughout the healthcare industry. Every provider and
facility covered by the Health Insurance Portability and Accountability Act (HIPAA) made the transition,
not just those who submit Medicare or Medicaid claims.
ICD-10 CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure
Coding System) consists of two parts 1) ICD-10-CM for diagnosis coding and 2) ICD-10-PCS for inpatient
procedure coding. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used
with ICD-9-CM, but the format of the code sets is similar. ICD-10-CM is for use in all U.S. health care
settings which includes:
•
•
•
•
•
•
•
Inpatient care, hospital admissions.
Outpatient care, same day surgery, outpatient testing
Physician office
Mental Health
Emergent Care
Home Care
Durable Medical Equipment (the diagnosis needed to demonstrate the necessity)
Procedure Coding – surgery/procedure coding is completed using two systems. ICD-10-PCS is for use in
U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric (letters and numbers) digits
instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is
much more specific and substantially different from ICD-9-CM procedure coding. All other procedure
coding is completed using Current Procedural Terminology –CPT- coding, a 5-digit coding system, was
designed by the American Medical Association.
CPT coding is also used for services provided such as a ‘new patient visit’ in the physician’s office or a
‘consultation’ service in the inpatient setting. This is commonly referred to as Evaluation and Management
coding (E&M). E&M coding is used for physician office coding and is used for facility medical billing for
professional services provided by healthcare providers including physicians, nurse practitioners and
physician assistants.
Finally, a 3rd commonly used coding system in the United States is the Healthcare Common Procedure
Coding System (HCPCS) code set. This is often referred to as ‘HickPicks’ in the HIM industry, and this
coding system was devised by Centers for Medicare and Medicaid Services (CMS) to respond to the
need to identify a plethora of billable services and products that were not identified in CPT. HCPCS
coding is known as Level II CPT coding while the original CPT coding book is known as Level I CPT
coding.
This group of codes was truly created in response to a billing need – Medicare wanted to have a code
associated with everything they would reimburse or pay for when patients utilized them. This code book
has everything from J-codes which reimburse for medications, like chemotherapy, to A-codes which
reimburse for an ambulance transport.
This summary should be familiar to you. It is an overview of ICD-10 CM and ICD-10-PCS coding, Level I
CPT coding and finally Level II CPT coding – which is called HCPCS coding.

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