Systematic Inflammatory Response Syndrome

(SIRS)

Codes used to describe circumstances or conditions that could influence patient care.

V codes are commonly used when the patient presents for treatment with no complaints.

Common reasons to report V codes: screening tests, routine physicals, when a patient has a personal history or family history of a disease or disorder.

For a V code to be listed first, it must meet the definition of a principal or first-listed diagnosis code.

Referred to as the Tabular List

The Tabular List is a numerical listing of disease and injury. There are 17 chapters for the classification of diseases and injury, grouped by etiology(cause) or anatomical (body) site.

Referred to as the Alphabetic List or Index to Diseases

Main terms in the Index to diseases vol 2 usually reference the disease, condition, or symptom. Sub terms add further modification to the main term. 

Medicare payments for physician services are stanrdized using a (RBRVS). Resource costs are divided into 3 components (physician work, physician expense, and professional liability insurance)

CMS annually publishes Physician Fee Schedule (PFS) information on its website and posts the formula for calculating PFS payment amounts.

PE-Physician Expense, MP-Malpractice, GPCI-Geographic practice cost index, CF- conversion factor (fixed dollar amount used to translate RFUs into fees)

refers to whether a procedure or service is considered appropriate in a given circumstance.

Generally, a medically necessary service or procedure is the least radical service/procedure that allows for effective treatment of the patient's complaint or condition.

Health Insurance Portability and Accountability Act of 1996

(HIPAA)

Provides federal protections for personal health information.

A key provision of HIPAA is the "minimum necessary" requirement. That is, only the minimum necessary protected health information (PHI) should be shared to satisfy a particular purpose.

To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided.

The person does not have to have knowledge of the violation in order for it to still be considered an offense.

1. Commercial Carriers- private payers that may offer both group and individual plans.
    
2. Government Insurance plans
   
   

The most significantgovernment insurer. Medicare is a federal health insurance program-administered by the Centers for Medicare & Medicaid Services (CMS)- that provides coverage for people over the age of 65, blind, or disable individuals, and people with permanent kidney failure or end stage renal disease (ESRD).

All physician offices and healthcare facilites should have, and actively use a compliance plan. The compliance plan is a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found.

The OIG has provided compliance program guidance.

The Office of Inspector General (OIG)

Work Plan

Each year in October, the OIG releases a work plan outlining its priorities for the fiscal year ahead.

The plan announces potential problem areas with claims submissions that it will target for special scrutiny.

• Part A: Inpatient hospital care, as well as care provided in skilled nursing facilities, hospice carem and home healthcare
  
  
• Part B: Medically necessary physician services, out patient care, and other medical serivces (optional - patient must pay a premium for this part)
  
  
• Part C: also called Medicare Advantage, combines benefits of Part A, B, and sometimes D. Managed by private insurers approved by Medicare.
  
  
• Part D: Prescription Drug Coverage, avaiable to all Medicare beneficiaries. 

National Coverage Determination (NCD)

Medicare Administration Contractor (MAC)

Local Coverage Determinations (LCD)

NCD:  explain when Medicare will pay for items or services.

MAC: is responsible for interpreting national policies into regional policies. **If an NCD does not exist for a particular item, it is up to the MAC to determine coverage.

LCD: explain when a given service is indicated or necessary, give guidance on coverage limitations, describe the specific CPT codes to which policies applies, and lists ICD-9-CM codes that support medical necessity for the given service or procedure. ***LCDs have jurisdiction only within their regional area.

Not elsewhere classified

Used when the ICD-9-CM does not provide a code specific for the patient's condition. Selecting a code with NEC means the provider documented more specific information regarding the patient's condition, but there is not a code in the ICD-9-CM that reports the condition accurately.

Not otherwise specified

This abbreviation is the equivalent of "unspecified" and is used only when the coder acks the information necessary to code a more specific 4th or 5th digit sub-category.

[] - Brackets
 

[] - Slanted Brackets
 

() - Parenthesis
 

: - colon

[] - enclose synonyms, alternate wording, or explanatory phrases.

