Hi, and welcome to the Awesome World of Medical Coding. I am Debbie Houston, CMA, AAMA, CPC, approved instructor for the AAPC. In the next several slides, we will be covering outpatient coding. There are three major books that you will need to become familiar with in order to be an accurate and efficient coder. We will cover each of these three books in the next several slides. Each one is important, and you will need to be familiar with each book and the guidelines within each book. There are many different brands, but we all have to adhere to the rules and regulations adopted by the AMA. Here is the first book that we will cover. It is the CPT. I am using 2024 when I did the PowerPoint, but you need to have a current edition each year, and it comes effective January the 1st of each year. So now let's begin our journey into the medical coding world. As you can see, CPT stands for Current Procedural Terminology. It's one of the most important books that a coder will use. We will be covering procedures, services done in the outpatient setting, which includes provider offices or some outpatient facilities. So in the CPT book, procedure codes that either a physician, a PA, which is a physician assistant, or an MP, which is a nurse practitioner, or staff can perform on a patient when these codes are applied correctly. Here are just a few examples of the codes that we will cover. As you can see, there are codes for new patients, codes for established patients. We will learn the difference. Hospital visits for your physician charges, and numerous codes, as it says, to define all your body systems and what's being done in the healthcare area for your patient. Another very important book, as you will see here, is ICD-10-CM, and it's also 2024. It's important to know when ICD-10 began, which was October the 1st of 2015. Prior to that, it was ICD-9. As I show here, ICD-10 stands for the International Classification of Diseases, 10th Edition Clinical Modification, and it did begin on October the 1st of 2015. And prior to ICD-10, it was ICD-9-CM was used, and there were major changes in the formatting of the diagnosis codes that were began using in 2010. As you can see, its official name is Classification of Diseases, 10th Edition, and the CM stands for Clinical Modifications. In the coding world, most of you will learn that we associate ICD-10-CM with the diagnosis codes that we use in the everyday setting in the office. You also need to know in ICD-10 that all the digits have to have at least three digits, but it now in ICD-10 can go up to a seven-digit code. As I stated just a moment ago, all codes in ICD-10 will have a format of at least three digits, and then you have a dot or a period, and then you can have a fourth, a fifth, a sixth, or a seven-digit code, and specificity is one of the major rules that you have to learn in ICD-10. Here are just some of the few clues that we think about when we're getting ready to code ICD-10. One, you have to have a working knowledge of medical terminology because that will be so very useful in finding diagnoses. When you're reading the chart, you need to read it for specific documented diagnosis. If you have a definitive diagnosis versus signs and symptoms, what to code when there is no diagnosis. And as always, you should always ask questions of the medical staff that saw the patient for any clarification. Make sure you have a current ICD-10 book, and is ICD-1011 coming soon? Soon, I don't know, but I'm sure it is coming. It is in the works today. So here's an example in ICD-10 sinusitis, and that's the only word that you have in your documentation. So then we need to ask, is it an acute sinusitis, or is it chronic? Does your note say whether it's classified as unspecified? How many digits are required to code this? And what does unspecified truly mean? The final and last book that we will be covering in these slides is called the HCPCS, H-C-P-C-S, Level 2 books. And this also, you need to always have a current edition, whether it's a CPT, an ICD-10, or a HCPCS, you should always have current editions to work from. So what's in the HCPCS book? It stands for Healthcare Common Procedural Coding System. And in this book, it is created by CMS, and it is used to report supplies used in the offices, services that are required by Medicare to use instead of a CPT book. You can code for durable medical equipment. You have ambulance services covered in this, and drugs and medications. On the HCPCS book, one of the first things you'll need to remember is to read the medical documentation to identify the service, or if it's a supply, or if it's a piece of equipment, or it's a drug that the provider documents and confirm before you actually build this one out. Here are just a few examples in your HCPCS book, that these are alphabetized. So at the beginning of the book with the letter A, one of the codes we have is A0130, a non-emergency transportation wheelchair. We also have durable medical equipment listed in the HCPCS book, such as an E0143. It's a walker, it's folding, it's wheeled, it's adjustable, or it can be a fixed height. And then the one that we use the most often, I seem to think, is in the J codes. And so the one I gave you an example was J1940, and that's for erythemide up to 20 milligrams. This is when you have to pay attention to the detail when you're coding from those drugs. So what is coding and why do we need it? As it shows here on the side, we are providing terminology for a uniform language that will accurately describe medical, surgical, and diagnostic services. We're trying to convert a message from what the physician's documentation says in words to actual numbers and letters to form an individual code. So where do these codes go? These codes are keyed into an electronic medical record, otherwise called an EMR, for