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Indexes and classification system syllabus

1442 year
Given by : Abeer bassam shaban
Index and classification systems
Course code MRT 1202
Credit hours 3
Prerequisites None

Course description

This course will explore CPT, ICD and HCPCS coding system and its use in various
reimbursement and data collection schemers. Students will apply CPT, ICD and
HCPCS coding principles in various exercises and practice health codes

Method of evolution
Marks distribution

First midterm 30 marks

Quizzes 10 marks
Home Work 10 marks
Project 10 marks
Final exam 40 marks

Text books and references

1. AMA CPT (American Medical Association code book)
2. Book, code, J, step by step medical coding.
3. Summarization text book done by instructor Abeer Shaban
4. PowerPoint on blackboard

Office hour:

11-12 on Wednesday

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So during this course you are going to learn about the following topics:
Week Lecture title
1 SMR request
2 Indexes
(Introduction, indexes definition, type of indexes1. Master patient index,
2.disease and operations indexes, 3. Physician index and 4. Special index)
3 Medical coding system, classifications and nomenclatures
(introduction, definition of coding, why do we need code)

4 Example of the coding system , typical use of classification

5 typical use of nomenclatures,

Important of medical coding systems

6 Health common procedure coding system (HCPCS)

Three levels of HCPCS
7 Current procedural terminology (CPT)
1. Describe the structure of code in CPT4
2. recognize the symbols used in CPT manual
3. understand the surgery section and subsection formats
4. explain the format of the pathology

8 International classification of diseases (I.C.D)

History of ICD 9-CM
Tabular list
V codes and E codes
Alphabetic index
Procedure index
Example and exercises

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History of ICD 9-CM
Tabular list
V codes and E codes
Alphabetic index
Procedure index
Example and exercises

10 International classification of diseases (I.C.D)

History of ICD 9-CM
Tabular list
V codes and E codes
Alphabetic index
Procedure index
Example and exercises
Part 2
11 International classification of diseases (I.C.D)
Edition 10 ICD-10

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 Comparison between ICD9 and ICD-10
Comparison between CPT and ICD-10

12 Reimbursement
Understand patient accoutrement role in reimbursement
13 Final exam

And remember to push yourself because nobody else is going to do it for

you.

Lecture 1

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 Medical index
Hospital maintain various indexes and register so that so that each health records and
other health information can be located and classified for

1. Patient care management and research purposes

2. Quality of care review
3. Utilization management
4. Administrative and financial purposes
5. Compliance with regulations or licensure requirement

Increasing demands for information and the availability of computerized systems

continue to increase the use of computerization in these areas. manual systems are still
in use in some facilities

Index is an alphabetical listing of items and their location.

Indexes may be
1. computerization index
2. manual indexes
a. card b. note book

Manual indexes computerization index

cheaper Expensive

slow Fast

Limited information according Give availability to add huge data and details
small size of manual card

Just can use name of patient for Give more chance to search about one
search information

we can find data just in record We can find data anywhere for medical stuff
store room

All section have data for patient We save patient data just one time for all
medical section

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Characters of success and good index are
1. Cheap cost and maintenance.
2. Use small size for indexes
3. Easy to correct any mistake in system
4. Flexible uses the system by adding or delete data.
5. Long period uses system without any damage occur

We have more than one type of medical indexes

1. Master patient index (MPI)
2. Disease and operation indexes
3. Physician index
4. Other special index

i. Master patient index (MPI)

MPI is a file that identifies patients and their health records. All patients who are
registered to receive hospital care as

• Inpatients
• Outpatients
• Emergency care patients
• Home care patients

Are entered in individually identifiable form into the MPI

Required information in the MPI to identification the patients

1. Last name, firs name, and middle initial

2. Birth date by month, day, and year
3. Sex
4. Address by street and city
5. Date of admission
6. Name of attending physician or clinical service assignment
7. Health record number
8. More information may be added as needed such as social security number

In computerized systems in which updating information is easy and not too time
consuming the dates of admission and discharge as well as clinic and emergency
service visits are entered.

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There are no recommended periods for retention of names in the MPI

The filling arrangement with in MPI usually follows one of two systems

1. Alphabetical
2. Phonetic

1. Alphabetical system patients name are filed in Alphabetical order by last name with
secondary Alphabetical fling by first name.

3. The Phonetic system which is used by many hospitals that serves communities
with greater diversity of last name

ii. Disease and operation indexes

List is arranged by

Illness

Injury

Procedure

That gives the record numbers of patients health records in which information on
specific Illness, Injury or Procedure can be indexes and registers found.

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The indexes are cross reference tool for locating health records by diagnosis or
procedure to carry out activities related to the following

1. Continuing medical education programs

2. Epidemiologic and biomedical studies
3. Health services research studies
4. Statistical data on occurrence rate age sex and complications or assocated
conditions.
5. Continuous quality improvement and total quality management activities.
6. Consultation on patient response to treatment in previous cases for
applicability in a current case
7. The disease and operation indexes are accessible only to authorized personnel
8. Control measures are needed to ensure that every inpatient health record is
accounted in the disease and operation indexes

Required information

The number of data items included in the disease and operation indexes depends on
the needs of the individual hospital .

Basic data for any type of disease indexes include

• Illness, injury, and procedure classification code.

• The patient's health record number
• The sex and age of patient
• Identification of the responsible physician by code or name
• The dates of admission and discharge or the year of hospitalization and length
of stay in days
• Any outcome of death and the findings from any autopsy and additional
disease or procedure codes.

