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A Quick Medical Coding Story
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| Coding Resources Page |
Prior to the 1960s, no uniform methods of billing and paying for medical services existed. Gradually, a system of numbers was developed to represent various problems and treatments. The treatment codes, Current Procedural Terminology (CPT-4), are copyrighted by the American Medical Association. The International Classifications of Diseases (ICD-9 is the codebook with the problems (diagnoses) numerically assigned. The ICD codebooks are published by a variety of companies. The government then got involved and developed their own codes, called "HCPCS," (Healthcare Common Procedure Coding System). The HCPCS go a step further to allow alphanumeric codes assigned to drugs, medical devices, etc., to allow even more detail for a payer to review and make more logical determinations for payment.
Let's illustrate coding with an example. A hospital summary or chart arrives on the desk of a coder who will abstract the following information, convert it to code and either data enter it or send it to data entry:
ER visit:
11 year-old male fell from a horse and sustained a broken leg
X-ray revaled an acute femur fracture 17 cm above patella
Procedure: Open reduction, internal fixation and cast application
Followup: 3 week FU with Dr. Marrow
From this simple note, several items may be identified, described and charged. Let's explore a little further. We look at the visit details and discover that a child has fallen from a horse and has broken his leg, which is the "problem," (diagnosis). He came to the emergency room and was seen by an ER doctor. The doctor sends the child off for x-rays. X-rays show an open transcervical fracture of the femur, which is the diagnosis (more definitive than the "acute femur fracture" in the note). The fracture was repaired with a procedure called an "open reduction internal fixation (ORIF)." When this is complete, the doctor places a cast.
The relevant coding from the above will result in a printed bill and/or insurance claim would look something like this when coded:
X-ray acute femur fx 17 cm above patella 820.12 / E828.2 (diagnosis codes)
ORIF & cast 99284 / 27506 / 29345 / 73550 (CPT codes)
When the insurance form is printed (and in the statement), the diagnosis would appear in the diagnosis input field as:
820.12 Transcervical Fracture, Open [and] E828.2 Accident, Horse
820.12 translated = 820 is femur fracture, the .1 means it is an open fracture, and the 2 notes it is the midcervical section of the femur. The E828.2 is a code describing how it happened. The 828 tells the payer that it was a result of an "animal ridden," and the .2 tells that the patient was the rider.
The 99284, 27236, 29345 and 73550 are all CPT codes describing the service to the patient.
The information on the claim or bill would appear something like this:
| SERVICE |
DESCRIPTION |
DIAGNOSIS |
AMOUNT |
| 99284 |
ER detailed exam |
820.12, E828.2 |
100 |
| 27236 |
ORIF |
820.12 |
400 |
| 29345 |
Cast |
820.12 |
150 |
| 73550 |
X-ray femur - 2 views |
820.12 |
100 |
For billing purposes, the use of the ICD codes, when juxtaposed to CPT codes, tells the payer not only what service has been provided but also lists the diagnosis, symptom, complaint, condition or problem (e.g., the reason for performing the service). The codes thus help establish the medical necessity as the first step in third party reimbursement.
The coder determines the codes to be used following each patient encounter. The reviewer/auditor must determine if the coder has in fact used the appropriate codes.
With this specialized training and expertise coders find work any place, any time, any where! In large medical record departments, experienced medical record coders may function as section supervisors, overseeing the work of the coding, correspondence, or discharge sections, for example. Eventually, experienced medical record coders and health insurance specialist-billers may advance to senior technicians who specialize in coding, particularly Medicare coding, or in tumor registry.
Training of medical coders and insurance specialists has a traditionally required from two to four years of college. Fortunately, this career training course is now available from Meditec.
National organizations and associations for Health Insurance Specialists, Billers and Coders are available for the future certification processes. Meditec certifies your course completion which will enhance your ability to find work. Various certifying association are provided in the course material.
Coding-Training.com Site Links:
Main Coding Resources Page
Case Studies
Category II Codes
Chart Notes [SOAP & SNOCAMP]
Coding From Home
CPT Codes
HCPCS Codes
HIPAA Privacy Act
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