[] - used to indicate multiple codes are required

() - used to enclose supplementary words that may br present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned.

: - used in Vol 1 (Tabular List) after an incompete term.

And

With

And - The word "and" in a code description can mean "and" or "or".

With - The word "with" in the code title can mean "assicoated with" or "due to"

Late Effect

A late effect is "usually an inactive, residual effect or condition produced after the acute portion of an injury or illness has passed." Key phrases "due to an old injury" or "due to a previous illness" are indicators of a late effect.

The residual condition is coded first and the code for the late effect is coded as a secondary diagnosis. An E code may be necessary to identify an external cause. 

The coding system used in the US to translate medical terminology for diseases and procedures into numeric codes.

The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the National Centers for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) performs maintenance on ICD-9-CM. Changes are published in the Federal Register and become effective October 1 of each year. 3 volumes.

Current Procedural Terminology (CPT)

origin

A compilation of guidelines, codes, and descriptions used to report healthcare services.

In August 2000, the Transactions and Code Sets Final Rule, aka CPT, Healthcare Common Procedural Coding System (HCPCS) Level II, and their respective modifiers were named as standard code sets for national use.

Category I - use a 5 digit numerical code. Reviewed annually by an AMA panal. It is mandatory to use Category 1 CPT codes for reporting and reimbursement.

Category II - optional "performance measurement tracking codes:. Alphanumeric, with the letter F in the last position.

Category III- may be reported in addition to evaluation/management (E/M) services or clinical services CPT Category I codes.

CPT Category I codes are divided into six main sections.

National Correct Coding Iniative 

(NCCI)

CMS implemented the NCCI to promote accurate and appropriate coding. NCCI identifies codes considered by CMS to be bundled, or not reported seperately, because one code is included in the work of another code.

Repeated unbundling may be characterized as fraudulent coding.

CPT code used to report a supplemental or additional procedure appended to a primary procedure (stand-alone) code. Add-on codes are recognized by the CPT symbol "+" used throughout the CPT codebook.

The Center's for Medicare and Medicaid Services

(CMS)

The agency with the U.S. Department of Health & Human Serivces (HHS) that administers the Medicare program and works in parternership with state governments to administer Medicaid and state Children's Health Insurance Programs (CHIP).

Current Procedural Terminology

(CPT)

A code set copyrighted and maintained by the American Medical Association (AMA).

The period (0-10 days or 0-90 days as determined by the health plan) and services provided for a surgery inclusive of preoperative visits, intraoperative services, post-surgical complications, postoperative visits, post-surgical pain management by the surgeon, and several miscellaneous services as defined by the health plan, regardless of setting (eg, in a hospital, an ASC, or physician office).

Global Surgery Status Indicator

An assigned payment indicator, which determines classification for a minor or major surgery, based on RVU calculations.

Healthcare Common Procedure Coding System

(HCPCS) Level II

HCPCS Level II is the national procedure code set for healthcare practitioners, providers, and medical equipment suppliers when filing insurance claims for medical devices, medications, transportation services, and other items and services.

Substitute physicians who takes over the professional practice of a physician who is absent for reasons such as illness, pregnancy, vacation, or continuing medical education. When locum tenens fills in, the regular physician submits the claim with modifier Q6 appended to the services.

Surguries classified as major have a global service period that includes the day before the surgery, the day of the surgery, and any related follow-up visits with the provider 90 days after the procedure.

Surgeries classified as minor have a global surgical period that includes the pre-operative service day, surgery, and any related follow-up visits with the provider 0-10 days after the surgery.

Resource-Based Relative Value Scale

(RBRVS)

Relative Value Unit

(RVU)

CMS reimburses physicians for Medicare, services using a national payment schedule based on the resources used in furnishing physician services. RVUs are configured using work based on specialties, practice expense, and physician liability insurance.

