Medical Coding
Medical Coding involves the conversion of diseases, diagnoses, procedures, and services into alphanumeric codes. It utilizes the following codebooks: ICD-10-CM, HCPCS Level I (CPT), and HCPCS Level II.
ICD-10-CM, short for International Classification of Diseases, 10th Revision, Clinical Modification, provides codes for signs and symptoms, injuries, diseases, neoplasms, adverse drug reactions, and poisonings. The guidelines for these codes are approved by four organizations that form the Cooperating Parties for ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and the National Center for Health Statistics (NCHS).
ICD-10-CM codes are alphanumeric and can have 3 to 7 characters. Each code begins with a letter, followed by up to six digits or alphanumeric characters. The first character is always an Alphabet, while the subsequent characters can be letters or numbers. ICD-10-CM codes require a minimum of three characters and a maximum of seven characters including additional specificity details like laterality or episode of care.
Let's understand with scenario:-
A patient presents to a primary care physician complaining of chest pain and shortness of breath. The physician conducts a thorough examination and orders several tests, including an ECG and blood work. The results indicate that the patient is experiencing acute myocardial infarction (heart attack).
In this scenario, the primary diagnosis would be acute myocardial infarction, which is coded as I21.9 in ICD-10-CM. This code is selected based on the documentation provided by the physician, which clearly states the diagnosis of acute myocardial infarction. if the chest pain and shortness of breath are directly related to the acute myocardial infarction and are not separately identifiable conditions, they would not be coded separately. Instead, they would be considered integral to the acute myocardial infarction diagnosis (I21.9).
To understand the structure, I21 is category code. Category codes are 3 digits code.
I21.9, is subcategory code which is giving the further specify.
HCPCS Level II (Healthcare Common Procedure Coding System Level II) is another standardized coding system in the United States. It is used to identify and code a broad range of healthcare products, supplies, and services not covered by CPT codes. HCPCS Level II codes are regulated and maintained by the Centers for Medicare & Medicaid Services (CMS).
CPT (Current Procedural Terminology), which falls under HCPCS Level I, is a standardized and widely accepted medical code set in the United States. It is used to describe medical, surgical, and diagnostic services and procedures provided by healthcare professionals, including physicians. CPT codes are published and maintained by the American Medical Association (AMA).
Let's understand with scenario:-
A patient presents to a primary care physician complaining of chest pain and shortness of breath. The physician conducts a thorough examination and orders several tests, including an ECG and blood work. The results indicate that the patient is experiencing acute myocardial infarction (heart attack).
In this scenario, physician conducted certain test like ECG and blood test. ECG can be coded by appropriate codes from below
