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A Decade in Coding

What’s Changed and What’s Ahead?

By Jeri Leong, RN, CPC, CPC-H, CPC-I
The 21st century began with a sigh of relief when the feared Y2K computer bug failed to materialize. From there, it was a decade of highs and lows, with news stories that shocked and awed us, leaving unforgettable marks on history. From natural disasters and terrorist attacks, to the swearing in of the first African American U.S. president, it was a decade to remember.
In 1999, anticipating potential systematic problems because of Y2K, the Health Care Financing Administration (HCFA) announced it would not implement any ICD-9 code changes for fiscal year 2000. By not undertaking system changes to capture the usual ICD-9-CM additions, deletions, and modifications, HCFA felt this would better ensure all computer systems were ready to function properly on Jan. 1, 2000. All’s well that ended well.
Early in the decade, the coding community waited patiently for ICD-10 to replace ICD-9. Now, 10 years later, we are finally moving towards implementation. The number of CPT® codes, ICD-9-CM codes, and HCPCS Level II codes have grown tremendously during the past decade, and continue to evolve into sophisticated classification systems. Medical records have become more automated—first, with word processing or pre-formatted templates; then, paper records being replaced by electronic health records (EHRs). Coders who once plodded through huge paper medical records learned to point and click and to use coding search engines.

Flashback—The New Millennium

In 2000, coders were still using “starred” (*) procedures, which were found throughout the surgical section of CPT®. An asterisk (*) preceding the procedure number indicated a relatively minor service with variable pre- and post-operative periods. The service included only the listed surgical procedure, and the asterisk indicated that modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service was to be appended to an office visit when it was provided at the same session. Starred procedures eventually were deleted in CPT® 2004, and we’ve struggled with appropriate use of modifier 25 ever since.
There were more than 400 code changes in CPT® 2001, with 204 new codes, 172 revised codes and 32 deleted codes. Two new modifiers were created; modifier 60 Altered surgical field, and modifier 27 Multiple outpatient hospital E/M services provided on the same date. Modifier 60 might just hold the record for the shortest-lived modifier. It was deleted in 2002.
In the January/February 2000 issue of Coding Edge, Terrell Curtis, then executive administrator of the AAPC, reflected on goals for the new decade ahead. She wrote that AAPC was at 14,000 members.
“It has been rewarding to watch the medical coding profession evolve and become recognized as the primary component in medical reimbursement,” Curtis continued. “But as with any metamorphosis, it is an ongoing process and AAPC continues to strive to bring recognition to medical coders.” Now, 10 years later, our coding profession continues to provide employment equity, salary advantages and the respect of colleagues in the health care field.
In other news of the decade’s first years, on July 1, 2001, U.S. Department of Health and Human Services (HHS) Secretary Tommy Thompson changed the name of HCFA to the Centers for Medicare & Medicaid Services (CMS). I still catch myself saying “HCFA” every now and then.

E/M Guidelines—’95, ’97, ’00, ’02?

In the year 2000 and again in 2002, medical associations continued to lobby HCFA actively to minimize the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services requirements. HCFA believed the 1997 guidelines and a set of American Medical Association (AMA) proposed changes (1999) were too complex and ambiguous, so they created another new draft based on the original 1995 guidelines. In the new draft, the patient history portion did not change substantially from previous versions. Proposed documentation requirements would continue to focus on the chief complaint, history of present illness (HPI), review of systems (ROS), and past, family and social history (PFSH). A significant change to the proposed guidelines was found in the physical examination section. The physical exam was to have been simplified from four levels of service (problem focused, expanded problem focused, detailed, and comprehensive) to three (brief, detailed, comprehensive). This draft ended up in the E/M guidelines graveyard. In 2002, the secretary of HHS Advisory Committee on Regulatory Reform recommended eliminating the documentation guidelines entirely. For the interim, physicians were advised to continue using either the 1995 or 1997 versions—as we continue to do today.

Evolution of Code Sets

Prior to Dec. 31, 2003, HCPCS Level III were used by Medicaid state agencies, Medicare contractors, and private insurers in unique programs. For purposes of Medicare, Level III codes also were referred to as locally assigned codes. These local codes were established when a third-party payer preferred that providers use a unique code to identify a service, for which there was no HCPCS Level I or Level II code. Typically, these codes were alpha numeric, starting with the letters X, Y, or Z. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required CMS to adopt standards for coding systems that were used for reporting health care transactions. HIPAA provided for the eradication of the non-standard Level III codes by October 2002. The elimination date was postponed, but they eventually were deleted on Dec. 31, 2003.
A new section of codes, CPT® Category III codes, initially were released during the mid-year update on July 1, 2001. They appeared in the CPT® 2002 manual. Category III “emerging technology” codes were introduced by the AMA as a way to collect data on new procedures. Medicare and some commercial payers recognize these codes for reimbursement purposes.
CPT® added Category II codes in 2004 to  help physicians track performance measures through their practice management systems. These codes were intended to facilitate data collection about quality of care, as well as decrease the need for record abstraction and chart reviews to collect quality measure data. Today, Category II codes represent the fastest growing section of CPT®.


To improve the efficiency and effectiveness of the U.S. health care delivery system, HIPAA included provisions for administrative simplification requiring HHS to adopt national standards for electronic health care transactions. At the same time, Congress recognized that the changes in electronic technology could affect the privacy of patients’ health information. As a result, Congress incorporated provisions that mandated the adoption of federal privacy protections. HHS published a final regulation in the form of the Privacy Rule in December 2000, which became effective on April 14, 2001. By the compliance date of April 14, 2003, covered entities were required to implement standards to protect patient’s health information. Medical offices were scrambling to implement HIPAA training for doctors, nurses, coders, and clerical staff, and soon “HIPAA” was our mantra.

Events Shaping the Coding World

In the November 2009 Coding Edge, Sheri Poe Bernard, CPC, CPC-H, CPC-P, CPC-I, wrote in the article “2010 ICD-9-CM Changes Provide a Glimpse of History” of new ICD-9-CM codes for 2010, and also of historical events that precipitated additions over the past decade. Terrorism E codes were added in October 2002 as a way to describe injuries resulting from acts of terrorism, such as the attacks of 9/11. Just last year, a code was added to describe a new strain of H1N1 virus, commonly called “swine flu.” As a result of war activity in Afghanistan, Iraq, and other campaigns, ICD-9-CM codes have been added to report effects of traumatic brain injury (TBI), as well as supplemental V codes for TBI screening and E codes to describe the mechanism of injuries resulting from war and other events.

Back to the Future

The decade ahead will be as exciting as it is challenging. Clearly, coding expertise will continue to be invaluable as health care organizations are forced to produce accurately coded data to meet compliance and reimbursement requirements.
Now is the time to strengthen your knowledge of anatomy and physiology, pathology, and medical terminology to prepare for ICD-10-CM. The AAPC Personal Progress Tracker gives members the ability to easily enter their personal ICD-10 progress with red/yellow/green lights that indicate whether you are on schedule for implementation.
The role of the Certified Professional Coder (CPC®) will evolve further as market and compliance demands unfold. Coding professionals at the top of their game will see health care reform and other future changes as an opportunity to fine tune skills and expand horizons. One such opportunity could be that of the medical records or compliance auditor. It’s time to look ahead and polish skills such as regulatory guideline knowledge, statistical sampling methodologies record abstraction, and reporting skills.

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