coding foundations module 1

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Coding Foundations Module 01 Live Classroom Overview of Coding Classification Systems, Coding Books, and Official Coding Guidelines
• Coding Classification Systems – ICD-10-CM and PCS – CPT (Current Procedural Coding) • Code Books – ICD-10-CM – ICD-10-PCS – CPT • Coding Guidelines by System – Inpatient vs Outpatient Coding • Coding Tools: Encoder vs Computer-Assisted Coding (CAC) • Clinical Documentation in Coding and Billing • Revenue Cycle Components • Payment Systems (DRGs, APC’s, DSM-V) • Professional Certifications • Career Opportunities in Coding and Revenue Cycle Agenda
• Three (3) physical code books are required for this course. • Check the Syllabus in the course for textbook details. • If you do not have the 3 code books, contact Personal Support, your Student Advisor, and your Instructor immediately. • Readings and assignments requiring the use of the code books begin in Module 02. Note: There is no eTextbook for this course. Important Information
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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 4 • To gain a general knowledge of the career field of Health Information and Coding. • To gain a general knowledge of the Revenue Cycle which includes coding and billing as well as patient information management. • To gain an introduction to the 3 Main Coding Systems. • To gain experience in the use the 3 different Code Books and 2 Encoders for Coding. • To gain an understanding of coding pathways in the coding process. Goals of the course
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 5 • Make you a skilled coder by the end of the course. • Give you in-depth information on how to code for each of the 3 coding systems. • Make you proficient in using a code book or an encoder. WHY THE ABOVE WILL NOT HAPPEN: Because coding, using a code book, and an encoder take practice over time. There is a large volume of information to take in for each coding system, each code book, and each encoder and takes time and practice to hone coding skills. What the course will NOT do:
• ICD 10 CM Coding – for assigning diagnosis codes both outpatient and inpatient encounters • ICD 10 PCS Coding – for assigning inpatient procedure codes only • CPT /Ambulatory Care Coding – for assigning outpatient procedure and service codes only 3 Coding Classification Systems
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• Utilized for assigning diagnosis codes for both inpatient and outpatient (ambulatory) encounters. – Section I - Conventions, General Coding Guidelines & Chapter Specific Guidelines – Section II - Selection of Principal Diagnosis – Section III – Reporting Additional Diagnoses – Section IV – Diagnostic Coding and Reporting Guidelines for Outpatient Services • Character values may be letters (alpha) or numeric. • Codes may consist of 3-7 characters. – The first character is always an alphabetic character. – The second character is always a numeric value. – All letters are used with the exception of “U”. • All categories consist of 3 characters followed by a decimal point. • CM Code books and coding guidelines are updated annually -effective for service dates and discharge dates as of October 1 of the respective year. • Review the Introduction in front of the ICD-10-CM code book for further information. ICD-10-CM Coding System
• ICD-10-PCS coding is HIPAA mandated for reporting Inpatient procedures. • Unlike ICD-10-CM codes, a PCS code always consists of 7 characters. – Each character in the PCS code represents a specific component of the coded procedure e.g. Medical and Surgical Section : Section, Body System, (Root) Operation, Body Part, Approach, Device and Qualifier. • The PCS code build process differs from how ICD-10-CM codes are assigned. – Based on the provider’s documentation, the coder chooses a specific value from the code tables for each of the 7 characters of the code. • Code character values include both letters (alpha) and numeric characters, with the exception of the alpha characters I and O as they are easily confused with the number 1 and 0 (zero). • In PCS coding, it is the coder’s responsibility to interpret the provider’s documentation in alignment with PCS definitions for the character values. (CG A11) • PCS Code books and coding guidelines are updated annually-effective for use for service dates and discharge dates as of October 1 of the respective year….the same as ICD-10-CM. • Review the Introduction in front of the ICD-10-PCS code book for further information. ICD-10-PCS Coding System
• CPT is a set of codes, descriptions and guidelines intended to describe both procedures and services performed by physicians and other health care professionals. • Each code consists of 5 letter (alpha) or numeric characters. • A CPT code may be further expanded by the application of a “Modifier” to explain specific circumstances identified in the modifier guidelines and must be applied cautiously. • In CPT, the term “procedure” describes services which include diagnostic tests. • The code book and guidelines are updated annually with an effective for service dates and discharge dates as of January 1 of the respective year. • Review the Introduction in front of the CPT code book for further information. CPT Coding System
