Basics Of Medical Billing Code Systems

As a healthcare quality employee and certified Risk Adjustment coder (CRC), I know the basics of ICD-10 (International Statistical Classification of Disease and Related Health Problems) coding, CPT-II (Current Procedural Terminology) codes and HCPCS (Healthcare Common Procedures Coding System). The difference between CPT, CPT-II, CPT-III and HCPCS (which I have seen referred to as CPT-4) has eluded me.  I am not 100 percent sure I have a clear understanding even now but here are the facts.

I do know that accurate coding is essential to report claims and quality measures.  ICD-10, CPT, and HCPCS codes identify:

• procedures performed

• diagnosis or diagnoses

• certain devices, supplies, and equipment acquired for the client

ICD-10 - International Statistical Classification of Diseases and Related Health Problems

Implemented in October 2015, this revision and replacement of ICD-9 includes codes for diseases, symptoms, abnormal findings, conditions, circumstances and external causes of injury or diseases.  ICD is the international standard for reporting diseases and health conditions including monitoring of diseases, observing reimbursement, strategizing resource allocation and keeping track of quality measures.  

ICD-10 is composed of two parts:

• ICD-10-CM (Clinical Modification) for diagnosis coding in all healthcare settings.  Around 68,000 codes.

• ICD-10-PCS (Procedure Coding System) used only for coding hospital inpatient procedures.  Around 76,000 codes.  

When most people talk about ICD-10, they are referring to ICD-10-CM.   

An example of an ICD-10 code is E11.21 – Type II Diabetes Mellitus with Diabetic Nephropathy.

CPT - Current Procedural Terminology

CPT codes are the codes used for reporting claims and getting paid. When a claim is filed with the CPT procedure code along with the appropriate ICD-10 diagnosis code, payment is made to the providing practitioner.  Example:  An insurance company won't pay just because the patient had a sore foot.  CPT codes will let the payer know an office visit was performed, pain was assessed, medications were ordered, tests were ordered.

The CPT system is maintained and copyrighted by the American Medical Association. Please refer to the AMA for specifics on these codes.

There are three categories for CPT codes:

CPT - used for reporting claims and getting paid. Example, reporting code 99201 will get you payment for an office visit.

CPT II - used to track additional services attached to a health care visit.  These codes are not payable but will help reduce the need for chart audits during HEDIS (Health Effectiveness Data and Information Set) season.  Example, reporting 1170F will let the payer know that during the 99201 office visit above, a functional status assessment was also conducted.  Unfortunately, since these codes are optional and non-money generating, they are often not reported. 

Category III - codes are not federally regulated and are fairly new to the healthcare industry.  They are reported to help health facilities and government agencies track the efficacy of new, emergent medical techniques. Using Category III codes is an important part of keeping the medical community up to date, and supporting advancements in the medical community and healthcare technology. 

For more information on these, please refer to the American Medical Association. 

Continue