The document provides an overview of medical coding topics including ICD-9-CM codes, CPT/HCPCS codes, global surgery periods, modifiers, and common terms. Key areas covered are diagnosis and procedure coding systems, bundled vs unbundled services, modifiers to identify services or avoid bundled edits, and global periods for major and minor surgeries.

2. INTRODUCTION Medical coding consists of a system designed to uniformly represent and report medical services CPT ( Current Procedural Terminology ) Level I HCPCS ( Healthcare Common Procedure Coding System ) code or an alphanumeric Level II HCPCS code . The process of assigning a CPT code to a procedure or service is dependent on both the supporting documentation and the procedure recorded. Assignment of an ICD-9-CM ( International Classification of Diseases, Ninth Revision, Clinical Modification ) diagnosis code, which must also be well-documented in the medical record, is required to support medical necessity.

3. Some Common Terms to be Understood: Medical Necessity refers to services rendered to a patient to affect a cure or change in the condition for which the patient is being seen. The medical record should have supporting documentation that the services ordered, rendered, and/or billed were necessary based on current standards of medical care. Medical Record outlines the patient’s care and treatment rendered. All services provided to a patient must be documented in the medical record. NCCI (National Correct Coding Initiative) is a database developed by CMS of CPT coding relationships that identifies CPT services considered inherently included (bundled) in other services. The database also identifies fragmentation or unbundling of services that could be captured with a single CPT code. When once procedure is included in another procedure, it should not be billed separately. Covered Services are those services that are payable in accordance with the terms of the benefit plan contract by the payer.

5. Types of ICD-9 codes: Numeric Codes: The selection of codes 001.0 through 999.9 is frequently used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries. Alpha-numeric Codes: V-codes are used to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of factors Influencing Health Status and Contact with Health Services (V01.0 – V83.89) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problems. E-codes , from the subsection Supplementary Classification of External Causes of Injury and Poisoning (E800 – E999) are used to code how an injury occurred.