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Medical Coding
• Conversion of clinical information to
alphanumeric code
Laboratory Information Systems
• Explanation of services
& Medical Coding
• Explanation of medical condition

LIS, ICD-9, CPT

Mitral and aortic valve insufficiency = 396.3

Importance of Coding HIPAA Coding Classifications

• Submit claims for reimbursement • Healthcare Common Procedure Coding System
• Repository for research (HCPCS)
• Rapid analysis of financials, patient care, etc.
• Current Procedural Terminology (CPT)
• International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)

Healthcare Common Procedure Coding

Current Procedural Terminology (CPT)
System (HCPCS)
• Centers for Medicare and Medicaid Services • Maintained by the AMA
(CMS) – Revised/Republished annually
• Level I
– Service • Codes & Reimbursement for:
– CPT system – Physician services
• Level II – Performance measurements
– Medical devices
– Supplies and services not found in CPT codes

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CPT Codes ICD or Diagnosis/Disease Codes

Currently the national standard for almost all • International Classification of Diseases
health insurers (Medicare, Medicaid and private
insurers)
• Developed by the WHO
• Facilitates classification of morbidity and
1960’s 1970’s 1983 mortality data and international disease
standardization

Developed by AMA to Expanded to Adopted and

standardize include medical standardized by
billing/coding for procedures and federal government to
Surgical Specialties services include all
subspecialties

ICD-9-CM Organization of ICD-9 Volume 1

• National Center for Health Statistics (17 Chapters Plus E & V Codes)
• Disease diagnosis codes 001-139
140-239
Infectious and Parasitic Diseases
Neoplasms
• 2013: ICD-10 codes – major changes 240-279
280-289
Endocrine, Nutritional and Metabolic Diseases
Diseases of the Blood and Blood-forming Organs
290-319 Mental Disorders
320-389 Diseases of the Nervous System and Sense Organs
390-459 Diseases of the Circulatory System
460-519 Diseases of the Respiratory System
520-579 Diseases of the Digestive System
580-589 Diseases of the Genitourinary System
630-676 Complications of Pregnancy, Childbirth, and the
Puerperium
680-709 Diseases of the Skin and Subcutaneous Tissue

Organization of ICD-9 Volume 1 Using ICD-9 Book

(17 Chapters Plus E & V Codes) • Turn to that ICD code in Volume 1
710-739 Diseases of the Musculoskeletal System & Connective 786.5 Chest pain
Tissue 786.50 Chest pain, unspecified
740-759 Congenital Anomalies 786.51 Precordial pain
760-779 Certain Conditions Originating in the Perinatal Period 786.52 Painful respiration
780-799 Symptoms, Signs and Ill-defined Conditions Pain: Pleurodynia
800-999 Injury and Poisoning anterior chest wall
E800-E999 Supplementary Classification of the External pleuritic
Causes of Injury and Poisoning epidemic pleurodynia (074.1)
786.59 Other
EXCLUDES

V01-V82 Supplementary Classification of factors Discomfort

influencing Health Status and Contact with Pressure in chest
Health Services Tightness

http://www.icd9data.com/

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V Codes Deciphering the Alphabet Soup…

• (V01–V85)
• Supplementary Classification of Factors
Influencing Health Status and Contact with
Health Services
• Classifies occasions when circumstances other
than disease or injury are recorded as
diagnoses or problems

Diagnosis (ICD) versus Service (CPT) Diagnosis (ICD) versus Service (CPT)

• ICD codes are diagnosis codes • CPT codes are service codes
–Describe new and established –Describe performed services, both
diagnoses procedures and
–Also include symptom codes evaluation/management (E/M)
–headache (symptom code), vs migraine –Service codes must be based on
(diagnosis code) necessity determined by
diagnosis/ICD-9 codes

CPT Codes – an example Medical Necessity Rule

An 65 yo man visits his PCP for his annual checkup and • There must be a connection between the
incidentally complains of 2 days of knee pain. On exam his
knee is erythematous, warm, tender and swollen. You diagnosis and the corresponding service CPT
perform a joint aspiration, and he also receives a Pneumovax code
as part of his routine preventative care.
• MD must decide what is medically necessary
• 3 codes apply (and can all be used for the single visit)
care for the given diagnosis, and bill
– Evaluation and management code accordingly
– Medication code (for vaccine)
• Even if documentation is extensive, only bill
– Surgery code (for joint aspiration)
for medically necessary care

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Medical Necessity Rule: CMS (centers for Medicaid and

Medicare Services) official statement Medical Coding - Challenges
“Medical necessity is determined based on the • Updated annually
diagnosis submitted for that service or supply. • Erroneously coded software
Specificity and accuracy of diagnosis code and • Complex, requires medical knowledge
linkage on the claim form determine
payment.” Physician notes
Scribes/Shadowing
Nursing staff
Lab personnel
Medical billing

Superbill Coding Software

• Computer Assisted Coding (CAC)
• ClaimCheck software (CMS)
• EHR/EMR
• HIS
• LIS

Role of LIS
• To manage
– Data
Laboratory Information – Work flow
– Changing business needs/processes
Systems (LIS) – Existing systems and improving where required
– Resources
– QA/QC

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Chemistry Hematology What Does A LIS Do?

Patient Results
Options:
Additional Workstations
Remote Printing
Quality Control Information
Practice Remote Faxing by schedule
Management Remote Inquiry Helps To Maintain CLIA/COLA
System/EMR
Remote Order Entry
Remote Lab Systems
Compliance
Interfaces Barcode Label Printing
Networking Cost/Revenue Analysis
Advanced Report Formatter

Reimbursement Reporting

Immunology Urinalysis

Specimen tracking
• Track specimens from receipt, processing,
testing, reporting to storage
• Electronically capture results from lab
diagnostic equipment and store with
LIS specimen details
• Protocols and algorithms for testing and final
result determination

Additionally…
 Levy-Jennings charts in graphics, tabular, and condensed reports

 Storage of linearity and calibration data

 User definable patient sample and cumulative reports for both display and
printing, CUMULATIVE GRAPHING of patient reports

 Tracking of ICD-9 and CPT coding

 ClaimsCheck software, speeds reimbursement

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Industry Standards LIS & CPT

• Laboratory reimbursement governed by CPT
COLA/CLIA/JCAHO and HIPPA compliant
codes in HCPCS
Preconfigured at the factory – Clinical Laboratory Fee Schedule
Have user customizable Order Entry Screens • www.cms.gov
Have bi-directional instrument interfaces – CPT codes for analysis
Are fully up gradable with no loss of data – Link to ICD-9 codes
• Incorporated into LIS
• Region specific
• Updated annually