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 4. Physician index

The Physician index is a list arranged by Physicians' names or numbers that gives the
health record numbers of patient who received treatment or consultation from a
particular Physician.

The minimum data requirements for an entry into a Physician index are:

-The patient's health record number.

- The patient's age and sex.

- The date of admission and the length of stay in days

-Identification of a the patient's death and any autopsy findings

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Consultation entries usually require:

-The patient's health record number. -

- The date of admission. -
-Identification of the entry as a consultation provided to another physician's patient.

The Physician index is regarded as a confidential record, and access to it must be

limited to authorized persons

Physicians have the right of access to their own data recorded in the Physician index

The hospital's governing board and chief executive officer (CEO) have the right of
access in accordance with their duties and responsibilities for ensuring the quality of
patient care and conducting hospital affairs

Other special Indexes

Special subject indexes may be maintained by the hospital, but the needed for these
indexes should first justify on the basis of:

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1- The interest and actual use of the data or as required for participation in payment
programs. For example, hospitals with trauma or burn centers may wish to maintain
an index that provides specific statistical data on the treatment provided and on the
utilization of the specialized service. A facility treating HIV- positive and AIDS
patients may develop a special registry for research purposes.

2- An index often is maintained to identify the organs or tissues removed from brain –
dead patients for transplantation purposes.

The index identifies items such as the patient's health record number, the organ( s)or
tissue removed, the date of the procedure, and identification of any outside team who
performed the procedure

3- Special indexes can also be established to meet the needs of an individual or group
of staff Physician.

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 Lecture 2

Medical Coding System

Introduction

To find specific pieces of information within documentation, It is necessary to use

documentary language. To put it into simple terms, you need a set of keywords ( or
authorized terms) and rules for their application.

So we call the documentary language a coding system.

In medical field, coding systems are common to document diagnosis and therapies.

Coding means translation or converting the verbal description of disease, injuries,

diagnosis, and services into numerical and /or alphanumeric designations for statistical
reporting and reimbursement purpose.

The transference of words to numbers

Coding was developed for a number of reasons

1. Tracking disease processes

2. Classification of medical procedures
3. Medical research.
4. Evaluation of hospital utilization.
5. To facilitate the processing of large number of insurance claims.
6. Study hospital cost.
7. Predict health care trends.
8. Plan for future health care needs.

Coding system: Why we need them?

Problems:

1-The freedom of expression can cause certain problems

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Every term may have more than one possible spelling, several synonymous labels may be
selected and the whole statement may be structured according to the author's preference

Example liver rupture, hepatic laceration, hepatorrhexis

2- The usage of homonymous terms may lead selection of irrelevant data

Example in search of MI means myocardial infarction and can produce mesenteries

infection.

3- The terms used in documentation do not indicate the degree of similarity.

Ex. Two diagnosis as liver cirrhosis and subacute alcoholic hepatic dystrophy similar in
administrative analysis but different in epidemiological study

Solutions of these problems by coding system

Restrict the variability of expression and convert the authorized terms into a short and
formal code easier to record.

For example: to record the diagnosis of acute appendicitis, you might have to use the code
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Standards of ethical coding

The following standards for ethical coding developed by American Health Information
Management Association (AHIMA) on coding and classification are offered to guide the
coder in this process

1-Diagnosis that are present on the admission or diagnosis and procedures that occur during
the current encounter are to be abstracted after a thorough review of entire medical record.
Those diagnoses not applicable to the current encounter should not be abstracted.

2- Selection of the principal Diagnosis and procedures along with other diagnoses and
procedures must meet the definition the uniform Hospital discharge Data set (UHDDS)

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3-assessment must be made of the documentation in the chart to assure that it is adequate
and appropriate to support the diagnosis and procedures selected to be abstracted

4- Medical record coders should use their skills, their knowledge of ICD_9-CM and CP and
any other available resource.

5-medical record coders should not change codes so that the meaning of this represented
.Nor should diagnosis or procedure be included or excluded because the payment will be
affected, statistical database maintaining a quality database should be a conscientious goal

6- Physicians should be consulted for clarification when they enter conflicting

documentation in the chart

7- The Medical record coders is a member of the healthcare team, and as such, should assist
physicians who are unfamiliar with ICD_9-CM and CP and DRG methodology

8- The Medical record coder is expected to strive for the optimal payment to which the
facility is legally entitled but it is unethical and illegal to maximize payment by means that
contradict regulatory guidelines

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 Lecture 3

Classification
In planning a data management system, you must decide for every attribute if you
should apply a coding system for the objectives of the system, and if it's better to
choose a classification or nomenclature

Classification (classification system)

Are coding systems founded on the \constructing classes? Classes form an

aggregation of concepts that match in (at least) one classifying attribute

Classification is the categorizing arranging and grouping of diseases, diagnoses,

surgical and nonsurgical procedures that have common attributes or characteristics
that would signify classifying them in a group such as the body system,
communicable diseases, and operational procedures of the digestive system and so on.

Example

All diseases with classifying attributes of an inflammation of the myocardium as well

as of an infectious etiology may be aggregated to the class (infections
myocarditis).IM

You can think of class as a container for objects having this particular attribute. In the
example above this could be all discharge diagnoses of the health care institution
involving infectious myocarditis.

The classes of the classification should cover the relevant domain completely and
their contents should not overlap. Each object has to be assigned to exactly one class.
When this is done the object is classified. The diagnosis of septic myocarditis, ex
might be assigned to the class (infections myocarditis) mentioned above. For the sake
of brevity as well as of language independence (if you have edition of the
classification in different languages), each class is provided with a code. This could
be '357' for infectious myocarditis

'3..' –denoting diseases of cardiovascular system and '35.'- An acute inflammation of

heart. The hierarchy expressed in the coding example is typical construction principle
of larger classifications.