National Correct Coding Initiative (NCCI)

Correct Coding Modifiers (CCM)

The CCM indicator determines whether, under appropriate conditions, you may over-ride a code pair edit. This indicator will be either a "0",, "1", or "9"

0 = a CCM is not allowed and will not bypass the edits

1 = a CCM is allowed and will bypass edits

9= Modifer use is not specified, This indicator is used for all code pairs that have a deletion date that is the same as the effective date. This indicator was created so that no blank spaces would be in the indicator field.

• Digital Block
  
  
• General Anesthesia
  
  
• Talking with the family
  
  
• E/M  encounter on the date immediately prior to a major procedure 

A premalignant warty lesion occurring on the sun-exposed skin of the face or hands in aged light-skinned people.

Lack of hair, especially on the scalp, which may be partial or total, and can occur at any age.

A slow growing malignant neoplasm

A tumor that does not form metastases, and does not invade and destroy adjacent normal tissue

A process of removing tissue from a patient for microscopic diagnostic examination

A melanocytic nevus visible at birth, often larger than an acquired nevus.

Acute or chronic dermatitis caused by initial irritant effect of a substance that comes in contact with the skin.

Removal of foreign materials, necrotic matter, and devitalized tissue from a wound or burn

Focal ischemic necrosis of skin and underlying tissues at sites of constant pressure or recurring friction.

Procedure used to remove acne scars or pitsm performed with sandpaper or other abrasive materials.

A slow-growing, benign skin nodule consisting of poorly demarcated cellular fibrous tissue.

A physician who specializes in diagnosing and treating cutaneous and related systemic diseases.

An instrument for cutting thin slices of skin for grafting of excising small lesions.

Directly below the epidermis the dermis is the second layer of skin.

Cutaneous pigmented lesions with notched, irregular borders, considered pre-malignant.

The outer layer of skin

A thick, crusty covering or slough that develops after thermal or chemical burn or catherization of the skin

Excessive development of the male mammary glands

A contagious superficial pyoderma, caused by staphyococcus aureus (staph) ot Streptococcus pyogenes (strep).

A nevus in which nests of melanocytes are found in the dermis, but not the epidermal-dermal junction.

A nodular, firm, often linear mass of hyperplastic, thock scar tissue.

Surgical removal of a tumor or other lump from the breast along with some surrounding tissue, conserving normal breat appearance.

Plastic surgery for altering the breast(s) size by enlarging or reducing the breast(s).

Surgical removal of one or both breasts to treat or prevent breats cancer.

Plastic surgical fixation in doing a breast(s) lift or reshape the breast(s) to inprove the look of sagging breast(s).

Any disease caused by a fungus.

Pathologic death of one or more cells, or of a portion of tissue or organ, resulting from irreversible damage.

A circumscribed malformation of the skin, especially one colored by hyperpigmentation.

Hair-containing cyst or sinus in the tissues of the sacrococcygeal area.

Relating to itching

A common autoimmune condition characterized by the eruption of reddish, silvery-scaled maculopapules.

A common cyst of the skin and sucutis containing sebum and keratin.

Over activity of the sebaceous gland, resulting in an excessive amount of sebum.

A chronic condition characterizaed by lesions that are red, dry, elevated, and covered by silvery scales.

The armpit. There are numerous lymph nodes in this area, as well as muscles and tissue.

*There are times when the axilla may refer to the upper arm, back, or flank area.

Treatment of a fracture or dislocation by returning the part to its normal position, Reduction of a fracture can also mean surgical restoration.

Removing a scar tissue or bone from an area, most commonly the spine, to relieve pressure on nerves or nerve root. It is often performed with the placement of a bone graft, screws, plates, or rods to maintain the alignment of the bones. Another common decompression is of the median nerve in the wrist, also known as carpel tunnel.

Some fractures are treated with fixation, either internal or external, to maintain the alignment of the bone while it heals, or to reinforce the bone permanently.

Internal fixation can be done with pins, screws, plates, or wires placed directly in the bone to immobilize it.

External fixation is primarily on the outside of the body, and can include a cage-like structure, as well as pins and rods.

When coding orthopedic surgeries, it is vital to first determine the approach-the method and direction the surgeon uses to access the part of body that needs to be repaired.

