Author: Dr Md. Madani, (Pharm. D).

Someway or the other you probably came across something called Medical Coding. You might be wondering what it is.

In simpler terms, Medical Coding is kind of the same as translation. Coders take doctors’ medical reports and convert them into a set of codes that form an important part of the medical claim. These reports may contain crucial information about a patient such as his condition, diagnosis report, treatment plan, etc.

Let me ask you a basic question: Why are medical reports converted into codes? Wouldn’t it probably be sufficient to list all of the symptoms, diagnoses, and procedures and submit them to an insurance provider to see which services will be compensated?

To answer this question, we must look at the massive amount of data generated by each patient visit. If you visit a doctor with a sore throat, so the symptoms of sore throat, the enlarged lymph nodes, the signs of fever, the treatments as well as the medicines prescribed will be recorded.

In this case, the doctor will only report his diagnosis, but the part of this report that will be codified includes a prognosis, a procedure, and a treatment plan.

Step back a little bit, and suddenly it’s a lot of very accurate information. And this is only for a relatively simple medical examination. What happens when a patient seeks medical attention for a complex illness, such as a type 2 diabetes-related eye disability? As injuries, conditions, and illnesses become more complex, the amount of data to be reported to insurance companies increases dramatically.

That’s where Medical Coding comes into action.

Over the last year, there have been more than 1.4 billion patient visits, according to the Centers for Disease Control (CDC). This includes visits to doctors’ offices, out-patient hospitals, and emergency rooms. If only five pieces of coded information were transferred per visit, an almost absurdly low estimate, that would equate to 6 billion individual pieces of information transferred each year. In a data-rich system, medical coding allows large amounts of information to be transferred efficiently.

Medical Coding also ensures consistency of documentation across medical facilities. The code for streptococcal pneumonia is the same in Hyderabad as that in Kolkata. Consistent data allows for more effective research and analysis, which governments and health agencies can use to track health trends more effectively.

If the CDC wants to look into the prevalence of viral pneumonia, they can use the ICD-11-CM code to look up the number of recent pneumonia diagnoses.

Lastly, Medical Coding allows jurisdictions to examine the prevalence and effectiveness of treatment in their institutions. This is particularly significant for large medical facilities such as hospitals. Like government agencies that monitor, for example, the incidence of some diseases, medical facilities can track the effectiveness of their practice through analysis.

Now that we’ve defined the significance of medical coding, let’s look at the different types of code that are used:

MEDICAL CODING TYPES

There are three series of codes used in Medical Coding that you will use every day as a medical coder.

1. International Classification of Diseases (ICD)
2. Current Procedure Terminology (CPT)
3. Healthcare Common Procedure Coding System (HCPCS)

ICD MEDICAL CODING

The International Classification of Diseases (ICD) are a set of codes that helps to maintain a standardised vocabulary for defining the causes of injury, disease, as well as death. The World Health Organisation (WHO) developed this code in the late 1940s. Since its inception, it has been updated numerous times. The number following “ICD” denotes the current revision of the code.

For instance, the current code used in the United States is ICD-11-CM. This represents the tenth revision of the ICD code. The suffix “-CM” stands for “clinical modification which is a collection of changes implemented by the National Center for Health Statistics (NCHS), a division of the Center for Medicare and Medicaid Studies (CMS).

Clinical change significantly increases the number of diagnosis codes. This expanded scope provides coders with much more flexibility and specificity, which is essential to the profession. In general, the ICD-11 contains 14,000 codes. ICD-11-CM, its clinical modification, contains over 68,000 codes.

ICD codes are used to represent a physician’s diagnosis report as well as the patient’s medical status. These are used in billing. Coders must ensure that the procedure being billed is logical in relation to the given diagnostic.

The ICD-11-CM is an alpha-numeric code of seven characters. Each code begins with one letter, followed by two digits. The first three characters representing ICD-11-CM are the “category.” The class describes the general type of lesion or illness. The decimal point and a subcategory follows the category. This is followed by two sub-categories, which further explain the cause, occurrence, location, severity, and type of injury or illness. The last character is called the extension.

The type of encounter is indicated by the extension. That is, if a physician examines the patient for the first time for this specific condition/injury/disease, it is referred to as an “initial encounter.” Each encounter after the first is referred to as a “subsequent encounter.” “Sequelae” are patient visits that are related to the effects of a previous illness.

CPT MEDICAL CODING

The vast majority of medical procedures performed in a doctor’s office are coded using Current Procedure Terminology (CPT). The American Medical Association (AMA) updates these codes annually.

CPT codes are 5-digit numeric codes organized into three categories. The first category is divided into six ranges & it is most commonly used. These ranges correspond to the following six major medical fields:

1. Medicine
2. Surgery
3. Anesthesia
4. Radiology
5. Pathology and Laboratory
6. Evaluation and Management

Second Category CPT codes are related to performance measurement and, in some cases, laboratory or radiology test results. These five-digit alphanumeric codes are typically appended with a hyphen to the end of a Category-I CPT code.

Category II codes are optional and may not be substituted for Category I codes. These codes are useful for other physicians and health professionals, and the American Medical Association expects that Category – II codes will decrease the administrative burden on physicians’ offices by providing more and more accurate information about the performance of health professionals and health facilities.

CPT code category III corresponds to emerging medical technology.

As a coder, you’ll spend the vast majority of your time dealing with the first two categories, though the first is undoubtedly more common.

Addendums to CPT codes increase the specificity and accuracy of the code used. Because many medical procedures necessitate more detail than the basic Category-I CPT code provides, the AMA has created a set of CPT modifiers. These are two-digit numeric or alphanumeric codes that are appended to the end of the CPT code for Category – I. CPT modifiers add important information to the procedure code. A CPT modifier, for example, describes which side of the body a procedure is performed on, and there is also a code for a discontinued procedure.

CPT codes are an essential component of the billing process. CPT codes inform the insurance payer about the procedures for which the healthcare provider wishes to be reimbursed. As a result, CPT codes work in tandem with ICD codes to provide the payer with a complete picture of the medical process.

CPT codes, like ICD codes, are used to track vital health data and assess performance and efficiency. CPT codes can be used by government agencies to track the prevalence and value of specific procedures, and hospitals can use them to evaluate the efficiency and abilities of individuals or divisions within their facility.

HCPCS MEDICAL CODING

The Healthcare Common Procedure Coding System (HCPCS), also known as “hick picks,” is a collection of codes based on CPT codes. HCPCS codes were created by the Center for Medicare and Medicaid Studies (CMS) and are maintained by the American Medical Association (AMA). They primarily refer to services, procedures, and equipment not covered by CPT codes. Durable medical equipment, prosthetics, ambulance rides, and certain medications and drugs are all covered.

Among other things, HCPCS is the official code set for outpatient hospital care, chemotherapy drugs, Medicaid, and Medicare. HCPCS codes are one of the most important codes a medical coder can use because they are used in Medicaid and Medicare.

There are two levels to the Healthcare Common Procedure Coding System (HCPCS) code set. Level 1 & 2.

Level – 1 is the same as the CPT codes we discussed earlier.

Level 2 is a set of alphanumeric codes divided into 17 sections, each based on a specific area of expertise, such as Medical and Laboratory or Rehabilitative Services.

Each HCPCS code, like CPT codes, should be paired with a diagnostic code that justifies the medical procedure. It is the responsibility of the coders to ensure that whatever outpatient procedure is detailed in the doctor’s report makes sense with the listed diagnosis, which is typically described using an ICD code.