ü Now, to document a medical fact all you have to do is to find out the
appropriate class (put it in the right container) and record the class code. This
is what we call coding a medical fact.

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 o Application

Classifications are useful in those cases where documentation is used:

1. For patient group analyses (ex. To find out the frequency of cases of infectious
myocarditis in the PMC 'Ploetzberg Medical Center' during the last year.
2. To find out all objects that is similar in certain respect (ex. All patient of the
PMC having an extended hemicolectomy).

o forms

The structure of the classification can exhibit certain peculiarities

1. hierarchy:

The classes of a hierarchical classification are related exclusively either in a generic

or in a portative way, ex the subordinate concept, or class, in the hierarchy is either a
specialization, or a part of the super ordinate concept.

2. Monohierarchy vs. polyhierachy

In monohierarchy classification there is exactly one superordainate class to every

class (expect the topmost or the root of hierarchy).

In polyhierarchy classification allow classes to be subordinate to more than one class,

which results in several overlying hierarchies.

3. Multiaxial classification (or multidimensional classification)

Consist of two or more independent partial classifications. Here, a classifying

attribute for each axis is needed, describing an object within different semantic
dimension. The object is

Typical axes or dimensions you will find in multiaxial disease classification are
etiology, topography, and pathology.

The partial classifications may themselves be structured hierarchically. In this case

you can think of axes as a separate branch or sub- tree of the hierarchy.

Example

A simple monoaxial and monohierarchial classification of diagnoses is as follows

D1 Disorders of fat metabolisim

D11 hyperlipiemia

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 D12lipoproteinemia

D121 Tangier Disease

D122 A-Beta-Lipoproteinemia

D123 other Lipoproteinemia

D13 other sidorders of fat metabolism

D2 Disorder of carbohydrate metabolism

An additional axis for etiology could contain the classes

A1 Nutritional

A2 Congenital

A3 mixed or other etiology

Together with the first axis (what would be its semantic dimension),it forms atow –
axial classification (multiaxial classification). hyperlipidemia caused by dietary habits
would be code as A1- D11

If you find one class (ex. Viral meningitis) subordinate to two or more different
superordinate classes (ex neurological diseases as well as viral diseases)you are
dealing with a polyhierarchical classification.

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 Lecture 4

Nomenclatures

Basically a nomenclature is no more than a systematic compilation of authorized

terms or descriptors for a certain documentation task.

Due to their systematic structure and the provision of codes,nomenclatures usually

take the form of coding system.

Additionally the authorized terms may be complemented by definitions synonymous

terms, and other terminological notes, in that case the nomenclature takes the form of
a thesaurus.

A nomenclature is used to mark objects by assigning them all authorized terms (often
called descriptors) that apply. We say that an object is indexed. In contrast to
classifications; the concepts labeled by the descriptor may overlap. Moreover an
object is usually indexed with more than one descriptor.

If an object is not indexed completely ex. Not all appropriate descriptors have been
selected there will be problems in retrieving the data object reliably.

For example if you have recorded the descriptor (localization head) in documentation
of pain symptoms, but have forgotten to record "characteristic: throbbing" you will
miss the patient in a retrieval of all patients suffering a throbbing headache.

For the sake of brevity as well as for language independence, the authorized terms of
a nomenclature are usually provided with a code. As for classifications, assigning a
code is called coding.

Application

Nomenclatures are useful in those cases where documentation is used to

1. Retrieve the data on objects with a particular combination of attributes (ex. All
patients having had a meniscectomy under epidural anesthesia).
2. And also to let computer programs process the information about objects (ex.
To translate it into another langusge, to warn of contraindications or to suggest
atreatment).

Retrieval quality:

To measure the quality of the result of specific retrieval you have to check:

- Wheather all relevant cases or patients have been retrieved.

- Wheather the retrieved patients are all relevant.

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Later we will introduce the measures of precision and recall for this purpose. These
quality indicators are essential for the usefulness of a nomenclature , to a great degree,
they are determined by how precisely relevant object features are expressed by the
descriptors of the nomenclature.

For example if you only have the descriptors {operation on the knee} and “local
anesthesia” to index a menisectomy under epidural there might be too many irrelevant
retrievals results for the question above.

Forms

Just like classifications nomenclatures can have different constructions

1. Hierarchy

For easier orientation, extensive nomenclatures can exhibit hierarchical structures (ex.
Can be based on a hierarchical concept system.

2. Multiple axes or dimension:

dividing the set of authorized terms into several semantic dimensions will
lead to multiaxial nomenclatures. By checking the dimensions on after the
other applicable descriptors, the completeness of indexing is improved.
Moreover, the reduced complexity serves the user with better orientation. In
contrast to multiaxial classifications (where you have to choose exactly one
class in every axis ), you may well assign several descriptors per axis to one
object.

Example

Simple monoaxial nomenclature.

Imagine this list of descriptors for the localization of pain:

L1 head

L2 Back

L3 extremities

L4 joints

Assuming a hierarchical construction, this is a possible subdivision:

L1 head

L11 Face

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 L12 Forehead

L13 Temples

L14 Skull

By adding another partial nomenclature for the quality of pain, a tow axial
nomenclature emerges:

Q1 dull pressing

Q2 Burning, hot

Q3 Stabbing, searing

Q4 Tearing

A stabbing, hot pain at the wrist would be coded as (L3, L4,Q2,Q3)

A dull pain at the forehead and a pressing pain at the temples would be two
separate facts:( L12,Q1) AND (L13,Q1).

