Friday, 9 August 2013

Health care Coding system

There are different coding system used in Healthcare industry. Let us see one by one now. Let us again recall our first definition as follows

"Medical Billing is a Process of Submission of Bills/Claims to the Insurance Company in a specified format for the service rendered (for the treatment given) by the doctor for the patient."

Pay more attention to the word "treatment given by the doctor to the patient". How that information passed to the insurance company ? in plain text via email ? in audio file ? ???

The information passed by means of coding system called Current Procedural Terminology (CPT), simply by numbers, so that other end (insurance company) easily understand what the doctor did for the patient.

Say for example, For example, if you cut your finger and the doctor repairs the cut(treatment) , there is a procedure code(CPT) to put on the bill/claim to collect the payment from the insurance company. So what is that number ? The number is 12001. Search in the Google with "CPT Code 12001" for more stories/articles/information on that :).

Ok, Next who is defining all these numbers ? Well procedure codes owned, copyrighted and developed by the American Medical Association
(  Next question ? AMA also define the price (reimbursement amount) for each procedure ? Yes. But that
is a another big story in healthcare about price(charges) for each procedure code. We will see later about that.

Basically there are three types of CPT which as classified as Category 1 , Category II and category III.
Category I codes include surgery, Anaesthesiology, Vaccines, etc.
Category II is used for performance measurement. Say for an example, if you are smoker, and if the doctor gives counselling to stop smoking,then that is also treated as treatment and identify by the procedure number 0002F .
Category III codes represent temporary codes for new diseases.


HCPCS (HCFA Common Procedural Coding System) is a series of codes developed by the federal government and specifically the Center for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Finance Administration (HCFA)). CMS uses these codes primarily for Medicare and Medicaid to describe procedures or items not listed in the CPT manual

What is the difference between CPT codes and HCPCS?'
CPT codes are owned and copyrighted by the American Medical Association. They describe common procedures used in the course of health care delivery and are oriented to physician use in one way or another. HCPCS are codes generated by the federal government to describe procedures that have special significance to either the Medicaid or Medicare programs.

International classification of diseases (ICD)

ICD is developed and copyrighted by the World Health Organization. ICD is a set of 3, or 5 digit codes that convert a disease, an injury
or a history of a medical condition to a number or numbers. For example, Chicken Pox or Varicella has an ICD-9 code of 052.9. We use numbers so computers can recognize them quickly because insurance companies process millions of claims daily. The 9 means the 9th revision being used. Soon ICD-9 will be eliminated due to being out-dated and because there are so many current codes that there will no longer be any room for new codes. ICD-9 will be replaced by ICD-10. Every year, in October, the codes are released and are effective. There are new codes, codes with different descriptions, and codes that are eliminated. Why do we have new codes? New diseases and injuries are identified every day.

Most commonly used ICD Codes

ICD Code



Abdominal Pain


Stomach Disorder – Acid Reflux


















Common Cold


Chest Pain


Neck Pain






Weight Loss


Cluster headache syndrome, unspecified


Tension-type headache, unspecified


Sleep Disturbance


Liver disease - chronic, unspecified


Asthma, unspecified

Relationship between an ICD and a CPT code

CPT codes describe what you do, and ICD codes describe why you do it.

The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure. Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. For example, a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD-9 826.0, closed fracture of a phalanges of the foot. Such a claim would be quickly identified and rejected.

Each service you provide becomes a line item (a CPT code) on an insurance claim form. Although your level of reimbursement is linked to a claim's CPT codes, you need to record a symptom, diagnosis or complaint (an ICD-9 code) to establish the “medical necessity” of each service. Showing medical necessity basically means that you justify your treatment choice (CPT code) by linking it to an appropriate diagnosis, symptom or complaint (ICD-9 code). Up to four ICD-9 codes can be linked to each CPT code on a HCFA-1500 form.

For example, a patient in the office for routine diabetes monitoring also complains of chest pain suggesting angina pectoris. As part of the work-up that day, you perform an ECG in your office. On your claim form, however, you list only the ICD-9 code for diabetes. In all likelihood, the insurer won't pay for the ECG because it's not clear from the claim form why the test was medically necessary. The ICD-9 code for chest pain or angina pectoris should also have been listed to indicate the medical necessity for the ECG Link the diagnosis code (ICD-9) to the service code (CPT) on the insurance claim form to identify why the service was rendered, thereby establishing medical necessity.

Here is an another example
if you cut your finger and the doctor repairs the cut, there is a procedure code to put on the claim form. The code is recognized by coders, and insurance company claims software. Let’s look at the cut on the finger. To convert the repair to a CPT code, you need to know the length of the wound, in centimetres so you can select the correct CPT code. For the purpose of this example. You have a 1cm simple cut on your index finger. The repair of this cut would be 12001. Every procedure performed MUST be supported by a correct diagnosis code or ICD-9 code. The diagnosis or ICD-9 code for an unspecified wound of the finger would be 883.0. Now, if you saw ICD-9 code 042 used with CPT code 12001, you would be confused. That would be like saying the doctor sutured the patient’s finger cut because the patient had AIDS. Therefore it doesn’t make sense to suture a wound if there is no open wound diagnosis.




  1. Well this a great website i like it very much. Thanks a lot.

    Need help in billing? Please visit:
    Medisoft Software

  2. So these coding systems actually determines the amount that should be
    paid in order to provide health insurance cover.Thanks for sharing

    William Martin

    PPI Claims Made Simple

  3. I got excellent information from here. thanks

  4. Excellent website. Lots of useful information here, thanks in your effort! . For more information please visit
    Emergency Department training in Hyderabad

  5. Very informative and well written post! Quite interesting and nice topic chosen for the post Nice Post keep it up.
    Best Pharmacovigilance Training in Hyderabad


Passing Parameter between two files using MVVM

This examples shows how to pass parameter between two zul screens. In this example, we are passing some parameters from the parent vm to...