An approach can be from the front of the body (anterior), from the back (posterior), or from the side (lateral).

Used primarily in the spinal area to permanently align the vertebrae. Segmental instrumentation is defined as a spinal rod or device placed with three or more areas anchored by screws or wires. With non-segmental instrumentation, rods or wires are anchored at the top and bottom of the device only.

A sprain or strain is the twisting or stretching of a joint in a way that causes pain and damage to a ligament. A sprain involves the non-contractile tissue (the ligament), and a strain involves the contractile tissue (muscle or tendon)

The scapula is a flat, triangular-shaped bone on the dorsal thorax or back. The acromion is an extension of this bone that joins with the clavicle at the shoulder to form the acromioclavicular joint.

These are often named after the physician who first documented or described the fracture or treatment.

A fracture of the wrist at the distal radius. Sometimes the ulnar styloid also is involved.

A stress fracture of the fifth metatarsal of the foot.

Similar to the Colles' fracture except the bones are displaced toward the palm.

An epiphyseal plate fracture; a common injury seen in children.

Fracture of the distual fibula with rupture of the distal tibiofibular ligaments and lateral dislocation of the radial head.

Fracture of the proximal third of the ulna with associated dislocation of the radial head.

An inflammation of the bone and/or bone marrow caused by infection.

Use of a currette to remove tissue by scraping.

A spoon-shaped instrument used to cut or scoop away (currettage) tissue.

A bunion, or hallux valgus, is the swelling and deformity of the metatarsophalangeal joint, usually at the base of the big toe. There are numerous ways to repair a bunion.

a simple resection of the medial eminence of the metatarsal bone

removal of the medial eminence of the metatarsal bone and the base of the proximal phalanx. Sometimes a wire holder or implant is used to stabilize the joint.

includes the transplant of the extensor tendon to the head of the metatarsal bone.

a double step-cut, biplanar osteotomy through the metatarsal bone

a fusion of the first metatarsal and first cuneform joint, and the first and second metatarsal bases.

A muscle that causes flexion or bending of a limb or body part.

The term for the fibrous sheath of the flexor tendons of the hand, specifically in the zone from the distal palmar crease to the proximal interphalangeal joint. Stiffness following injury is a common problem in this area.

A muscle that causes straightening of a limb or body part.

A muscle that moves a part of the body towards the midline of the body.

A muscle that moves a part of the body away from the midline of the body.

An extra digit on the hand or the foot. This digit may be smooth tissue or may contain bones and tendons.

Removal of a large portion of the dorsal metatarsal head and associated bone spurs.

Tendons, aponeuroses, and directly to bone

Filtering of the blood to remove stem cells

Collection of pus between the lung and the lining of the lung (pleural space)

In total or in full; as a single piece

A lid or flap that covers the larynx to protect the trachea from inhaled food or liquid.

Vocal cords seperated by a triangular opening through which air flows. The glottis narrows, controlling the flow of air, which causes the vocal cords to vibrate and create sound.

Pertaining to blood

A horseshoe shaped bone in the anterior midline of the neck. It is not part of the trachea and does not articulate with any other bone. It provides attachment to the muscles of the floor of the mouth and the tongue above, the larynx below, and the epiglottis and pharynx behind.

Use of mirrors with a rigid laryngoscope to view the larynx.

Connects the nasopharynx to the trachea, covered by the epiglottis during swallowing to prevent aspiration.

The right lung has three lobes and the left lung has two lobes.

The portion of the thoracic cavity between the lungs containing the heart, aorta, esophagus, trachea, and thymus gland, as well as blood vessels and nerves.

A serous membrane that folds back onto itself to form a two-layered structure.

Superior, middle, and inferior bony structures found in each right and left nasal cavity to assist with air movement

The maximum volume of air a person can exhale after meximum inhalation. The measure is used in diagnostic pulmonary testing.

String-like tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle.

Generates and distributes electrical impulses over the heart to stimulate contraction, allowing blood to move throughout the body.

