Chapter two medical coding, code assignment and reimbursement

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Procedure Codes While ICD codes are used to specify diseases, Current Procedural Terminology (CPT) codes
are used to specify medical procedures (treatments. CPT codes were developed and are copyrighted by the American Medical Association. The purpose of CPT is to create a uniform language (set of descriptive terms and codes) that accurately describes medical, surgical, and diagnostic procedures. CPT and its corresponding codes are revised periodically to reflect current trends in clinical treatments. To increase standardization and the use of electronic health records, federal law requires that physicians and other clinical providers, including laboratory and diagnostic services, use CPT for the coding and transfer of healthcare information. (The same law also requires that ICD codes be used for hospital inpatient services)

5 To illustrate CPT codes, there are ten codes for physician office visits. Five of the codes apply to new patients, while the other five apply to established patients (repeat visits. The differences among the five codes in each category are based on the complexity of the visit, as indicated by three components (1) extent of patient history review, (2) extent of examination, and (3) difficulty of medical decision making. For repeat patients, the least complex (typically shortest) office visit is coded 99211, while the most complex (typically longest) is coded 99215. Because government payers (Medicare and Medicaid) as well as other insurers require additional information from providers beyond that contained in CPT codes, an enhanced version called the
Healthcare Common Procedure Coding System (HCPCS, commonly pronounced hick picks) was developed. This system expands the set of CPT codes to include nonphysician services and durable medical equipment such as ambulance services and prosthetic devices. Although CPT and HCPCS codes are not as complex as the ICD codes, coders still must have a high level of training and experience to use them correctly. As in ICD coding, correct CPT coding ensures correct reimbursement. Coding is so important that many businesses offer services, such as books, software, education, and consulting, to hospitals and medical practices to improve coding efficiency. Below is a list of all chapters of the ICD-11 MMS, the primary linearization of the Foundation Component
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