Medical Billing & Coding Terminology

Medical billing and coding terminology and CPT codes references linked below.

Anesthesia (CPT): The section of the CPT code set that contains codes for anesthesia. These codes fall into the range of 00100 to 01999, and are subdivided by both the area of the body that is anesthetized and by the type of procedure being performed. There are, for example, a cluster of codes for anesthesia of the shoulder and axilla, and there are also anesthesia codes for radiological procedures.

Category (CPT): The CPT code set is divided into three Categories. Category I,which is the largest and most commonly used, describes medical procedures, technologies and services. Category II is used for performance management and additional data. Category III houses the codes for emerging and experimental medical procedures and services.

Category (ICD): In ICD, the category is the first three characters of the code, which describes the basic manifestation of the injury or sickness. In some cases, the category is all that is needed to accurately describe the condition of the patient, but more often than not the coder must list a more detailed description of the injury or illness (see “Subcategory,” and “Subclassifcation”). In ICD-9-CM, categories are three numbers, except in the case of E- and V-codes, which are alphanumeric. In ICD-10-CM, all categories are alphanumeric.

Clinical Modification: This designation, created by the National Center for Health Statistics, is added to the ICD codes sets when they are implemented in the United States. Many countries expand and clarify ICD code sets for their national use; the US, for example, expanded ICD-10 from 14,000 codes to over 68,000 individual codes. This term is abbreviated “-CM” and is added to the end of the ICD code title. For instance, ICD-9-CM can be read “International Classification of Diseases, Ninth Revision, Clinical Modification.

CMS: The Center for Medicare and Medicaid Services. This federal agency updates and maintains the HCPCS code set and is one of the most important organizations in healthcare today.

CPT: Current Procedural Terminology. Published, copyrighted, and maintained by the American Medical Association, CPT is a large set of codes that describe what procedure or service was performed on a patient. This code is divided into three Categories, with the first Category being the most important and widely used. CPT codes are an integral part of the reimbursement process. These codes are five characters long and may be numeric or alphanumeric.

HCPCS: Healthcare Common Procedure Coding System, pronounced hick-picks. This is main procedural code set for reporting procedures to Medicare, Medicaid, and a large number of other third-party payers. Maintained by CMS (See “CMS”), HCPCS is divided into two levels. Level I is identical to CPT, and is used in the same way. Level II describes the equipment, medication, and out-patient services not included in CPT.

E-codes: E-codes are a set of ICD-9-CM codes that includes codes for external causes of injury, such as auto accidents, poisoning, and homicide. Evaluation and Management (CPT): Evaluation and Management, or E&M, is a section of CPT codes used to describe the assessment of a patient’s health and the management of their care. The codes for visits to doctor’s office and trips to the emergency room, for instance, are included in E&M. E&M is found at the front of the CPT manual, despite being out of numerical order. The codes for E&M are 99201 – 99499.

ICD: The International Classi!cation of Diseases is a set of medical diagnostic codes established over a hundred years ago. Maintained today by the WHO (See “WHO”), ICD codes create a universal language for reporting diseases and injury. In the United States, we use ICD-9-CM (See “Clinical Modi!cation”), while the rest of the world uses some form of ICD-10. The US is slated to upgrade to ICD-10-CM in 2014. ICD codes are numeric or alphanumeric. They have a three-character category (See “Category (ICD)”), which describes the injury or disease, which is typically followed by a decimal point and two-to-four more characters, depending on the code set, which give more information about the manifestation and/or location of the disease.

Medical Necessity: Medical necessity is the justification of medical services as reasonable, necessary, or appropriate. Medical necessity is often “proven” using ICD codes. A coder would use the ICD code for a broken arm, for example, to demonstrate the medical necessity of an X-ray and the application of a cast. Medicine (CPT): The final section of the first Category of CPT. This range of codes describes procedures directly related to the application of medication, medical procedures, and medical equipment to the patient. This section does not include basic patient evaluations or surgical procedures, which have their own sections (See “Evaluation and Management” and “Surgery”). The codes for Medicine are 90281 – 99199 and 99500-99607.