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• DISCLAIMER: • Please note that there are a number of code book publishers. Although each publisher may have a different look or organization to their coding books, the essential context will be the same to provide consistency in the code assignment or code build process. • Code books are updated on an annual basis. The most current version must be used based on service and discharge dates. Code Books
ICD-10-CM Code Book
ICD-10-PCS Code Book
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CPT Code Book
• For each of the individual coding systems there is a unique set of accompanying coding guidelines which are organized in different manners in the code books. • The coding guidelines are updated annually corresponding with the updated code books. • Guidelines are a set of “rules” intended to provide official direction for the interpretation, assignment and code build process. • Coding with integrity involves understanding and applying the Official Coding Guidelines. Official Coding Guidelines
• Each coding system has unique coding guidelines. • Published by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), the guidelines are rules intended to provide direction in the assignment of codes using ICD-10 code sets. • Updated annually in conjunction with the updated code books. • Effective for use on October 1 for service and discharge dates as of October 1 of the respective year….the same for both ICD-10-CM and ICD-10-PCS. • Located in the front of the code book. – Chapter Specific Coding guidelines are available in the front of the code book and at the beginning of the chapters in the Tabular List of Diseases and Injuries. – It is imperative to review the coding guideline to ensure the procedure code being reported is accurate and complete • The guidelines are also available online at… https://www.cms.gov/Medicare/Coding/ICD10 • Search by classification (ICD-10-CM or ICD-10-PCS) • Locate the current year based on service/discharge dates to be coded ICD-10-CM Coding Guidelines
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• ICD-10-CM and ICD-10-PCS Official Coding Guidelines are unique from each other. • Published by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). The guidelines are a set of rules intended to provide direction in the assignment of codes using ICD-10 code sets. • Updated annually in conjunction with the updated code books. • Effective for use on October 1 for service and discharge dates as of October 1 of the respective year….the same for both ICD-10-CM and ICD-10-PCS. • Located in the Introduction at the front of the code book and throughout the manual. – Within the manual, the section guidelines are presented after the Introduction to the sections: Medical and Surgical, Obstetrics and New Technology. – Throughout the Code Listings, applicable guidelines are identified by an instruction note to remind users to reference the guidelines. The instruction note Review Coding Guideline followed by the guideline reference (e.g. B3.4a ) is included after the section header. – It is imperative to review the coding guideline to ensure the procedure code being reported is accurate and complete. The guidelines are also available online at-- – https://www.cms.gov/Medicare/Coding/ICD10 • Search by classification (ICD-10-CM or ICD-10-PCS) • Locate the current year based on service/discharge dates to be coded ICD-10-PCS Coding Guidelines
• CPT Coding Guidelines are unique to the Current Procedural Terminology (CPT) code set. • Guidelines are updated annually by the American Medical Association (AMA) with an effective for service and discharge dates as of January 1 of the respective year. • Specific guidelines are presented at the beginning of each section within the CPT code book e.g. Medicine, Surgery, Radiology etc. • It is imperative to review the coding guideline to ensure the procedure, service or diagnostic test being reported is accurate and complete. CPT Coding Guidelines
• Conventions and General Guidelines apply to all settings, however, coding guidelines for outpatient and provider reporting of diagnoses vary in certain instances from inpatient diagnoses: – The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital- based outpatient services and provider-based office visits. – Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients. • First Listed Diagnosis - In the outpatient setting, the term “First-Listed Diagnosis” is used in lieu of Principle Diagnosis • Symptoms and Signs - Codes that described symptoms and signs are acceptable for reporting when a diagnosis has not been established or confirmed • Uncertain Diagnosis- Code conditions to the highest degree of certainty for that encounter such as symptoms, signs, abnormal test results. This differs from coding practices for short term, acute care, long term care and psychiatric hospitals. • Diagnostic Services or Therapeutic Services Only –Sequence first the diagnosis, condition, problem chiefly responsible for the services provided during the encounter • Ambulatory Surgery- Code the diagnosis for which the procedure was performed • See: Section IV – “A” for additional information on “First-Listed Conditions ”. ICD-10 Diagnostic Coding and Reporting Guidelines for Outpatient Services