processing. CMS, the Centers for Medicare and Medicaid Services, will only take electronic claims now and not do paper claims at all. There are still some small offices that have paper claims and that you will have to fill in with the correct procedure code and the correct diagnosis codes in order to submit for payment for the services that you rendered. So let's dive into each of these books and see what we can learn about the world of medical coding. So one of the basics in CPT is the professional coder reviews the physician's documentation thoroughly. You read the whole note and you select the procedure or procedures or services accurately describing the care that was provided to that patient. In the CPT book, you'll learn general coding guidelines. It will show you how to locate a code. The necessary words and definitions and medical terminology are just a few rules that we will follow. When I talk about necessary wording, what I mean is each CPT code has a definite and definitive description that fits just that CPT code. One word, one number can change the code to mean something else. So each time you begin to code, you need to always go back and review all of the documentation for that encounter. So CPT. The CPT book is then subdivided into Category 1 codes. It's into six sections as you can see here on the screen. Evaluation and Management. They begin with 99. Anesthesia codes begin with 00 and also 99-100 to 99-140. Then you have surgery codes. They begin with 1000 and actually go to 69990 because this is the largest section in the CPT book because it covers all the surgeries involved with the entire body. Then the next section you see there is Radiology. These are codes for including like MRIs, CTs, and they begin with the number 70010 and go up to 79999. Then we have Pathology and Lab. Those codes begin with 8000, 8047, and then 8289398. And then we have some new ones 001U and 0222U. And then the last section in the CPT book is called the Medicine section and those codes go back to the 9000 again, 9281 to 99607. All of the CPT codes are at least five digits. So again, with the first section, it's called Evaluation and Management, otherwise called E&Ms as you can see on the slide. And these represent office setting, home visits, hospitals for physician charges, consultations, critical care, and the list goes on and on. And they run from code 99202 to 99400. Now in 2023, there were major changes in the E&Ms and it continued on so in 2024. The CPT book becomes effective on January the 1st of each year. So in January 1st of 2023 and January 1st, 2024, there were major changes. And so that is another reason that you should have a current edition. Because now one of the biggest things in coding E&Ms is medical decision making is the key to coding your visits. So here's an example you'll find in the CPT book, 99214. As I stated, there are five digits. But so what does that mean to you as a potential coder? So let's take a look. In the book, it says when this code is picked after reviewing your documentation, it says it is going to be for an established patient. There are guidelines to determine if your patient is new or established. So the CPT book defines 99214, an established patient who's one who has received professional service from the physician or other qualified health care providers, such as a PA, physician assistant, or an NP, a nurse practitioner, or another physician or other qualified health care professionals of the exact specialty and subspecialty who belongs to the same group practice within the past three years. You notice exact and subspecialty and three are very important terms that are associated with the 99214. So also that you read a 99214, not only is it for an established patient, but it would apply to an office or an outpatient services. It would also have to have a moderate medical decision making, otherwise known as MDM. And there are rules on how to determine how you get a moderate medical decision making. In addition, you also have to have a medically appropriate history and exam. This is one of the biggest changes in 23 and 2024 that we came about was it used to be coded doing history, exam, and medical decision making. And now the key driving factor is your medical decision making. Here's an example of the way we can get into that moderate medical decision making. You see there are three areas that we have to look at. The number and complexities of problems addressed at the encounter or visit, the amount or complexity of data that has to be reviewed or analyzed, and then the risk of complications and or morbidity or mortality of the patient. And for a 99214, you have to have two out of those three in order to get the moderate medical decision making. Now, here's another example, 99223. This is a code that we can bill for initial hospital inpatient visits, or we can use it for observation care for provider charges. So 99223 says it can either be for a new patient or it can be an established patient. It requires a medically appropriate history and or exam, but its medical decision making level must be high. and these rules will also apply to telecoder what's required in the documentation to get that high medical decision-making. Okay, let's move on to our next section in the CPD, and this is called the anesthesiologist services. And as I told you earlier, these codes begin with 00100 and run to 01999. There are also what we call qualifying circumstance modifiers for anesthesia. They are located in the medicine section but apply when you're using the anesthesia codes. So in anesthesia, if we are using a qualifying circumstance modifier, it would be a QC. And we, like I said, only use it in anesthesia, but it will depend on factors such as extraordinary conditions of a patient and or unusual risk factors. So here's an example