Decoding healthcare codes: ICD-10, DRG, CPT, HCPCS

Decoding Health Care Codes:
ICD-10, DRG, CPT, HCPCS
Chicago Technology for Value-based Healthcare

Scope of this presentation
What’s included:
For each code, this presentation will answer:
● Who created it
● Who maintains it
● Where is it found
● What does it look like
Please speak up if you have questions
or experience with coding you can
share
What’s not included but worth noting
important:
● Limitations within the codes
● In depth information about how codes relate,
translate, encode and decode meaning
● How coding impact payer and provider
financing
Where does information from this presentation
come from?
● Wikipedia
● CMS
● AMA

Why do we code?
● There is a massive amount of
data created for each episode of
care:
● Very specific information
○ Example DRG code:
Intracranial hemorrhage or
cerebral infarction with CC
or tPA in 24 hours
● Uniform documentation between
medical facilities
○ Interoperability
● To get paid properly
○ UB-40 form
Image Source: http://www.outsourcestrategies.com/medical-billing-outsourc ing.htm

Decoding
Health Care
Codes
International Statistical Classification
of Diseases and Related Health
Problems (ICD-10)
Diagnostic Related Groups (DRG)
Current Procedural Terminology (CPT)
Healthcare Common Procedure
Coding System (HCPCS)

International Statistical Classification of
Diseases and Related Health Problems (ICD)
● Who created it? Who maintains it?
○ World Health Organization, countries have their
own versions. In the US, CMS has ICD-10-CM and
ICD-10-PCS. CMS contracted with 3M to develop
ICD-10-PCS
● Who uses it? What is it for?
○ UK, Sweden and Brazil all adopted ICD-10 before
2000
○ US adopted it in Oct. 2015
○ Used for classifying:
■ disease states
■ signs and symptoms
■ abnormalities
■ procedures Image source:
https://www.aapc.com/medical-coding-books/2016/2016-icd-10-pcs-book.aspx

International Statistical Classification of
Diseases and Related Health Problems (ICD)
● Where is it found?
○ EMR systems, billing
■ Codes for reasons for
visits in all American
health care settings
● What do ICD10 codes look like?
○ 7 digit, mix of letters and
numbers
○ The position of the digit has
significance (e.g. Indicate a
part of the body)
○ Don’t always expect a
decimal point
Image Source: http://www.mtuitive.com/synoptic-reporting-can-solve-icd-10-woes/

Technologies
● IT systems using ICD:
○ EDW and Business
intelligence
○ Clinical documentation
○ Electronic data interchange
○ Computer assisted coding
○ Revenue cycle management
● Example solutions:
○ Aqua.io: code conversion API
○ Computer assisted coding
Image source: http://hitconsultant.net/2015/02/17/computer-assisted-coding-market-expected-to-reach-3-5b-by-2019/

● What is it for?
○ statistical system of classifying
any inpatient stay into groups
for the purposes of payment
○ intended to identify the products
that a hospital provides
● Who uses it?
○ Medicare uses it for
reimbursements
○ Countries develop their own
DRG version (i.e. SwissDRG)
● Who created it?
○ Professors from Yale
Image Source: http://www.slideshare.net/stefanst/introduction-to-swissdrg-english

○ Medical billing
○ Many versions:
■ Medicare DRG (CMS-DRG &
MS-DRG)
■ Refined DRGs (R-DRG)
■ All Patient DRGs (AP-DRG)
■ Severity DRGs (S-DRG)
■ etc.
● What do the codes look like?
○ 3 numeric digits
○ High level code, MDC codes offer
more granularity
○ Examples: CMS Index
○ ICD-10 codes fall into a DRG

○ Maintained by AMA
○ Copyrighted, you need to license it from AMA
■ Pay AMA a fee
○ the code set used to bill outpatient and office
procedures
○ Similar to ICD10
○ It identifies the services rendered rather than
the diagnosis on the claim
“the use of the code is
mandated by almost all
health insurance payment
and information systems,
including the Centers for
Medicare and Medicaid
Services (CMS) and HIPAA,
and the data for the code
sets appears in the Federal
Register.”

○ Insurance claims
● What do ICD10 codes look like?
○ Category 1: Numeric, 5-digits
○ Category 2: Alphanumeric, 4-digits,
5th is a character (i.e. F)
■ clinical components usually
included in evaluation and
management or clinical services
and are not associated with any
relative value
○ Category 3: Alphanumeric, 4-digits,
5th is a character (i.e. T)
■ Emerging technology
Image source: https://www.mtnmedical.com/physician/cpt-codes-mri.php

Healthcare Common Procedure Coding System (HCPCS)
○ Developed by the CMS
○ Maintained by the AMA
○ Covers services, procedures, and equipment not covered by CPT codes
■ durable medical equipment
■ prosthetics
■ ambulance rides
■ certain drugs and medicines
○ Superset of CPT codes

Healthcare Common Procedure Coding System (HCPCS)
○ official code set for
outpatient hospital
care, chemotherapy
drugs, Medicaid, and
Medicare, among other
services
○ HIPAA mandated
● What do HCPCS codes look
like?
○ Level 1: CPT codes
○ Level 2: 5-digits,
alphanumeric
Image Source: http://heartlandtrc.org/2013-telehealth-codes/

Questions?
Thanks for joining us tonight!
Chicago Technology for Value-based Healthcare

Decoding healthcare codes: ICD-10, DRG, CPT, HCPCS

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Decoding healthcare codes: ICD-10, DRG, CPT, HCPCS