Implantable device that delivers and electrical shock to restore normal heart rhythm.

Relating to the myocardium (second layer of the wall of the heart)

A catheter is placed in the main trunk; contrast may be injected and images may be taken, but the catheter is not moved into any other branches.

A catheter that is tunneled through the skin and subcutaneous tissue to a central vessel; the entrance point of the catheter is distant from the entrance to the vascular system.

Exposing an internal structure outside the body for observation, surgery, or experimentation, such as creating a passage from the bladder to the abdominal wall.

Exploring the abdomen and pelvic cavities using a scope placed through a small incision in the abdominal wall

Visualization of the abdominal cavity using a scope placed through a small incision in the abdominal wall

The Splenic (left colic) flexure lies in the upper-left quadrant, between what two portions of the large intestine?

Failure of the development of sperm of the absence of sperm in semen; one of the most common factors in male fertility

Form of radiation therapy in which radioactive pellets or seeds are implanted directly into the tissue being treated to deliver their dose of radiation in a more directed fashion

Abnormal, stone-like concretion of calcium, cholesterol, mineral salts, or other substances that forms in any part of the body.

Ventral (downward) curvature of the penis due to a fibrous band along the corpus spongiosum seen congenitally with hypospadias, or downward curvature seen on erection in disease conditions causing a lack of distensibility in the tissues.

Persistently inflamed lesion of the bladder wall, usually accompanied by urinary frequency, pain, nocturia, and a distended bladder.

Infectious tumor-like growth caused by the human papilloma virus, with a branding connective tissue core and epithelial covering that occurs on the skin and mucous membranes of the perianal region and external genitalia

Coiled tube on the back of the testis that is the site of sperm maturation and storage and where spermatozoa are propelled into the vas deferens toward the ejaculatory duct by contraction of smooth muscle.

Male anomaly in which the urethral opening is abnormally located on the dorsum of the penis, appearing as a groove with no upper urethral wall covering.

Congenital anomaly occuring when the bladder everts itself, or turns inside out, through an absent part of the lower abdominal and anterior bladder walls with incomplete closure of the pubic bone.

Temporary indwelling urethral catheter held in place in the bladder by an inflated balloon containing fluid or air.

Blood in the seminal fluid, often caused by inflammation of the prostrate or seminal vesicles, or prostrate cancer.

Blood in the urine which may be present as gross visible blood or as the presence of red blood cells visible only under microscope.

Congenital anomaly in which the kidneys are fused together at the lower end during fetal development, resulting in one large, horseshoe shaped kidney, often associated with cardiovacular, central nervous system, or genitourinary anomalies.

Distension of the kidney caused by an accumulation of urine that cannot flow out due to an obstruction. It may be caused by conditions such as kidney stones or vesicoureteral reflux.

Fairly common birth defect in males in which the meatus, or urinary opening, is abnormally positioned on the underside of the penile shaft or in the perineum, requiring early surgical correction.

Involuntary escape of urine

Psychosexual or organic dysfunction in which there is partial or complete failure to attain or maintain erection until completion of the sexual act.

Destruction of calcified substance in the gallbladder or urinary system by fragmenting the concretion into small particles to be washed out.

Placement of a stent, tube, or catheter to form a passage from the exterior of the body into the renal pelvis or calyx, often for drainage of urine or an abcessm for exploration, or calculus extraction.

Dysfunctional bladder due to a central or peripheral nervous system lesion that may reult in incontinence, residual urine retention, infection, stones, and renal failure.

Surgical removal of one or both testicles via a scrotal or groin incision, indicated in cases of cancer, traumatic injury, and sex reassignment surgery.

Pertaining to the pelvic floor area between the thighs: the diamond-shaped area bordered by the pubic symphysis in front, the ischial tuberosites on the sides, and the coccyx in the back.

Development of fibrotic hardened tissue or plaque in the cavernosal sheaths in the penis.