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Encoders • Coding software called an “encoder” helps coders find codes more efficiently than using a book. – However, it is very important that all coders know how to use their code books as well as the coding software. – There are two coding software systems used in all Rasmussen coding courses. 3M Encoder and a Quantim (Clintegrity) Encoder. – You will learn how to use both encoders in this course. Computer Assisted Coding (CAC) • CAC is software designed to provide assistance in the coding process. True to its name, CAC is intended to “assist” and not replace the coder in the coding process. – To be effective, the coder must read the full medical record in order to validate the narrative identified by the CAC review of the documentation . Coding Tools
What is Clinical Documentation? • Clinical documentation is a record of the provider’s orders and progress notes, documentation of treatment and services, and a statement of diagnoses/procedures resulting from the patient care encounter . Why is Clinical Documentation Important? • Clinical documentation tells the story of the patient’s care and is critical for coding and billing purposes. • Regulatory and accrediting agencies mandate documentation standards for providers based on the type of health care setting. • The patient’s clinical chart is a means to communicate with other health care personnel regarding the patient’s condition and treatment. • Timely and accurate documentation is critical for a compliant medical and legal record. • A well-documented medical record can provide support in the event of a malpractice claim. • Proper documentation can generate data for statistical analysis. • Abstracted data from quality clinical documentation can be used for research to trend diagnoses and treatment outcomes. • In the event of a claim denial or audit, clinical documentation substantiates the treatment and services provided. Importance of Clinical Documentation
Possible Risks to the patient(s) due to the missing clinical documentation • Misdiagnosis • Readmission with serious complications or death • Incorrect medication prescribed • Inappropriate or incorrect surgery Possible Coding impact due to incomplete documentation • Delays in coding • Inaccurate codes can be applied • Inappropriate reimbursement Billing & Reimbursement Impact • Claims submission delays • Non-payment from insurer Importance of Clinical Documentation
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• See the lesson content entitled: • Revenue Cycle Components and Key Players Revenue Cycle Components
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Revenue Cycle The Big Picture Copyright Rasmussen, Inc. Proprietary and Confidential
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Copyright Rasmussen, Inc. Proprietary and Confidential 24 • Revenue Cycle Overview • Revenue Cycle Key Players • Revenue Cycle Working Relationships • Management of the Revenue Cycle • High Quality Outcomes Agenda
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25 • The Revenue Cycle is a term for the life cycle of a patient’s account. – There are very specific steps in the cycle. – The cycle has a specific beginning and end. – Each step of the cycle is a particular job. – The steps are performed by key players. Revenue Cycle Overview Copyright Rasmussen, Inc. Proprietary and Confidential
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Copyright Rasmussen, Inc. Proprietary and Confidential 26 Revenue Cycle Key Players Key Player Roles Administration Determines strategic goals. Accountable for ensuring overall operational efficiency and effectiveness. Patient Access (Registration, Admissions) Responsible for: scheduling, preauthorization/Medical Necessity checking, and patient registration. Clinical Services (all individuals or departments providing treatment or services for the patient e.g. Physicians, Nursing, Lab, Radiology, Surgery, etc.) Providers of treatment and services. Documents treatment and services, diagnoses/procedures, and patient outcomes Enters charges for billing of services performed. Health Information Management/Coding Accountable for record timeliness and completeness. Coding and abstracting of data for billing and reporting. Patient Accounts/Billing Processes claims for billing and manages collections. Finance Monitors cash flow e.g. days in Accounts Receivable Case Management/Utilization Management Case Management is responsible for ongoing care services post discharge. Utilization Management is responsible for resource management and management of length of stay.