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 Lecture 5
Healthcare Common Procedure Coding System

Introduction

A standardized coding system used to process claims for insurance payments by the
Centers for Medicare and Medicaid Services. It consists of two parts: a coding
system devised by the American Medical Association called the Current Procedural
Terminology, which describes procedures and services provided by health care
professionals; and a system that identifies health-related products and services that are
not provided by physicians, e.g., ambulance services and durable medical equipment,
prosthetics, orthotics, and supplies (DMEPOS).

The Healthcare Common Procedure Coding System (HCPCS, often pronounced

by its acronym as "hick picks") is a set of health care procedure codes based on the
American Medical Association's Current Procedural Terminology

Levels of HCPCS before end of year 2003

HCPCS includes three levels of codes:

• Level I consist of the American Medical Association's Current Procedural

Terminology (CPT) and is numeric . include physician services

• Level II codes are alphanumeric and primarily include non-physician services

such as ambulance services and prosthetic devices, and represent items and
supplies and non-physician services, not covered by CPT-4 codes (Level I).

• Level III codes, also called local codes, were developed by state Medicaid
agencies, Medicare contractors, and private insurers for use in specific
programs and jurisdictions. The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) instructed CMS to adopt a standard
coding systems for reporting medical transactions. The use of Level III codes
was discontinued on December 31, 2003, in order to adhere to consistent
coding standards. Level III codes were different from the modern CPT
Category III codes, which were introduced in 2001 to code emerging
technology.

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Levels of HCPCS Codes and Modifiers after 2003

HCPCS includes two levels of codes.

1. Level I consist of CPT codes. CPT or Current Procedural Terminology codes

are made up of 5 digit numbers and managed by the American Medical
Association (AMA). CPT codes are used to identify medical services and
procedures ordered by physicians or other licensed professionals.

2. Level II of the HCPCS are alphanumeric codes consisting of one alphabetical

letter followed by four numbers and are managed by The Centers for Medicare
and Medicaid Services (CMS). These codes identify non-physician services
such as ambulance services, durable medical equipment, and pharmacy. These
are typically not costs that get passed through a physician's office so they must
be dealt with by Medicare or Medicaid differently from the way a health
insurance company would deal with them.

Some HCPCS codes required the use of modifiers. They consist of a two digit
number, two letters or alphanumeric characters. HCPCS code modifiers provide
additional information about the service or procedure performed. Modifiers are used
to identify the area of the body where a procedure was performed, multiple
procedures in the same session, or indicate a procedure was started but discontinued.

Sometimes services are always grouped together, in which case their codes may also
be grouped. These are called "bundled" codes.

Importance for Medical Office Staff and Providers

Providers should be aware of the HCPCS code guidelines for each insurer especially
when billing Medicare and Medicaid claims. Medicare and Medicaid usually have
more stringent guidelines than other insurers.

Providers and medical office managers must make sure their medical coders stay up-
to-date on HCPCS codes. HCPCS codes are updated periodically due to new codes
being developed for new procedures and current codes being revised or discarded.

Where Patients May Find HCPCS / CPT Codes

Patients can find HCPCS / CPT Codes in a number of places. As you leave the
doctor's office, you are handed a review of your appointment which may have a long
list of possible services your doctor provided, with some of them circled. The
associated numbers, usually five digits, are the codes.

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If your appointment requires a follow-up billing by your doctor for copays or co-
insurance, then the codes may be on those bills.

A wise patient and smart healthcare consumer will use these codes to review medical
billings from practitioners, testing centers, hospitals or other facilities. It's a good way
to be sure your insurance (and your co-pays and co-insurance) are paying only for
those services you received.

If you receive statements from either the doctor or your health insurance and the
HCPCS / CPT codes do not appear, then contact the party who sent them and request
a new statement that does include the codes.

Alphabetic index HCPCS Level II

• A Codes ~ Transportation Services, Med/Surg Supplies, Admin

• B Codes ~ Enteral and Parenteral Therapy

• C Codes ~ Pass-Through Items

• D Codes ~ Dental Procedures

• E Codes ~ Durable Medical Equipment

• G Codes ~ Procedures/Professional Services

• H Codes ~ Alcohol and Drug Abuse Treatment Services

• J Codes ~ Drugs Admin Other Than Oral Method/Chemotherapy Drugs

• K Codes ~ DME Supplies

• L Codes ~ Orthotic/Prosthetic Procedures

• M Codes ~ Medical Services

• P Codes ~ Lab/Path

• Q Codes ~ Temporary Codes

• R Codes ~ Diagnostic Radiology

• S Codes ~ Temporary National Codes (Non-Medicare)

• T Codes ~ Nat’l Codes for State Medicaid Agencies

• V Codes ~ Vision/Hearing Services

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 Lecture 6

CPT Coding

Introduction

Earlier, we introduced you to Current Procedural Terminology, or CPT. This

expansive, important code set is published and maintained by the American Medical
Association (AMA), and it is, with ICD, one of the most important code sets for
medical coders to become familiar with. Note also that all the codes featured in this
course, and every course that touches on CPT codes, are copyrighted by the AMA.

CPT codes are used to describe tests, surgeries, evaluations, and any other medical
procedure performed by a healthcare provider on a patient. As you might imagine,
this code set is extremely large, and includes the codes for thousands upon thousands
of medical procedures.

