The ICD-9-CM is used for diagnostic coding in the United
States. ICD-9 codes are required for reporting patients'
conditions on health-care claims. Codes are made up of
three, four, or five numbers and a description. New codes
are issued annually, and current codes should be used because
they can affect billing and reimbursement. The ICD-9 has two volumes that are used in medical
practices: the Tabular List (Volume 1) and the Alphabetic
Index (Volume 2). To find a code, use the Alphabetic Index
first. Its main terms may be followed by related terms. The
codes themselves are organized into 17 chapters and are
listed in numerical order in the Tabular List. Code categories
consist of three-digit groupings of a single disease
or a related condition. Further clinical detail is shown
by four- or five-digit codes. The conventions used in the
ICD-9 must be observed to correctly select codes. V codes identify encounters for reasons other than illness
or injury and are used for healthy patients receiving
routine services, for therapeutic encounters, for a problem
that is not currently affecting the patient's condition, and
for preoperative evaluations. E codes, which are never
used as primary codes, classify the injuries resulting from
various environmental events. CPT provides a standardized list of five-digit procedure
codes for medical, surgical, and diagnostic services.
Add-on codes and modifiers may also be selected. CPT is divided into six sections: (1) evaluation and
management, (2) anesthesiology, (3) surgery, (4) radiology,
(5) pathology and laboratory, and (6) medicine. The
three main factors that influence the level of service for
coding purposes are the type and extent of (1) history,
(2) examination, and (3) medical decision making. Surgical
packages and laboratory panels should be coded as
single procedures rather than broken into component
parts. The Health Care Common Procedure Coding System
(HCPCS), used to code Medicare services, has codes from
CPT as well as Level II national codes. Diagnoses and procedures must be correctly linked
when services are reported for reimbursement because
payers analyze this connection to determine the medical
necessity of the charges. Correct claims also comply with
all applicable regulations and requirements. Codes should
be appropriate and documented as well as compliant with
each payer's rules. A medical practice compliance plan addresses compliance
concerns of government and private payers. Furthermore,
having a formal process in place is a sign that the
practice has made a good-faith effort to achieve compliance
in coding. |