Coding Preventive Care and Office visit on the same day

If an abnormality/ies is encountered or a preexisting problem is addressed

in the process of performing this preventive medicine evaluation and

management service, and if the problem/abnormality is significant enough

to require additional work to perform the key components of a problem-

oriented E/M service, then the appropriate Office/Outpatient code 99201-

99215 should also be reported. Modifier 25 should be added to the

Office/Outpatient code to indicate that a significant, separately identifiable

Evaluation and Management service was provided by the same physician

on the same day as the preventive medicine service. The appropriate

preventive medicine service is additionally reported.

An insignificant or trivial problem/abnormality that is encountered in the

process of performing the preventive medicine evaluation and management

service and which does not require additional work and the performance of

the key components of a problem-oriented E/M service should not be

reported.

Example: A 50-year-old established patient comes in to the office for an annual wellness visit and at the same time also complains of a severe chest pain.

The physician performs comprehensive preventive evaluation as well as a separate level III elements of an office visit  for chest pain and reports it in addition to the preventive medicine service, then the coding can be done as follows:

CPT       MOD        ICD

99396                   V70.0

99214    25           786.50.

What is Medical coding and purpose of it ?

The most common definition of medical coding is transforming the patient charts and disease conditions into alphanumeric codes.

Internationally, coding is done for the purpose of  mortality statistics.  These reports are scaled depending on the location, age, race, gender, etc.  Based on the statistics reports the governments identifies the root cause of these disease conditions and takes necessary steps and eradicate the disease conditions.

In the US Healthcare coding is done for the above reasons as well as it is the first step of billing process.

There are 3 types of coding:
Basically there are 3 books from which coding is done (outpatient physician coding):

1.  ICD-9-CM:  International classification of diseases  9 Revision, Clinical Modification.  Whenever a patient visits a physician or a hospital, all the conditions that the patient has been diagnosed are needed to be documented in the patient's chart.  All these diagnoses are coded from ICD-9-CM.  All these codes are either numeric of alphanumeric.  The code ranges from 3-5 digits.

2.  CPT:  Current Procedural Terminology.  These codes are also known as the HCPCS Level I codes.  These are the codes that represent physician services.  Codes are given based on the effort the physician has put in treating the particular patient's condition.  Each and every CPT code have different charges ($ value).  Based on these CPT codes the insurance company pays the physicians.  All the codes are 5 digit numeric codes.

3.  HCPCS:  Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks").  These and HCPCS Level II codes.  These codes basically represent the supplies that a physician or hospital has provided to a patient.  There are also some G-codes which represent physician services and are billed to Medicare.

In conclusion, whenever a patient visits a physician and is treated for the disease conditions. All the physician services are coded from the CPT/HCPCS and the diagnoses are coded from ICD-9-CM.

What is Medical coding and purpose of it.

Medical Coding Career

Medical coding is going to be one of the best career in the Healthcare Industry, especially for the people who are associated with the US Healthcare Industry.  It is the fastest-growing career compared to other industries.  This is going to be a good job especially for the transcriptionists, who have the knowledge of US Healthcare Industry.  The good about it is that they need not wear a headphone/earphone or operate a foot pedal and fight with their keyboards.  It is all about application of ideas.  The good news for us is that there are many companies coming into coding in the near future and scope for growth is more.   Already, many big companies have been set up in Hyderabad (UHG, Humana, etc these are the leading health insurance companies in US)

Anyways, I will be updating this blog with all the news in the coding industry.

Anybody who wants Medical Coding in Hyderabad, contact me.  You can mail me at arunkumar.palakala@gmail.com