CPT codes are an integral part of the billing process. CPT codes tell the insurance
payer what procedures the healthcare provider would like to be reimbursed for. As
such, CPT codes work in tandem with ICD codes to create a full picture of the
medical process for the payer. “This patient arrived with these symptoms (as
represented by the ICD code) and we performed these procedures (represented by the
CPT code).

Format

Let’s look a little closer at what these codes look like and how they’re organized.
Each CPT code is five characters long, and may be numeric or alphanumeric,
depending on which category the CPT code is in. Don’t confuse this with the
‘category’ in ICD. Remember that in ICD codes the ‘category’ refers to the first three
characters of the code, which describe the injury or disease documented by the
healthcare provider.

With CPT, ‘Category’ refers to the division of the code set. CPT codes are divided
into three Categories.

Category I is the most common and widely used set of codes within CPT. It describes
most of the procedures performed by healthcare providers in inpatient and outpatient
offices and hospitals.

Category II codes are supplemental tracking codes used primarily for performance
management.

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 Category III codes are temporary codes that describe emerging and experimental
technologies, services, and procedures.

Note that while CPT codes have five digits, there are not 99,000-plus codes. CPT is
designed for flexibility and revision, and so there is often a lot of “space” between
codes. Unlike ICD, each number in the CPT code does not correspond to a particular
procedure or technology.

Here’s a closer look at the three categories of CPT codes.

Category I

Medical coders will spend the vast majority of their time working with Category I
CPT codes. For the sake of simplicity, we’ll refer to the CPT codebook when we’re
describing the code set. This book, which is updated yearly by the AMA and the CPT
Editorial Board, is an essential tool for every medical coder.

Like the ICD code set and its division into chapters by type of injury or illness,
Category I CPT codes are divided into six large sections based on which field of
health care they directly pertain to. Here’s the sections of Category I CPT codes, as
arranged by their numerical range.

• Evaluation and Management: 99201 – 99499

• Anesthesia: 00100 – 01999; 99100 – 99140
• Surgery: 10021 – 69990
• Radiology: 70010 – 79999
• Pathology and Laboratory: 80047 – 89398
• Medicine: 90281 – 99199; 99500 – 99607

Each of these sections has its own subdivisions, which correspond to what type of
procedure, or what part of the body, that particular procedure relates to.

Each of these sections also has specific guidelines for how to use the codes in that
section.

In the CPT codebook, these codes are listed in mostly numerical order, except for the
codes for Evaluation and Management. These Evaluation and Management, or E&M,
codes are listed at the front of the codebook for ease of access. Physician’s offices
frequently use E&M codes for reporting a number of their services. The code 99214,
for a general checkup, is listed in the E&M codes, for example.

Within each of these code fields, there are subfields that correspond to how that
topic—say, Anesthesia—applies to a particular field of healthcare. For instance, the

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Surgery section, which is by far the largest, is organized by what part of the human
body the surgery would be performed on.. Likewise, the Radiology section is
organized into sections on diagnostic ultrasound, bone and joint studies, radiation
oncology, and other fields.

Category II

These codes are five character-long, alphanumeric codes that provide additional
information to the Category I codes. These codes are formatted to have four digits,
followed by the character F. These codes are optional, but can provide important
information that can be used in performance management and future patient care.

Here’s a quick example. If a doctor records a patient’s Body Mass Index (BMI)
during a routine checkup, we could use Category II code 3008F, “Body Mass Index
(BMI), documented.”

These codes never replace Category I or Category III codes, and instead simply
provide extra information. They are divided into numerical fields, each of which
corresponds with a certain element of patient care.

Category III

The third category of CPT codes is made up of temporary codes that represent
emergent or experimental services, technology, and procedures. In certain cases, you
may find that a newer procedure does not have a Category I code. There are codes in
Category I for unlisted procedures, but if the procedure, technology, or service is
listed in Category III, you are required to use the Category III code.

Category III codes allow for more specificity in coding, and they also help health
facilities and government agencies track the efficacy of new, emergent medical
techniques.

Think of Category III as codes that may become Category I codes, or that just don’t
fit in with Category I. Category I codes must be approved by the CPT Editorial Panel.
This Panel mandates that procedures or services must be performed by a number of
different facilities in different locations, and that the procedure is approved by the
FDA (Food & Drug Administration). Due to the nature of emerging medical
technology and procedures, it’s not always possible for an experimental procedure to
meet these criteria, and thus become a Category I code.

Whether a Category III code becomes a Category I code or not, all Category III codes
are archived in the CPT manual for five years. If at the end of this five year period the
code has not been converted to Category I, this procedure must be marked with a
Category I “unspecified procedure” code. When flipping through the Category III

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 section of the CPT manual, you’ll notice that each of the codes has a phrase listing its
sunset date below the code. Think of the sunset dates as expiration dates on the code.

Like Category II, these codes are five characters long, and are comprised of four
digits and a terminal letter. In this case, the last letter of Category III codes is T. For
example, the code for the fistulization of sclera for glaucoma, through ciliary body is
0123T.

Now that you have a better idea of what CPT looks like, how it’s formatted, and when
to use which category of codes, let’s dive a little deeper into modifiers and how CPT
codes look in action.

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 Lecture 7

How was CPT developed?

The American Medical Association (AMA) first developed and published CPT in
1966.

The first edition helped encourage the use of standard terms and descriptors to
document procedures in the medical record; helped communicate accurate
information on procedures and services to agencies concerned with insurance claims;
provided the basis for a computer oriented system to evaluate operative procedures;
and contributed basic information for actuarial and statistical purposes.

The first edition of CPT contained primarily surgical procedures, with limited sections
on medicine, radiology, and laboratory procedures.

