Coding Basics

60889-R5-V1 • This information is provided for your background education and is not intended to serve as guidance for specific coding, billing, and claims submissions. The decision on which codes best describe the services provided must be made by the individual providers based on specific payor guidance and requirements.

2 Agenda • Define each code set – HCPCS – CPT® – NDC – ICD-9-CM – ICD-10-CM • Discuss general formats • Apply coding basics to sample claim forms – Physician office setting (CMS-1500 claim form) – Hospital outpatient setting (UB-04 claim form)

CPT is a registered trademark of the American Medical Association. All rights reserved.

3 Healthcare Common Procedure Coding System (HCPCS)1

HCPCS codes describe products, supplies, items and services not included in CPT

They establish a standard coding system that allow claims to be processed in a consistent manner

The use of the HCPCS is mandatory

• It is alpha-numeric. The format is a single alphabetical letter (A to V) followed by 4 numeric digits • Maintained by Centers for Medicare and Medicaid Services (CMS)

1. Centers for Medicare & Medicaid Services (CMS), New CMS Coding Changes Will Help Beneficiaries. https://www.cms.gov/MedHCPCSGenInfo/Downloads/HCPCSReform.pdf. Accessed January 30, 2012.

4 Current Procedural Terminology (CPT)1 Developed by the American Medical Association (AMA), it is a list of descriptive terms that identify medical services and procedures

It allows for communication of uniform information among physicians, coders, patients, and payers

Category I CPT codes

•Describe a procedure or service identified with a 5-digit code and descriptor nomenclature

Category II CPT Codes

•Supplemental tracking codes that can be used for performance measurement (optional)

Category III CPT Codes

•Temporary set of tracking codes for new and emerging technologies intended to facilitate data collection on and assessment of new services and procedures

1. American Medical Association (AMA), CPT Process - How a Code Becomes a Code. http://www.ama- assn.org/ama/no-index/physician-resources/3882.shtml. Accessed January 30, 2012. . 5 National Drug Code (NDC) • A universal product identifier for all human drugs • It is a unique sequence consisting of three parts • Once an NDC code is assigned to one product it cannot be later re- assigned to a different product

Labeler Product Package Code Segment Segment

4 or 5 digits long. 3 or 4 digits long and Assigned by the identifies a specific 1 or 2 digits long and Food and Drug strength, dosage identifies package Administration (FDA). form, and forms and sizes. A labeler is any firm formulation. This is This is assigned by that manufactures, assigned by the the labeler repacks or distributes labeler a drug product

1. Food and Drug Administration (FDA), National Drug Code Directory. http://www.fda.gov/drugs/informationondrugs/ucm142438.htm. Accessed January 30, 2012.

6 International Classification It consists of th of Diseases, 9 Edition, three volumes: Clinical Modification (ICD-9- CM)1 assigns codes to diagnoses Volume 1 - •Each code is unique and up to five Tabular Listing digits long •Revised periodically to incorporate changes Volume 2 - Index •The National Center for Health to Diseases Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) are agencies responsible for Volume 3 - overseeing all changes and Procedure Codes modifications

1. Centers for Disease Control and Prevention (CDC), International Classification of Diseases, Ninth Revision (ICD-9). http://www.cdc.gov/nchs/icd/icd9.htm. Accessed January 30, 2012. “ 7 International Classification of Diseases (ICD-10-CM) • Intended to replace ICD-9-CM • Specific improvements include: – Addition of information relevant to ambulatory and managed care encounters – Expanded injury codes – Creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition – Addition of sixth and seventh characters – Incorporation of common 4th and 5th digit sub-classifications – Laterality – Greater specificity in code assignment

1. CDC, CDC International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed January 30, 2012.

8 Physician Office: Sample CMS-1500

Enter patient's diagnosis based on chart in the form of an ICD-9-CM (ie, 287.31)

Enter CPT code for the procedure 287.31 provided (ie, 96372)

96372 J0881 Enter HCPCS code for the drug provided (ie, J0881) Hospital Outpatient: Sample UB-04

96372 Enter HCPCS code for the J2796 procedure provided (ie, 96372)

Enter HCPCS code for the drug provided (ie, J2796)

Enter ICD-9 diagnosis code based patient's diagnosis based on medical records (ie, 287.31)

287.31 Summary Code Set Definition Format Example HCPCS Describes items and Single letter followed by 4 J3590- Product X services numbers CPT Describes medical services Five numbers 96372 - Therapeutic, prophylactic, and procedures diagnostic injection (identify drug or substance); SC or IM NDC Identifies drugs for human 10 or 11-digit format with 10-digit format: 12345-123-12 use 3 sections: Labeler- 11-digit format: 12345-1234-12 Product-Package Size ICD-9-CM Describes patient’s diagnosis 3-5 Numeric 237.31 – Immune thrombocytopenic purpura or health condition. The 4th (+V and E codes) digit defines etiology and the 5th digit defines severity or acuteness ICD-10-CM Describes patient’s diagnosis 3-7 Alphanumeric D69.5 – Secondary thrmbocytopenia or health condition Summary • Code sets include several standardized systems (CPT, HCPCS, ICD-9-CM) for the purpose of efficient claims processing • Selecting the procedure code that accurately identifies the service provided is important for appropriate reimbursement