Conventions and General Coding Guidelines - PART 2

Continuation of PART 1 

Includes Notes 

This note appears immediately under a three-character code title to further define, or give examples of,  the content of the category. 

Inclusion Terms

A list of terms is included under some codes. These terms are the conditions for which that code is to be used.  The terms may be synonyms of the code title, or, in the case of “other specified” codes,  the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the  Alphabetic Index may also be assigned to a code. 

Excludes Notes 

The  ICD-10-CM  has two types of excludes notes. Each type of note has a  different definition for use,  but they are all similar in that they indicate that codes excluded from each other are independent of each other. 

Excludes1 

A type1 Excludes note is pure excludes note. It means “NOT  CODED HERE!”  An  Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1  note.

Excludes2 

A type 2 Excludes note represents “Not  included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

Code Assignment and Clinical  Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a  particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. 

ICD-10 CM Conventions and General Coding Guidelines - PART 1

Format and Structure

The Tabular List contains are Categories Subcategories codes.  

All categories are 3 characters. A three-character category that has no further subdivision. The Subcategories are either 4 or 5 characters. The Codes maybe 3,  4, 5,  6, or  7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a  code. 

Placeholder Character

The ICD-10-CM utilizes a placeholder character  “X”.  The “X” is used as a placeholder at certain codes to allow for future expansion. 

An example of this is at the poisoning, adverse effect, and underdosing codes, categories  T36-T50.  Where a placeholder exists, the X  must be used in order for the code to be considered a valid code

NEC - Not  Elsewhere Classifiable

NEC - This  abbreviation  in the  Alphabetic  Index & Tabular List represents “other  specified.” When a  specific code is not available for a  condition,  the  Alphabetic Index directs the coder to the “other specified”  code in the  Tabular  List. 

NOS - Not Otherwise Specified 

NOS - This abbreviation is the equivalent of unspecified. 

Punctuation

[ ] Brackets are used in the  Tabular  List to enclose synonyms, alternative wording, or explanatory phrases. Brackets are used in the  Alphabetic  Index to identify manifestation codes. 

( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. 

: Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

Other Specified Codes

“Other” codes Codes titled  “other”  or  “other specified”  are for use when the information in the medical record provides detail for which a specific code does not exist in the alphabetic index or Tabular list

Unspecified Codes

 “Unspecified” codes Codes  titled  “unspecified”  are for use when the information in the medical record is insufficient to assign a more specific code.

Usage of ICD 10 CM - Drive the Codes

Alphabetic Index and Tabular List

The ICD-10-CM is divided into two main part,

• Alphabetic Index 
• Tabular List

Alphabetic Index

An alphabetical list of terms and their corresponding code and contains the following parts.

• Diseases
• Injury
• External Causes of Injury
• Neoplasms Table
• Drugs and Chemicals Tables

Tabular List 

A structured list of codes divided into chapters based on body system or condition.

Drive the Codes

To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record.

First, locate the term in the Alphabetic Index, and then verify the code in the Tabular List.

Read thoroughly and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.

It is essential to use both the Alphabetic Index and Tabular List when driving and assigning a code. The Alphabetic Index does not always provide the full code.

Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List.

A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.

Stay connected continuation of the ICD 10 CM guidelines -PART 1

Update to Medicare Deductible, Coinsurance & Premium Rates - 2021

Medicare Deductible, Coinsurance  Rates'2021

The Centers for Medicare & Medicaid Services (CMS) issued for the 2021 deductibles, coinsurance, and premium rates for beneficiaries covered through the Medicare fee for service program. 

The 2021 deductible, coinsurance, and base premium rates are below and effective from 01/01/2021

2021 Part B - Supplementary Medical Insurance (SMI)

Based on Part B, the Medicare Supplementary Medical Insurance (SMI) program, enrolls are subject to a monthly premium. 

Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrolled must pay), which are set by statute.

