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The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
HCPCS includes three levels of codes: Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric.; Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I).
Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.
The services are classified under a nomenclature based on the Current Procedural Terminology (CPT) to which the American Medical Association holds intellectual property rights. [2] Each service in the fee schedule is scored under the resource-based relative value scale (RBRVS) to determine a payment.
These guidelines indicate that a coder must seek further detail within a record in order to correctly assign the correct diagnoses code. An inexperienced coder may simply just use the description from the discharge summary such as Infarction and may not use the correct detail which could be further found within the details of the medical record ...
A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system.
Description: Value: Average length of stay 3.8 [17] Large urban labor-related rate $2,809.18 Large urban non-labor-related $1,141.85 Wage index 1.4193 Standard Federal Rate: labor * wage index + non-labor rate $5,128.92 DRG relative weight (RW) factor 1.8128 Weighted payment: Standard Federal Rate * DRG RW $9,297.71 Disproportionate Share ...
They represent items, supplies and non-physician services not covered by CPT-4 codes (Level I). Level II codes are composed of a single letter in the range A to V, followed by 4 digits. Level II codes are maintained by the US Centers for Medicare and Medicaid Services (CMS).