Question

A) Describe, define and explain the components of the medical coding systems used at:

1) hospitals (ICD codes), and

2) medical practices (CPT & HCPCS codes).

B) Describe, define and explain the methodologies used by both Medicare and Medicaid to pay providers for the following services:

1) hospital in-patient services,

2) physician professional services.

3) out-patient medical services and tests (lab, x-ray, etc.).

C) Describe, define and explain in detail what are DRG's and RVU's and how they are used.

Answer 1

A)1. Hospitals use International Code of diseases (ICD) as a standard diagnostic tool. It was framed by WHO in 1992 to monitor the incidence and prevalence of the diseases and associated conditions. Currently the tenth revision of ICD is being used - ICD 10. It consists of 14000 codes.

ICD is used for disease classification and diagnostic data recording for clinical, quality and epidemiological purposes and also for reimbursement of insurance claims. It consists of codes for diseases, signs and symptoms, abnormal findings, circumstances and external causes of diseases or injury.

It can be broadly classified into 2 categories :

1. ICD-10-CM (Clinical Modification) – Diagnostic codes
2. ICD-10-PCS (Procedure Coding System) – Procedure Codes (for inpatients)

ICD 10 code provide accurate information regarding the disease and its treatment. It is also used for global comparison of quality of health and healthcare.

2. Medical practices code :

HCPCS code : HCPCS stands for Healthcare Common Procedure System. It was developed by centres of medicare and medicaid (CMS). It is used to represent medical procedures to Medicare, Medicaid, and several other third-party payers. It consist of three levels:

Level I: it describes the treatment procedures

Level II: refers to non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that don’t fit readily into Level I.

Level III: used in specific programmes snd jurisdiction

CPT code: stands for current procedural terminology. It stands for American Medicsl Association (AMA). It is used for medical, surgical and diagnostic purposes. It helps to distribulte uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. It consists of 3 categories.