• Standard premium: $148.50 a month
• Deductible: $203.00 a year
• Pro-Rata  Data  Amount 
• $145.31  for  the  1st  month 
• $57.69  for  the  2nd  month
• Coinsurance: 20%

2021 Part A - Hospital insurance

• Deductible: $1,484.00
• Coinsurance
• $371.00 a day for days 61 through 90
• $742.00 a day for days 91 through150 (lifetime reserve days)
• $185.50 a day for days 21 through 100 (Skilled nursing facility coinsurance)

Usage of CPT Index - Instructions

The alphabetic index is not a substitute for the main text of the CPT codebook.

Even if only one code is present, the coder must refer to the main term to ensure that the code is selected accurately and correctly to identify the services rendered.

Main Terms

The index is organized by main terms. Each main term can stand alone or can be followed by up to three modifying terms.

There are four primary classes of main entries,

• Procedures or Services - E.g, Scopic, Anastomosis, Splint, Opening
• Organ or Other Anatomical Site - E.g, Knee, Arm, Ear, Tibia, Colon
• Conditions - E.g, Abscess, Entropion, Tetralogy of Fallot.
• Synonyms, Eponyms, and Abbreviations. - ECG, EEG, PET, Brock Operations, Clagett Procedures

Modifying Terms

The main term may be followed by up to three indented terms that modify the terms they follow.
EG. The main term "Endoscopy" is subdivided by the anatomical sites in which the procedure is used. And within these anatomical sites, the specific purpose of the procedures is identified.

In the following example, The code for endoscopic removal of a foreign body from the bile duct could be located.

• Bile Duct
• Removal
• Foreign Body........ 43275

Code Ranges

Whenever more than one code applies to a given index entry, a code range is listed. If several inconsequential codes apply, they will be separated by a comma. In the following example, three inconsequential codes apply,

• Esophagus
• Reconstruction ......... 43300, 43310, 43313

If three or more sequential codes apply, they will be separated by a hyphen. If more than one code range applies the code ranges will be separated by a comma as in the following example,

• Anesthesia
• Forearm...............01810-01820, 01830-01860

Conventions

As a space-saving convention, certain terms carry meaning inferred from the context. This convention is primarily used when a procedure or service is listed as a sub-term.

Example,

• Knee
• Exploration .............. 27310,27331

Pathology & Laboratory Codes

The pathology and Laboratory listing in the index presents the headings, subheadings, procedures, and analyzes in the Pathology and Laboratory action of the CPT codebook.

Analytes are either listed alphabetically or cross-referenced to the index main heads where they are alphabetically listed.

CMS Expands Medicare Payments for At-Home COVID-19 Vaccinations

PROVIDER RECEIVE THE INCREASED PAYMENTS UPTO 5 TIMES

To enhance access to COVID-19 vaccinations and promote health equity, the Biden-Harris Administration is expanding home-based vaccination options through CMS.

To ensure Medicare beneficiaries who have difficulty leaving their homes or are otherwise hard-to-reach can receive the vaccination, health care providers can now receive additional payments for administering vaccines to multiple residents in one home setting or communal setting of a home.  

This announcement aims to further boost the administration of COVID-19 vaccination – including second and third doses – in smaller group homes, assisted living facilities, and other group living situations.

The allowing vaccine providers to receive the increased payment up to 5 times when fewer than 10 Medicare beneficiaries get the vaccine on the same day in the same home or communal setting. 

CMS' Amended repayment process for accelerated and advance repayments

AAP - Repayment Process

CMS issued payments to providers and suppliers to help ease financial strain due to a disruption in claims submission and/or claims processing related to the COVID-19 public health emergency.

The Congress amended repayment process for the accelerated and advance payments through the Continuing Appropriations Act, 2021 and Other Extensions Act:

Repayment will now begin one year after the date of the issuance of the payment.

During the first 11 months after repayment begins, repayment will occur through automatic recoupment of 25% of Medicare payments otherwise owed to you.

During the succeeding six months, repayment will occur through an automatic recoupment of 50% of Medicare payments otherwise owed to you.

If AAP payment is not completed within 29 months, the provider will receive a demand letter requiring repayment of any outstanding balance with an interest rate of 4%.