Persistent, painful erection lasting more than four hours and unrelated to sexual stimulationm causing pain and tenderness

Falling, sliding, or sinking of an organ from its normal location in the body

Male gland surrounding the bladder neck and urethra, which secretes a substance into the seminal fluid.

Located behind the peritoneum, the membrane that lines the abdominopelvic walls and forms a covering for internal organs.

Skin pouch that holds the testes and supporting reproductive structures.

Paired glands located at the base of the bladder in males that release the majority of fluid into semen through ducts that join with the vas deferens forming the ejactatory duct.

Paraurethral ducts that drain a group of the female urethral glands into the vestibule.

Structure of the male reproductive organs that consists of the ductus deferens, testicular artery, nerves, and veins that drain the testes.

Narrowing of an anatomical structure

Male gonadal paired glands located in the scrotum that secrete tertosterone and contain the seminiferous tubules where sperm is produced.

Twisting, turning, or rotation of the testicle upon itself

Triangular, smooth area of mucous membrane at the base of the bladder, located between the ureteric openings posteriorly and the urethral opening anteriorly.

Serous membrane that partially covers the tests formed by an outpocketing of the peritomeum when the testes descend.

Embryonic tube containing the urinary bladder to the umbilicus during development of the fetus that normally closes before birth, generally in the fourth or fifth month of gestation.

Small tube lined with mucous membrane that leads from the bladder to the exterior of the body.

Small polyp-like growth of a deep red color found in women on the mucous membrance of the urethral opening.

Creation of an opening to the abdominal surface to divert urine flow.

Duct that arises in the tail of the epididymis that stores and carries sperm from the epididymis twoard the urethra.

Abnormal communication between the bladder and another stricture.

Urine passage from the bladder back up into the ureter and kidneys that can lead to bacterial infection and an increase in hydrostatic pressure, causing kidney damage.

Placement of stitches to hold the cervix closed.

A fold of mucous membrane surrounds or partially covers the external vaginal opening, called the hymen. When this membrane completely covers the vaginal opening, or is too tough, surgery may be used to cut it away.

Destruction; often used in relation to scar tissue or adhesions. It can be used by itself or can be used as a suffix, as in "adhesiolysis", which means destruction of adhesions.

Located in the vulvar area, several glands found on the anterior wall of the vagina around the lower end of the urethra. They are also called the lesser vestibular glands, or periurethral glands.

Miscarriage or the natural loss of pregnancy when there is an expulsion of products of conception before completion of 22 weeks gestation.

A congenial anomaly. Extra tissue divides the vagina either longitudinally or horizonally. A longitudinal vagina is sometimes called a double vagina

The external femal genitalia including the labia majora and minora, mons pubis, clitoris, vestibule (introitus of the vagina, and the urethra

Any one of three hollows (anterior, middle, and posterior) in the base of the cranium for the lobes of the brain.

Encephalocele

(cephalocele meningoencephalocele)

A rare disorder in which the bones of the skull do not close completely, creating a gap through which cerebral spinal fluid, brain tissue, and the meniges can protrude into a sac-like formation.

A voltage change observed after electrical stimulation is applied to the skin surface above the distal region of a nerve; often used to measure nerve conduction velocity.

To tie off

Collective name for the membranes that envelop the central nervous system. The meninges consists of three layers; the dura mater, the arachnoid mater, and the pia mater. Its primary function is to protect the brain and spinal cord

Protrusion, through a bone defect in the vertebral column, of the meninges that cover the spinal cord.

A birth defect in which the back-bone and spinal canal do not close before birth; a type of spina bifida. The spinal cord and the meninges protrude.

Agent used to destroy nerves; for instance alcohol, phenol, etc.

Triphination

(Trepanning, Trephining, Burr Hole)

A condition in which blood vessels spasm, leading to vasoconstriction and possible stroke or other injury; may arise in the context of subarachnoid hemorrage.

Zygapophyseal Joint

(Z Joint, Paravertebral Facet Joint, Facet Joint)

Located on the posterior spine on each side of the vertebra where it overlaps the neighboring vertebra; the facet joints provide stability and give the spine the ability to bend and twist.