of a qualifying circumstances, and you see it says a plus sign 99100. That plus sign tells us it's an add-on code in addition to a primary code. But when you're using the 99100, you're going to be giving anesthesia to patients of an extreme age. They can be younger than one or older than 70. And so the qualifying circumstances would be used due to the anesthesia services that are going to be provided under particular difficult circumstances, depending on facts such as a young age when you're trying to give anesthesia to a child under one year of age or unusual risk factors if someone is older than 70. In addition to qualifying circumstances, we also have modifiers in anesthesiology that are called physical status modifiers. And these modifiers are used to determine the physical status of the patient. Here are just a couple examples. A P1 stands for a normal healthy patient, where a P4 is a patient with severe systemic disease that is a constant threat to life. Here's one more modifier, physical status modifiers. You know they all begin with P. A P3, it will be a patient with a mild systemic disease. And these levels are used to determine the levels of complexity of the anesthesia being provided. Now let's move on to the largest section in the CPT book, the surgery section. As you can see from the slides, it's divided into subsections. Just a few are integumentary, musculoskeletal, respiratory, cardiovascular. And this is the largest section in the book. And it starts with codes 1004 and goes up to 69990. And they range and cover all of the body areas that would possibly have some type of surgery done on it. So here's an example for the integumentary, think skin. These would be codes ranging from 10030 to 19396. And these would be any codes that have to do with what you are doing on your skin. So the next section we'll cover is radiology. And as you can see, it's divided into diagnostic imaging, ultrasound, MRIs, radiology guidelines. And these codes begin with a 70010 and run to 79999. Think x-rays when you're thinking radiology, but you also have CTs and MRIs. And the one thing that you want to watch for when you're coding in radiology is the detail as, for example, how many views are included in your code, as each code is individually and specific as to how many views it covers. Another section we'll cover is path and lab. And so this is divided into subsections. You have organ or disease-oriented panels, which means if there's 20 tests in a panel, you have to do all 20 tests in order to code for that panel. And then you have individual single tests you have that you code for separately. And these codes begin with the 80047 and go to 89398. And then we also have some laboratory analysis, which we use with code 001U to 0419U. And our last section in the CPT book is the medicine section. And this is the place where a lot of your tests are done or coded from. It also has your immunizations there, the administrations to give you vaccines, dialysis testing, psychiatric testing. And these codes begin with 90281 and go to 99607. OK, so now let's go back and get into what else you need to know in the CPT book other than just the codes. One, you have to learn and become familiar with Category 2 codes and Category 3 codes. Category 2 codes, they're a set of tracking codes that can be used for performance measures. And Category 3 codes are emerging technology service procedures. These are good only for five years. And they either go then to a new CPT code or they're retired. As you can see here, you also need to be aware of their guidelines. They're just as important as the codes because they give you specific instructions and tell you how to code it correctly. You need to learn to be familiar with the guidelines. They're found in each section of the CPT book. But they're also found right above a CPT code or right below a CPT code. So always make sure that you're very familiar with your guidelines in CPT. We also have CPT modifiers. These modifiers are appended to the actual five-digit codes. And basically, what it tells you is you're going to report a specific circumstance or changes to a procedure or services. But we're not going to change any of the definition of the code. So here's an example of the modifier 25. You're adding it to that E&M code. And I use the example 99214. And then you would be the 25 added onto it. It will not change the definition of the 99214. It's given additional information or circumstances that you want the insurance companies to be aware of when you use it. As we stated early on, it's ICD-10, International Classification of Diseases. But as a coder, you will probably always associate diagnoses when you think ICD-10. There are four parties or organizations that make up the ICD-10. As you can see, the AHA, the American Hospital Association, AHIMA, American Heart Association, AHIMA, American Health Information Management Association, CMS, the Centers for Medicare and Medicaid Services, and then NCHS, the National Center for Health Statistics. As you can see, the ICD-10, it goes into effect on October 1st. The first ICD-10 began October 1st of 2015. And prior to that, we used an ICD-9. One of the things that you always need to be very familiar with is the format and the structure of the ICD-10. Remember, it begins as a three-digit code. But some will be four, some will be five digits, some will be six, some will be seven. You need to know about abbreviations and punctuations. And most of all, you need to be very, very familiar with medical terminology. So here's an example. As I said, basic three-digit code, and you must learn how to add onto that three-digit code. And so the example I gave you is E11, which stands for type 2 diabetes melaninus. Instead of building onto E11, I have now coded E11.351. You have just coded type 2 diabetes melaninus