What needs to be coded? Reimbursement for medical services and supplies is based on coded data. And this is mandated by law, by HIPAA, The Health Insurance Portability and Accountability Act of 1996. All of these had to be in place by 2003.
It requires the establishment of electronic transactions in coding standards and inquires all covered entities to use official medical coding sets. Covered entities under HIPAA, we are a hybrid entity because we submit claims electronically and yet we're a part of a university-wide education system.
So anyone who submits claims must use coded data. None of the payer will accept the claim without these codes. You just wouldn't get reimbursement if you only have a narrative on the claim.
There are the official medical coding sets identified by HIPAA including ICD-9-CM, the International Classification of Diseases, 9th edition, Clinical Modification. This is maintained by the World Health Organization and Centers for Medicare and Medicaid Services that has distributed this information. And they are a part of the organization that does update and maintain these codes.
The ICD-9 or diagnostic codes that represent the reasons why patients require and/or seek medical care. These codes show medical necessity for the services that are provided.
When you go through the Medicare manuals and read the instructions, oftentimes they will refer to HCPCS codes.
But the person who is reading this needs to understand that there are two levels and they may mean what we call HCPCS code which are codes for healthcare equipment and supplies, durable medical equipment, some drugs that are costly and so on.
They also may refer to the CPT codes, Current Procedure Terminology which is considered level 1. And these codes that are used in an outpatient setting whether it’s a standalone clinic, a surgical center, a hospital outpatients setting to identify services that have been provided to patients.
It reports medical services and procedures formed by physicians and non-physician practitioners. By non-physician practitioners, it means physician assistant, nurse practitioners and there are couple others listed in Medicare as non-physician practitioners who can now submit claims under their own identification number.
In the past, they had to be directly supervised by a physician. Their claims were submitted under a physician and payment for those which received at 85% of what a physician would receive.
But in the last few years, they've changed that. So physician assistant and nurse practitioners can submit claims directly under their own identification number.
If you can get your hands on a code book whether it's HCPCS, ICD-9 or CPT, it really helps to take a look at it. Not just to hear someone talk about what it is and how you use it.
When you read about this, it's difficult to comprehend. But once you actually see a book and use it, maybe someone can help you use it, it really helps to clarify what these codes are and how they're used.
ICD-9 is the HIPAA mandated diagnosis codes set. It identifies the reason for the visit or the treatment. All claims must include a diagnosis code whether it's outpatient, inpatient. Any medical claims submitted for reimbursement has to have a diagnosis code.
These codes are updated two times a year, April 1st to October 1st of each year. We have some changes we need to implement here because there are some codes that have been deleted, some codes that have been revised or the definition has changed a little bit or new codes that they have implemented, according to the recent medical coding articles.
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