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27 • The revenue cycle starts with the registration/pre-registration of the patient. • Case Management and Utilization Review are involved to ensure that medical necessity is met.(i.e., performing tests or procedures to support diagnoses) • Next, information is entered in the patient record. • Charges for the services rendered are also entered into the system. • Discharge Analysis occurs after the patient is discharged or services are completed. • Coding follow discharge analysis when the record is complete. – Assure all required diagnoses are supported Note: A “legal” record must be established in order to be coded. The legal record includes signatures, dates, legal content, and accurate documentation . • Billing will process the claims following the coding process. – Assure all required codes are acknowledge on billing claims Revenue Cycle…Beginning to End Copyright Rasmussen, Inc. Proprietary and Confidential
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28 • After the bill has been submitted for payment… • Patient Financial Services becomes involved to monitor Accounts Receivable. • Their role will be to… – Collect payment from patients who are uninsured. – Address any payment disputes received from the patient by working with other teams within the Revenue Cycle. – Remediate reimbursement issues with third party. – Facilitate any denials by arranging for coding, clinical services, billing etc. to prepare appropriate appeals. (4 • It is important that all clinical information is reflected as appropriate codes to accommodate the most accurate payment. • Support in clinical documentation to support any denials that may need to be proved by providing the medical record to support and overturn previous denials. Revenue Cycle Continued Copyright Rasmussen, Inc. Proprietary and Confidential
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29 • Management of the Revenue Cycle is designed to ensure that a healthcare facility is properly reimbursed for the services it provides. • Effectively managing this cycle involves: – Many different processes (job titles) – Many different people (at various levels) – Many different skills and technology ALL WORKING TOGETHER AS A TEAM. Management of the Revenue Cycle Copyright Rasmussen, Inc. Proprietary and Confidential
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30 Revenue Cycle Management Copyright Rasmussen, Inc. Proprietary and Confidential Revenue Cycle Overview (Davis & Doyle, 2016, p. 2)
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31 • As a new Health Information Professional it is important to… – Understand the “Big Picture” – Understand your Role and Responsibilities – Understand the Revenue Cycle Working Relationships Summary Copyright Rasmussen, Inc. Proprietary and Confidential
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32 Davis, N. A., & Doyle, B. M. (2016). Revenue cycle management best practices . Chicago, IL: AHIMA Press. References Copyright Rasmussen, Inc. Proprietary and Confidential
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• Diagnostic Related Groups (DRG) A formula created by the federal government (CMS) and adopted by other payers as a way to determine payment for an inpatient stay. Related diagnosis are grouped together because management and treatment would be similar or interrelated and tend to incur similar cost and length of stay. Each diagnostic related group is assigned a number which factors into the formula which determines the cost of the inpatient stay. • APCs Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. ... APCs are an outpatient prospective payment system applicable only to hospitals. • DSM-V Diagnostic and Statistical Manual of Mental Disorders - A set of codes used in billing for the treatment of patients with substance abuse disorders and mental disorders. These codes are designed to help the payer understand better the nature of what is being treated. Payments Systems
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• Rasmussen College encourages Medical Billing and Coding students to prepare and sit for the CCA (Certified Coding Associate) exam. The college also encourages Health Information Technology students to prepare and sit for the RHIT (Registered Health Information Technician) exam. • The CCA and RHIT designations (credentials) are nationally recognized standards of achievement in the health information management (HIM) field. Professional Certifications
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• There are a variety of job titles and career paths for individuals interested in coding and billing career opportunities . • It is important to keep in mind that different organizations may have different job titles for positions that perform similar responsibilities and require similar skill sets. • When looking at a position always review the required education, credential, and experience desired along with the responsibilities outlined and the skills the organization desires. • Access the AHIMA Career Map link below for job descriptions, required skills, education and experience, and salary information . • Link: https://my.ahima.org/careermap Career Opportunities
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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 36 Any job in the Health Information Field/Revenue Cycle has certain goals in common that help a team function and provide accurate reimbursement: • Accuracy of data • Quality of data • Confidentiality of data • Each follows the standards, guidelines, and policies • Efficiency of data processing for efficient payment • High quality skills and knowledge of their job What Is Common to All Jobs?
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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 37 Free Job Search Tools & Strategies Search: Symplicity Jobs and Careers
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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 38 • This week you will need to read the information provided under Lesson Content which will provide an overview of coding, including key terms, information on Revenue Cycle and Clinical Documentation. There are some ungraded activities to check your understanding and re-enforce important concepts. • Live classroom provides in-depth review of all of the topics introduced in Module 01. • Assignments consist of: – A lab activity on the 3 coding classification systems – An activity around clinical documentation – A 40-question quiz on the learning concepts from lecture and “Lesson Content” Module 01 Assignments
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• A lab activity on the 3 coding classification systems – ICD-10-CM Diagnosis Coding – CPT Coding – ICD-10 PCS Coding • An activity around clinical documentation – Provide answers to scenario questions on importance of clinical documentation • 40 Question Quiz – Provide answers based on course reading; practice assignments; live class; and all other information included in Module 1 Module 01 Assignments ( continued)
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40 • Check your Course Calendar for due dates. • Use the Live Classroom Recording and Course Articles for your Quiz and Written Assignments. • When doing research, be sure to give references for all written assignments. • Make sure you have all three physical code books needed beginning with for Module 02. • Email questions to your instructor via the Course Messages or the General Course Questions. • Tutoring is available to you by using the “Tutor” link on the left side of Course Home Page. • Contact Personal Support with any technical concerns. Reminders 12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential
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• Reminder to enter the Live Classroom Assessment Code provided during the course of the Live Classroom presentation. • Enter the code in the “Live Classroom” quiz to be eligible to earn points for attending/viewing. Live Classroom Assessment Code
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