with prolific diabetic retinopathy with macular edema in the right eye. Amazing, huh? There are also abbreviations, and I've only gave you a couple here, NOS and NOC, that you need to know what their definitions are. In words like and and but, they mean something in particular to a code. These simple words have definitive meanings in the ICD-10. So in addition to learning three digits, four digits, five, seven digits, whatever, you also have general coding guidelines that you need to be familiar with. You'll have chapter-specific guidelines and the level of detail coding that's going from a three-digit to a seven-digit and anything in between. Outpatient surgery coding, observation studies, all of these are rather unique coding guidelines in the ICD-10. So here are several chapter-specific guidelines. So when you're looking in ICD-10 chapter 2, it's going to give you specific guidelines on neoplasms, where chapter 4, you're going to deal with endocrine, nutrition, and metabolic diseases. And if we go over to chapter 10, then we're looking at the respiratory system. So here's an example. In chapter 2, neoplasms, these are the codes for most benign and or all malignant neoplasms. But one of the things you have to know on your encounter, are you treating a primary site? Are you treating a secondary site? Has the malignancy been previously excised? Are they involved in chemotherapy, immunotherapy, and radiation therapy? All of these are the guidelines that you have to follow to code from the neoplasm chapter. In ICD-10, to me, the most important thing you need to learn about coding is the level of specificity. There are three-digit codes. We don't have very many. I want to say less than 50 in the whole ICD-10 book. But you have to know which codes are four digits, which are five, which are six, and which are seven. The level of specificity, it has to be coded correctly. Otherwise, you've just coded it incorrectly. We touched base a little on this at the beginning, that if you have a definitive diagnosis, and that is if a physician has given you a diagnosis, you've gotten it from an x-ray or a lab, it's a definitive diagnosis, then you code that definitive diagnosis first. But if you don't have a definitive diagnosis, then there's a possibility that you would code signs and symptoms. This is our last book we'll cover. This is called HCPCS, Healthcare Common Procedure Coding System. And it's been created by CMS to be able for us to bill for supplies. If you give a vaccine, you need to be able to bill for it. If you bill in for an injection, you need to be able to bill for it. So supplies, injections, all of that is covered in the HCPCS book. As I stated earlier, they start with the letter A, and they're alphabetized in order. You have A codes, you have L codes, you have J codes. So what you begin with is the alpha index. You'll look that up, and then you cross-reference to your tabular indexes so that you know that you're going to be coding it correctly. So this is just a few in the HCPCS book. The A codes is transportation codes. The E codes are durable medical equipment. They will all begin with E. The G codes, it says procedures or professional services. Medicare is using G codes now for some things that are coded in the CPT book, but also they want you to use the G codes from your Medicare patients. And then the J codes are for drugs administered other than if they're oral or injectable chemo. And so these codes are made up of five alphanumeric characters. And as you can see, I gave you an example, J3420. It's going to be found in the J section under your drugs. And it starts with J. And this particular one stands for vitamin B12 up to 1,000 mCGs. You have to pay attention to the detail with these because some say up to a certain drug, and others say specific like 20 milligrams. And so we're talking about modifiers here, and we had talked about them earlier in slide 45. But what they are, they are appended to a CPT code to report specific circumstances or changes to a procedure or services without changing the definition of the codes. Now, your modifiers are found in the CPT book, and then there are others that are found in the HCPCS book. So coding as a career. One of the first things you'll learn, it is a very detailed oriented position. You can work in a medical office or an outpatient setting. Now, if you're working there as a medical assistant or a nurse, you'll find that you may be interested in a coding career since this can become a stepping stone to advancement in the office. A new career in coding may require you to be in the office setting. But once your skills in coding become apparent to your employer, then this would increase the possibility of remote coding from a home environment. Here, I'll give you an example. You may live here in Virginia, but with your computers and your software and your internet and your experience in coding, you may be coding for a physician or an employer in California, and yet you live here in Virginia. Wouldn't that be awesome? The basic credential in coding is a CPC, a Certified Professional Coder. It is offered to the coding person. You can either take classes in a public school, a community college, or you can do it online. It is offered by AAPC. There is a test that you have to pass, and you would become a CPC. And then after that, you would have to keep up your CEU credits afterwards. It is a fantastic learning experience when you begin to code. And once you learn and dive in deeper into all the facets of medical coding, it is so very rewarding. I thank you for participating and reviewing the slides, and I hope that this will inspire you to get into medical coding and the world of medical coding. Thank you again.

Debbie Houston

medical coding

outpatient coding

CPT

ICD-10-CM

HCPCS Level 2

AMA guidelines