The second edition was published in 1970, and presented an expanded system of
terms and codes to designate diagnostic and therapeutic procedures in surgery,
medicine, and the specialities. At that time, a five-digit coding system was introduced,
replacing the former four-digit classification. Another significant change was a listing
of procedures relating to internal medicine.

In the mid to late 1970s, the third and fourth editions of CPT were introduced. The
fourth edition, published in 1977, represented significant updates in medical
technology and a system of periodic updating was introduced to keep pace with the
rapidly changing medical environment. In 1983, CPT was adopted as part of the
Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing
Administration's (HCFA), Healthcare Common Procedure Coding System (HCPCS).
With this adoption, CMS mandated the use of HCPCS to report services for Part B of
the Medicare Program. In October 1986, CMS also required state Medicaid agencies
to use HCPCS in the Medicaid Management Information System. In July 1987, as
part of the Omnibus Budget Reconciliation Act, CMS mandated the use of CPT for
reporting outpatient hospital surgical procedures.

28

Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used
extensively throughout the United States as the preferred system of coding and
describing health care services.

HIPAA and CPT

The Administrative Simplification Section of the Health Insurance Portability and
Accountability Act (HIPAA)of 1996 requires the Department of Health and Human
Services to name national standards for electronic transaction of health care
information. This includes; transactions and code sets, national provider identifier,
national employer identifier, security, and privacy. The Final Rule for transactions
and code sets was issued on August 17, 2000. The rule names CPT (including codes
and modifiers) and HCPCS as the procedure code set for:

• Physician services.

• Physical and occupational therapy services.

• Radiological procedures.

• Clinical laboratory tests.

• Other medical diagnostic procedures.

• Hearing and vision services.

• Transportation services including ambulance.

The Final Rule also named ICD-9-CM volume 1 and 2 as the code set for diagnosis
codes, ICD-9-CM volume 3 for inpatient hospital services, CDT for dental services,
and NDC codes for drugs.

All health care plans and providers who transmit information electronically are
required to use established national standards by the end of the implementation

29

period, October 16, 2003. In addition, all local codes have been eliminated and
national standard code sets must be used after October 16, 2003.

30

 Lecture 8

International Classification of Diseases (ICD)

It is the coding system that classification different diseases in grouped according same
attributed , and give each disease number or alphabetic number to easily revision,
easy to coding and to help in statically report special to its.

ICD is published by world health organization (WHO) with 10 revisions

Revision Years Covered

1st 1900-09
2d 1910-20
3d 1921-29
4th 1930-38
5th 1939-48
6th 1949-57
7th 1958-67
8th 1968-78
9th 1979-98
10th 1999-present

WHO put 2 volumes for ICD

Volume 1: is a tabular listing containing a numerical list of the disease code numbers.

This volume is have three digital number start from (001- 999)

The 999 digital number to 17 main section for diseases and, injures and surgery and
else.

Each 17 main part are divided to 10 branch

Inside each group the 3 digital numbers specialize for main case then for less
important case.

31

Volume 2: is an alphabetical index to the disease entries.

Why is the ICD important?

The ICD is important because it

1. Provides a common language for reporting and monitoring diseases. This
allows the world to compare and share data in a consistent and standard
way – between hospitals, regions and countries and over periods of time.
2. It facilitates the collection and storage of data for analysis and evidence-
based decision-making.
3. Easley the statically report.

Who uses it?

Users include physicians, nurses, other providers, researchers, health information

managers and coders, health information technology workers, policy-makers,
insurers and patient organizations.
ICD has been translated into 43 languages and it is being used by all member
States. Most countries (117) use the system to report mortality data, a primary
indicator of health status.
All Member States are expected to use the most current version of the ICD for
reporting death and disease statistics (according to the WHO Nomenclature
Regulations adopted by the World Health Assembly in 1967).

32

 Lecture 9
International Classification of Diseases (ICD)-9

In 1979 the WHO modifite the revision of ICD to ICD-9 and translate to Arabic

Languge to used it in Arabic country hospital.

ICD -9 have 4 volumes

Volume 1 :

This volume is have three digital number start from (001- 999)

The 999 digital number to 17 main section for diseases and, injures and surgery and
else.

Chapter Titles Code categories

1- Infectious and parasitic disease 001-139

Example1

Chapter 1: Infectious and parasitic disease 001-139

-Cholera 001

Typhoid and paratyphoid 002

-TB 010-018

Primary tuberculosis infection 010

TB of lung 011

-Zoonotic bacterial diseases 020-027

Plague 020

Brucellosis 023

-Other bacterial diseases 030-041

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Leprosy 030

Diphtheria 032

Whooping cough 033

2-Neoplasms 140-239

3- Endocrine, nutritional and metabolic Disease and Immunity disorder 240-279

4- Diseases of the blood and blood forming organs 280-289

5- Mental disorders 290-319

6- Diseases of the nervous system and Sense organs 320-389

7- Diseases of the Circulatory system 390-459

8- Diseases of the Respiratory system 460- 519

9- Diseases of the Digestive system 520-579

Disease of oral cavity, salivary glands and jaws 520-529

Disease of oesophagus, stomach and duodenum 530-537

Appendicitis 540-543

Hernia of abdominal cavity 550-553

10- Diseases of the Genitourinary system 580-629

11-complication of pregnancy, childbirth, and the puerperium 630-679

e.g. pregnancy with abortive outcome 630-639

complication with puerperium 670-676

12- Diseases of the of skin and subcutaneous tissue 680-709

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13- Diseases of the musculoskeletal system and connective tissue 710-739

