There are three sets of code you’ll use on a daily basis as a medical coder.
ICD
The first of these is the International Classification of
Diseases, or ICD codes.
These are diagnostic codes that
create a uniform vocabulary for describing the causes of injury, illness and
death. This code set was established by the World
Health Organization (WHO) in the late 1940s. It’s been updated several
times in the 60-plus years since it’s inception. The number following “ICD”
represents which revision of the code is in use.
For example, the code that’s
currently in use in the United States is ICD-9-CM. This means it’s the ninth
revision of the ICD code. That “-CM” at the end stands for “clinical
modification.” So the technical name for this code is the International
Classification of Diseases, Ninth Revision, Clinical Modification. The clinical
modification is a set of revisions put in place by the National Center for Health
Statistics (NCHS), which is a
division of the Center for
Medicare and Medicaid Studies (CMS).
The Clinical Modification
significantly increases the number of codes for diagnoses. This increased scope
gives coders much more flexibility and specificity, which is essential for the
profession. It’s clinical modification, ICD-10-CM, contains over 68,000.
ICD codes are used to represent a
doctor’s diagnosis and the patient’s condition. In the billing process, these
codes are used to determine medical necessity. Coders must make sure the
procedure they are billing for makes sense with the diagnosis given.
ICD codes are updated by the NCHS on
a regular basis. One of the biggest issues in coding—and, indeed, in the health
information business at large—is the switchover from ICD-9-CM to ICD-10-CM.
ICD-10-CM provides significantly more codes and thus more flexibility and
accuracy in the coding process. The entire medical system has been changed over
from ICD-9-CM to ICD-10-CM in October of 2015.
Let’s turn our attention now to the
two types of procedure codes.
CPT
Current Procedure Terminology, or CPT,
codes, are used to document the majority of the medical procedures performed in
a physician’s office. This code set is published and maintained by the American Medical Association (AMA). These codes are copyrighted by
the AMA and are updated annually.
CPT codes are five-digit numeric
codes that are divided into three categories. The first category is used most
often, and it is divided into six ranges. These ranges correspond to six major
medical fields: Evaluation and Management, Anesthesia, Surgery, Radiology,
Pathology and Laboratory, and Medicine.
The second category of CPT codes
corresponds to performance measurement and, in some cases, laboratory or
radiology test results. These five-digit, alphanumeric codes are typically
added to the end of a Category I CPT code with a hyphen.
Category II codes are optional, and
may not be used in the place of Category I codes. These codes are useful for
other physicians and health professionals, and the AMA anticipates that
Category II codes will reduce the administrative burden on physicians’ offices
by providing them with more, and more accurate, information, specifically
related to the performance of health professionals and health facilities.
The third category of CPT codes
corresponds to emerging medical technology.
As a coder, you’ll spend the vast
majority of your time with the first two categories, though the first will
undoubtedly be more common.
CPT codes also have addendums that
increase the specificity and accuracy of the code used. Since many medical
procedures require a finer level of detail than the basic Category I CPT code
offers, the AMA has developed a set of CPT modifiers. These are two-digit
numeric or alphanumeric codes that are added to the end of the Category I CPT
code. CPT modifiers provide important additional information to the procedure
code. For instance, there is a CPT modifier that describes which side of the
body a procedure is performed on, and there’s also a code for a discontinued
procedure.
HCPCS
Healthcare Common Procedure Coding
System (HCPCS), commonly pronounced as “hick picks,” are a set of codes
based on CPT codes. Developed by the CMS (the same
organization that developed CPT), and maintained by the AMA, HCPCS codes
primarily correspond to services, procedures, and equipment not covered by CPT
codes. This includes durable medical equipment, prosthetics, ambulance rides,
and certain drugs and medicines.
HCPCS is also the official code set
for outpatient hospital care, chemotherapy drugs, Medicaid, and Medicare, among
other services. Since HCPCS codes are involved in Medicaid and Medicare, it’s
one of the most important code a medical coder can use.
The HCPCS code set is divided into
two levels. The first of these levels is identical to the CPT codes that we
covered earlier.
Level II is a set of alphanumeric
codes that is divided into 17 sections, each based on an area of specificity,
like Medical and Laboratory or Rehabilitative Services.
Like CPT codes, each HCPCS code
should correspond with a diagnostic code that justifies the medical procedure.
It’s the coders responsibility to make sure whatever outpatient procedure is
detailed in the doctor’s report makes sense with the listed diagnosis,
typically described via an ICD code.