Modifier: A modifier is a two-character code that is added to a procedure code to demonstrate an important variation that does not, by itself, change the definition of the procedure. CPT codes have numeric modifiers, while HCPCS codes have alphanumeric modifiers. These are added at the end of a code with a hyphen, and may provide information about the procedure itself, that’s procedure’s Medicare eligibility, and a host of other important facets. The CPT modifier -51, for example, notifies the payer that this procedure was one of multiple procedures. The HCPCS modifier –LT, on the other hand, describes a bilateral procedure that was performed only on the left side of the body.

Modifier Exempt (CPT): Certain codes in CPT cannot have modifiers added to them. This is a fairly short list that can be found in the appendices of the CPT manual.

Morbidity: The rate or incidence of disease in a patient or a population. ICD codes are used to report morbidity.

Mortality: The rate or incidence of death in a patient or population.

NCHS: The National Center for Health Statistics. The NCHS is a government agency that tracks health information, and is responsible for creating and publishing both the clinical modifications to ICD codes (See “Clinical Modification”) and their annual updates.

Pathology: The science of the causes and effects of disease.

Pathology and Laboratory (CPT): The section of Category I CPT codes that pertains to laboratory testing and pathological investigations. This section includes codes for procedures used to determine the status and root cause of a patient’s illness or condition. The codes for Pathology and Laboratory are 80047-89398.

Professional Component: In CPT, a professional component refers to the services performed by a fully licensed medical professional. This is important for the reimbursement process, and is usually noted with the inclusion of modifier -26 after a procedure code (See “Modifier”). Professional services include the evaluation of a radiologic test, but not the administration of the test, which is a technical component (See “Technical component”).

Radiology (CPT): The section of the CPT manual that covers radiologic tests and procedures like X-rays, ultrasounds, and oncology. The codes for Radiology are 70010-79999.

Sequela: A condition that is the result of a previous injury or condition. You will encounter this term in ICD-10-CM in the code’s Subclassifications (See “Subclassifications”).

Subcategory: In ICD codes, the subcategory describes the digit that comes after the decimal point. This digit further describes the nature of the illness or injury, and gives additional information as to its location or manifestation.

Subclassification: The subclassification follows the subcategory (See “Subcategory”) in ICD codes. The subclassification further expands on the subcategory, and gives additional information about the manifestation, severity, or location of the injury or disease. In ICD-10-CM there is also a subclassification that describes which encounter this is for the doctor—whether this is a first treatment for the ailment, a follow-up, or the assessment of a condition that is the result of a previous injury or disease (See “Sequela”). There is one subclassification character in ICD-9-CM; in ICD-10-CM there may be as many as three.

Surgery (CPT): The section of the CPT manual that covers surgical procedures performed on patients. The largest and most complicated section of CPT’s first Category, the Surgery section is divided into sections based on which part of the body the surgery is performed on, and then further subdivided based on what type of procedure is being performed. For instance, there is a section for excisions of the hand and fingers, which is itself part of the larger section of surgical procedures performed on the musculoskeletal system. The codes for Surgery are 10021 – 69990.

Technical Component: The portion of a medical procedure that concerns only the technical aspect of the procedure, but not the interpretative, or professional aspect (See “Professional component”). A technical component might include the administration of a chest X-ray, but would not include the assessment of that X-ray for disease or abnormality.

V-codes: V-codes are a special section of ICD-9-CM that describe patient visits related to circumstances other than disease or injury. This includes live-born infants, people with risk or disease due to family history, people encountering health services for specific or mandated evaluation or aftercare, and a host of other not easily classifiable situations. V-codes have been replaced in ICD-10-CM by Z-codes (See “Z-codes”).

WHO: The World Health Organization. This international body, which is an agency of the United Nations, oversees the creation of ICD codes and is one of the most important organizations in international health.

Z-codes: Much like V-codes in ICD-9-CM (See “V-codes”), these codes describe circumstances outside of injury or disease that cause a patient to visit a health professional. This may include a patient visiting a doctor because of family medical history.

Reference:

CPT Codes Reference on AAPC

Medical Billing & Coding Ebook

CPT/ HCPCS changes for 2019

ICD-10-CM, ICD-10-PCS, CPT, AND HCPCS CODE SETS, (2018)

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