14-Congenital anomalies 740-759

15-certain conditions originating in the prenatal period 760-779

16- symptoms, signs, and Ill –defined conditions 780-799

e.g symptom 780-789

17-Injury and poisoning 800-999

e.g fracture of skull 800-804

fracture of spine and track 805-809

fracture of upperlimb 810-819

Volume 2:

Supplementary classification for external causes of injury and poisoning

This code is (800 s- 999 s) and divided to many section

1. Railway accidents : ( 800 S - 807 S)

2. Traffic accidents caused by motorized vehicles: (810 S- 819 S)
3. Accidents vehicles but not traffic: (820 S- 825 S)
4. Another accidents traffic vehicles : (826 S- 829 S)
5. Accidents aquatic transport :( 830 S- 838 S).
6. Accidents by plane and space transport :( 840 S- 845 S).
7. Accidents not classify in another place like left :( 846 S- 848 S).
8. Toxic in vaccine, drugs and biology material:( 850 S- 858 S)
e.g. Accidental poisoning of tranquillizers (S853)

9. Toxic in solid, liquid, gases and vapor material :( 860 S- 869 S).
10. Medical error during surgery or treatments :(870 S-876 S)

35

 11. Bad response for patient or compilation after surgery or medical procedures:(
878 S-879 S).
12. Fall down from high place ( 880 S-888 S)
13. Fire accident :(890 S-899 S)
14. Natural and environmental accident :(900 S- 909 S)
e.g. Excessive heat 900S

15. Accidents caused by diving or choking or strange objects:(910 S-915 S)

16. Pump of pressure container :(916 S-928 S)
17. Late appear for some injury:(929 s)
18. Side effect for some drugs, vaccine and biology material:(930 S-949 S)
19. Self- injury and Suicide( self-murder): (950 S-959 S)
20. Killing people :(960 S-969 S)
21. Injuries caused by firearms:(970 S-978 S)
22. Unspecified injuries that were casual or deliberate or spend as much:(980 S-
989 S)
23. Injuries resulting from war operations:(990 S-999 S)

Volume 3

Also supplementary classification list for factor influencing health status and contact
with health service it takes code from (01 F-82 F)

This volume is divided to many sections

1. Medical risk for communicable disease :(01 F- 7 F)

2. Medical risk for genetics disease :(10 F-19 F)
3. Person attached with medical service for reproduction and growth :(20 F-28 F)
4. New health born with kind of delivery type:(30 F-39 F)
5. Person that have special case effect on its health :(40 F-49 F)
6. Person attached with medical service for care after treatment:(50 F-59 F)
7. Person attached with medical service for another state:(60 F- 68 F)
8. Person without diagnosis meet with them during Examination and survey of
individuals and communities:( 70 F- 82 F)

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Volume 4

Its contain special tabulation lists

1. The basic Tabulation list in volume 1 for disease.

2. Fifty list for disease reasons.
3. Fifty list for death reasons.

And volume 4 has many international classifications like

1. International classification of procedures in medicine

Publications of the World Health Organization for laboratory tests, surgery, radiation
treatment and chemotherapy.

2. International classification disease for oncology

Publications of the World Health Organization .This classification is to determination

of the oncology position and kind of it if its Malignant cancer or benign cancer.

3. Diagnostic and statistical manual of mental disorders

This classification for mental disease and treatment this classification is special for
psychosomatic hospital.

Publications by American psychiatric association.

37

 Lecture 10

ICD-9- CM codes

The International Classification of diseases ICD, 9th revision, clinical modification

(ICD-9- CM) is a modification of ICD-9 which are created by the world health
organization (WHO).

Since 1979, ICD-9- CM has provided a diagnostic coding system for the compilation
and reporting of morbidity and mortality statistics for reimbursement purposes in
United States.

It allows for reporting of conditions, injuries, and traumas along with complications
and circumstances occurring with the illness or injury. It also provides the reason for
patient care

The ICD-9- CM contains three volumes. All health care facilities utilize volume 1

|( Tabular list of disease ) and vol.2 ( Alphabetic Index of Diseases) report diagnoses.
Hospitals use Vol 3 to report inpatient procedures ( CTP is used to report procedures
performed in physician offices, ambulatory care centers and hospital outpatient
departments).

ICD-9-CM requires assignment of the most specific code to represent the problem
being treated by provider. This means the primary diagnosis should be the one for the
condition indicated within the medical record as the primary reason the patient sought
medical care in an outpatient or office setting, or the principal diagnosis in an
inpatient setting.

History and usage of ICD-9-CM

ICD-9-CM stands for International Classification of Disease, Ninth revision,

Clinical Modification. It is used for coding and classify diagnoses and procedures by a
numerical system. Classifying diseases by their cause has been done in various forms
for many years, even as far back as the Greek civilization.

38

The ICD-9-CM code book is updated every year with changes effective October 1 of
that year. It is essential that code books and coding software be updated yearly with
the revisions.

Tabular list (volume1)

volume1, the " Classification of Diseases and Injuries " is the tabular listing of
diagnoses. 1) Once a coder has identified a code in the alphabetic index. 2) It must be
vertified in the tabular list, codes are arranged numerically in 17 chapters and are
grouped according to their cause (etiology ), such as fractures, or body system, such
as digestive system.

