PROCEDURE DIAGNOSIS

CODE OVERVIEW

Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations.

Learning Objective

Medical coding is a uniform language that allows a reliable means of communication among physicians, patients and third parties.

Medical “Code Speak”

ICD means International Statistical Classifications of Diseases.

ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.

ICD-9 and ICD-10 Codes.

The Diagnosis

HCPCS Codes

Healthcare Common Procedure Coding System (HCPCS) is maintained by the Centers for Medicare and Medicaid Services (CMS).

Provide a system for reporting the medical services provided to Medicare beneficiaries.

HCPCS Code RangesA-codes: Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental

B-codes: Enteral and Parenteral Therapy

C-codes: Temporary Hospital Outpatient Prospective Payment System

D-codes: Dental Procedures

E-codes: Durable Medical Equipment

G-codes: Temporary Procedures & Professional Services

H-codes: Rehabilitative Services

J-codes:  Drugs Administered Other Than Oral Method, Chemotherapy Drugs

K-codes: Temporary Codes for Durable Medical Equipment Regional Carriers

L-codes: Orthotic/Prosthetic Procedures

M-codes: Medical Services

P-codes: Pathology and Laboratory

Q-codes: Temporary Codes

R-codes: Diagnostic Radiology Services

S-codes: Private Payer Codes

T-codes: State Medicaid Agency Codes

V-codes: Vision/Hearing Services

CPT codes enable healthcare providers to effectively and efficiently communicate with government or private insurance companies about medical, surgical and diagnostic services rendered to a patient.

The CPT Coding System

The Current Procedural Terminology (CPT) is a five digit coding system first published by the American Medical Association (AMA) in 1996.

The Procedure / Service

1

ToFrom

Medicine90281 9699997001 9779998925 99199

Surgery 10021 69999

Radiology 70010 79999

Pathology 80002 89399

Evaluation & Management 99201 99499

Hospital DRG Code DRG-001 DRG-999

Anesthesia 00100 0199999100 99142

CPT Code Ranges

Health InsuranceClaim Form 1500

Claim Form 1500Page 2

Medical Record Documentation

Cycle

DOL/OWCP Review Claim

Documents are Coded &

Submitted to DOL/OWCP

Doctor Examines Claimant

Doctor Renders

Treatment & Documents Diagnosis

Claimant Goes to Doctor

PaymentSent

Most provider offices use

“superbills” for billing purposes.