A Clear View Of The Intricacies Of Coding

Volume 15 - Issue 2 - February 2002
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A Quick Review Of The Common Coding Systems

CPT, HCPCS and ICD-9-CM are the three common coding systems that doctors use in the United States. Each of these systems is unique and serves a specific purpose in communicating to third-party payers what you did and why you did it. The following summarizes each of these three systems:

• Current Procedural Terminology (CPT), Fourth Edition. Created and maintained by the American Medical Association, CPT consists of over 8,100 codes and modifiers for CPT 2002 for reporting procedures and services. Using CPT codes enables you to communicate to third-party payers what you did. The codes are five-digit numbers accompanied by narrative descriptors. You may also provide two- or five-digit numeric modifiers for additional modification of CPT code descriptions. All third-party entities accept these codes.

Keep in mind that an entirely new section has been added for CPT in 2002. These Category III (Emerging Technology) CPT codes are located in a separate section of CPT, following the “medicine” section. Category III codes are assigned an alphanumeric identifier with a letter in the last field (e.g., 0020T – Extracorporeal shock wave therapy involving plantar fascia). Introductory language has been placed in this code section of CPT to explain the purpose of these codes.

• Healthcare Common Procedure Coding System (HCPCS). HCPCS (pronounced “hick-picks”) was created by the Centers for Medicare and Medicaid Services (CMS). HCPCS is a three-level coding system. Level I is the CPT codes. Level II is a national alphanumeric coding system that begins with a letter followed by four numbers (e.g., Q0185, L8641, L8642). Usually, Level II codes are the codes you use to report supplies, implant materials and injections to Medicare and other payers. Level III is a five-digit alphanumeric code system applicable only within your state. The state Medicare carrier uses it for very unusual procedures for which there is no other level I or level II code available. These codes usually begin with the letters S and W through Z.

• International Classification of Diseases – Ninth Revision-Clinical Modification (ICD-9-CM). This coding system is used to report patient illnesses, injuries, complaints, and/or symptoms, referred to as diagnoses.

Using ICD-9-CM codes allows you to communicate to third-party entities the appropriateness for medical services or why you performed the service. These codes range from three to five digits. For more information on how to use the ICD-9-CM codes properly, see “Essential Guidelines For Using ICD-9-CM Codes” in the March 2001 issue of Podiatry Today.

Author(s):

Billie C. Bradford, MBA

On the surface, it seems fairly simple. Incorrect codes will result in delayed payment or outright rejection of claims by carriers. Using codes appropriately helps ensure proper payment from third-party carriers and patients.
Appropriate coding also enhances your practice’s relationship with patients. When your office codes claims accurately, patients who file their own claims will have fewer problems obtaining payment from their insurance companies. Yet many major carriers identify the first five areas listed below as the most common coding errors causing delays or inaccurate payments for doctors’ claims. With this in mind, let’s take a closer look at these common problem areas cited by the carriers.
1. Additional code to identify manifestation. At times, it is required to provide an additional diagnosis code in order to provide a complete and accurate diagnosis picture. You may need the one code to describe a condition which is the underlying cause of the manifestation you are treating, and another code for the specific manifestation itself.
An ICD-9-CM tabular notation indicates when the code cannot stand alone and is not to be listed first. Likely companion codes are shown. In the index, the notation is indicated by codes appearing in italicized brackets [xxx.x].
An example of this is when you’re reporting the diagnosis of “diabetic neuropathy” for a patient. You must list the underlying disease code (“250.6x - Diabetes with neurological manifestations”) first and then list “357.2 - Polyneuropathy in diabetes manifestation” as the second code. Remember, you should never report manifestation codes as the patient’s primary diagnosis. You can easily identify these codes since they always appear in italics in ICD-9-CM.
Be Aware Of The Exclude Notes
2. Excludes. This ICD-9-CM notation indicates that any conditions following it are to be coded elsewhere, as indicated in each case. You may find exclude notes at the beginning of a chapter or section, or immediately after any three-digit, four-digit or five-digit code. Such a note following a three-digit code would apply to all four- and five-digit codes within that category. A note following a four-digit code would apply to all five-digit codes within that subcategory.
For example, if a patient presents with marked signs of unsteady walking and incoordination, you cannot code it as “781.2 - abnormality of gait” unless your assessment (and the documentation in the patient’s record) would support a more definitive determination beyond “difficulty in walking” at this time. Without a more definitive finding, ICD-9-CM code 781.2 specifically excludes “difficulty in walking” and directs you to review code “719.7x – difficulty in walking” instead. If you later determine your patient indeed has an ataxic gait, then it would be appropriate to report ICD-9-CM code 781.2 and document it in your patient’s record.
When Specificity Comes Into Play
3. Not Elsewhere Classifiable (NEC). This is appropriate when no code is provided which would permit using a more specific code for the condition, and your patient record contains more information than ICD-9-CM allows you to provide.
4. Not Otherwise Specified (NOS). Using NOS in ICD-9-CM coding refers to a lack of sufficient detail in the patient’s record. Reporting codes in this category will frequently result in denied payments until you can submit more specific information. Be aware that frequent reporting of such nonspecific codes to avoid the burden of looking up specific codes may cause third-party payers to identify your practice’s claims reporting and chart documentation for further review.
When possible, you should not use ICD-9-CM codes containing the terms “unspecified” or “other” (these codes usually have a fourth digit of .8 or .9) if information is available that allows you to use a more specific code. For example, “abscess” lists code 682.9 in the ICD-9-CM Index, yet is followed by almost 200 listings of various types and locations of abscesses. Carriers could perceive the routine reporting of the “682.9 – abscess unspecified site” as indicating that you failed to adequately document the location or type of abscess you were treating.

misterscruffsays: July 27, 2009 at 1:06 pm

As a recent graduate from SCI Texas in the field of Medical Coding and Billing, I would have to attest and agree to the importance of coding. The difficulty of diagnosing the conditions and symptoms and translating them to universal medical codes gave me the impression that my comprehensive training was absolutely necessary, and is important in helping doctors achieve a high level of patient care.

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