Chapter Titles Code categories

1- Infectious and parasitic disease 001-139

2-Neoplasms 140-239

3- Endocrine, nutritional and metabolic Disease and Immunity disorder 240-279

4- Diseases of the blood and blood forming organs 280-289

5- Mental disorders 290-319

6- Diseases of the nervous system and Sense organs 320-389

7- Diseases of the Circulatory system 390-459

Disease of circulatory system ( 390-459)

Hypertensive diseases(401-405)

Hypertensive heart diseases 402

Malignant 402,0

Malignant with congestive heart failure 402,01

8- Diseases of the Respiratory system 460- 519

9- Diseases of the Digestive system 520-579

39

Example

Chapter 9: Disease of digestive system (520-579)

Section: Hernia of abdominal cavity (550-553)

Category :other hernia of abdominal cavity ,with gangrene (551)

Subcategory : ventral hernia ,with gangrene 551,2

Subclassification: incisional, with gangrene 551,21

10- Diseases of the Genitourinary system 580-629

11-complication of pregnancy, childbirth, and the puerperuim 630-679

12- Diseases of the of skin and subcutaneous tissue 680-709

13- Diseases of the musculoskeletal system and connective tissue 710-739

14-Congenital anomalies 740-759

15-certain conditions originating in the prenatal period 760-779

16- symptoms, signs, and Ill –defined conditions 780-799

17-Injury and poisoning 800-999

Supplementary Classifications

The Alphabetical index (Volume2)

The Alphabetical index (Volume2) of ICD-9-CM consists of an alphabetic list of

terms and cods, two supplementary sections following the alphabetic listing

There are two Supplementary Classifications included in the tabular list (volume1)
these are:

40

 1- V codes ( V01-V83)
V codes can be used to describe the main reason for the pateint's visit in cases where
the patient is not " Sick" or used as a secondary diagnosis to provide further
information about the patient 's medical condition. One example would be a patient
who is not sick and comes in to receive a TB skin test. There is a V code,V74.1,

Screening for pulmonary tuberculosis that is used if a diagnosis is not identified for
the patient.

2- E Codes (E800-E999)
E codes are external causes of injury and poisoning. E codes are used as
secondary diagnosis to show the cause of injury, such as fall or automobile
accident, if it is known.

An example of injury E code is E828.2, accident involving animal being ridden,

rider of animal.

Procedures :tabular list and alphabetic index (Volume3)

Volume3 consists of two sections, tabular list and alphabetic index. These codes
define procedures instead of diagnosis.

Operations on the nervous system01-05

Operations on the endocrine system06-07

Operations on the eyes08-16

Operations on the ear18-20

Operations on nose, mouth and pharynx 21-29

Operations on the respiratory system30-34

Operations on the cardiovascular system35-39

Example of Vol 3(ICD9-CM)

Operations on the cardiovascular system35-39

Operations on valves and septa 35

41

Open heart valvulopasty 35.1

Open heart valvulopasty of mitral valve without replacement 35,12

Operations on the lymphatic system40-41

Operations on the digestive system42-54

Operations on the urinary system55-59

Operations on the male genital system60-64

0perations on the female genital system65-71

Obstetric procedures72-75

Operations on the integumentary system76-84

Miscellaneous diagnostic and therapeutic procedure 87-99

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 Lecture 11
ICD 10

In ICD-10 the information about diseases and conditions and their causes is
grouped as follows:

Communicable diseases
General diseases that affect the whole body
Local diseases arranged by site
Developmental diseases
Injuries
External causes

ICD-9-CM vs. ICD-10-CM Comparison

ICD-9-CM ICD-10-CM

13,000 codes 68,000 codes

17 chapters 22 chapters

3–5 character length Alphanumeric with up to 7 characters

Addition of a placeholder (x)

Greater specificity and laterality

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ICD-10-CM Structure –Format Example

S52Fracture of forearm

S52.5Fracture of lower end of radius

S52.52Torus fracture of lower end of radius

S52.521Torus fracture of lower end ofrightradius

S52.521ATorus fracture of lower end ofrightradius,initial encounter,closed

fracture

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 Different between ICD and CPT

1. Current Procedural Terminology (CPT) is a medical code manual published by

the American Medical Association while the International Classification of
Diseases (ICD) is a medical code manual published by the World Health
Organization.

2. The CPT code describes what was done to the patient during the consultation,
including diagnostic, laboratory, radiology, and surgical procedures while the ICD
code identifies a diagnosis and describes a disease or medical condition.

3. CPT codes are more complex than ICD codes.

4. The CPT book is updated every three to five years while the ICD book is updated
every 10 to 15 years.

45

 Lecture 12
Reimbursement

What is a healthcare reimbursement system?

Healthcare reimbursement describes the payment that your hospital, doctor,

diagnostic facility, or other healthcare providers receive for giving you a medical
service. Often, your health insurer or a government payer covers the cost of all or part
of your health care

What is a reimbursement rate?

A: Medicare reimbursement refers to the payments that hospitals and physicians

receive in return for services rendered to Medicare beneficiaries. The reimbursement
rates for these services are set by Medicare, and are typically less than the amount
billed or the amount that a private insurance company would pay.

What is prospective payment system in healthcare?

A Prospective Payment System (PPS) is a method of reimbursement in which

Medicare payment is made based on a predetermined, fixed amount. The payment
amount for a particular service is derived based on the classification system of that
service (for example, diagnosis-related groups for inpatient hospital services).

What is value based reimbursement in healthcare?

Value based healthcare reimbursement is a payment model that reimburses

healthcare providers based on the quality they provide to patients rather than the
number of patients they see.

What are reimbursement methods?

The three primary fee-for-service methods of reimbursement are

1. Cost based.

2. Charge based

3. Prospective payment.

46

Cost-Based Reimbursement. Under cost-based reimbursement, the payer agrees to
reimburse the provider for the costs incurred in providing services to the insured
population.

47