1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Medical Coding Transforms services/procedures/supplies/drugs into __________ codes Transforms diagnosis and procedures into ________ codes CPT/HCPCS diagnosis

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Levels of Service Codes Level I CPT—(Category 1: 99201-99607, Category III: 0019T-0339T) Level II HCPCS, National Codes—(A0021- V5364) Level III Local Codes—phased out due to HIPAA

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diagnosis Codes ICD-10-CM/ICD-9-CM International Classification of Diseases, 10th revision, Clinical Modification International Classification of Diseases, 9th revision, Clinical Modification

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Why Codes? Computers understand _______ Specific descriptions attached to each code numbers

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CPT Developed by the AMA in ____ Updated in ________ for use January 1 Divided into Category I, II, and III codes 1966 November

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Examples of Types of CPT Codes Medical Surgical Diagnostic services Anesthesia, etc. Category II and Category III codes—alpha numeric –Category II = __________ measuring –Category III = emerging _________ performance technology

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CPT Codes Allow For Communication that is both _______ and ______ A mechanism to report a service not described by a specific CPT or Level II code effective efficient

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Consider Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) OR 50575

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Codes Are Used to tell third-party payers about _______/procedures provided Often used as basis of _______ services payment

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Incorrect Coding Results in providers being paid ____________ –Either over or underpayment –Decreases cash flow –Liability risk inappropriately

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Codes Are Used By Clinics Hospitals Rehabilitation units Ambulance services Long-term care Wherever _________ services are provided health care

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Outpatient Services for Physicians Reported electronically in billing systems _________ = universal paper form CMS-1500

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. (Courtesy U.S. Department on Health and Human Services, Centers for Medicare and Medicaid Services.) CMS-1500

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CPT Format Symbols in CPT Used to convey _________ _______, moderate (conscious) sedation included (full list in Appendix G, CPT) –Example 45391, Colonoscopy with endoscopic ultrasound examination ___________, pending FDA approval (Appendix K, CPT) –Example 90650, Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use information Bullseye Lightning bolt

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pound Symbol (#) = resequenced code Bullet = ____ Code Figure: 13.2 New Figure: 13.9

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. ▲Triangle = _______ Code Figure: 13.3 Revised

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. ►◄ Right and Left ________ = Beginning and Ending of Text Change Figure: 13.4 Triangles

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. _____ = Add-On Code Figure: 13.7 + Plus

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Add-On Code (…Cont’d) Can only be used with another specific code Never used _____ No reduction for multiple services Full list in Appendix _ of CPT alone D

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. =Circle With Line, -51 Cannot Be Used With these Codes CPT Appendix E contains a listing of -51 exempt codes Services typically exempt from multiple procedure reductions Figure: 13.8

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc.  Circle = Recycled or Reinstated Code Circle symbol identifies codes previously published in CPT

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Appendices of CPT Appendix A: _______ Appendix B: Additions, ________, Revisions Appendix C: Clinical Examples, ___ Codes Appendix D: _______ Codes Appendix E: ___ Exempt Codes Appendix F: ___ Exempt Codes Appendix G: Include Moderate ( _________ ) Sedation Modifiers Deletions E/M Add-On -51 -63 Conscious (Cont’d…)

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. (…Cont’d) Appendix H: Performance Measures, Category __ Codes, on website Appendix I: Genetic Testing ________ (Deleted for 2013) Appendix J: Electrodiagnostic Medicine Listing of _______, _____, and Mixed Nerves Appendix K: Product Pending ____ Approval Appendix L: _______ Families Appendix M: ______ CPT Codes Appendix N:Resequenced CPT Codes Appendix O:Multianalyte Assays with Algorithmic Analyses II Modifiers Sensory Motor FDA Vascular Deleted Appendices of CPT

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. ___ CPT Sections (like chapters) 1.Evaluation & Management (E/M) 2.Anesthesia 3.Surgery 4.Radiology 5.Pathology & Laboratory 6.Medicine Category II Codes Category III Codes Appendices A-M Index Six

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Categorized By Sections Subsections Subheadings Categories (Cont’d…)

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Categorized By (…Cont’d) ________ –Knee or Shoulder _________ –Incision or Excision _________ –Fracture or Dislocation __________ –Cast or Strap ________________ –Anterior Cranial Fossa or Middle Cranial Fossa Anatomy Procedure Condition Description Surgical Approach (Cont’d…)

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Categorized By, Example Figure: 13.6 (…Cont’d)

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Guidelines Section-specific information begins each section Figure: 13.11

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Notes Must-reading located throughout the CPT Figure: 13.12

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Two Types of Codes Stand-alone: ___ description Indented: Dependent on ________ __________ –Verbiage before the semicolon applies to all indented codes that follow Full preceding stand-alone

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Types of Codes, Example Figure: 13.14

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Semicolon Indicates full description in _____________ You must return to the stand-alone for full description preceding code

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Modifiers Add Information CPT Modifier Two digits –62 Two surgeons performed a surgical procedure –Each surgeon applies his/her individual skill –Each surgeon bills the procedure with modifier -62

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Level II HCPCS Modifiers “-AS” Physician’s Assistant “-F1” Left hand, second digit __ modifiers used on CPT or HCPCS All

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Example of Modifier 43820 Gastrojejunostomy -62 two surgeons -43820-62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Modifier on the CMS-1500 Health Insurance Claim Form (Courtesy U. S. Department of Health and Human Services, Centers for Medicare and Medicaid Services)

38. Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Unlisted Services Codes ending in ___ = “no specific Category I or III code” Used if __________________ ___________ must accompany submission “99” no more specific code Special report

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Category I Codes Category _ codes (00100–99607) –Approved by AMA and Food and Drug Administration –Proven clinical effectiveness (efficacy) I

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Category II Codes— Supplemental Tracking Codes Used for __________ measurements Codes collect data concerning quality of care and test(s) required ___________ and end in the letter “F” (1006F) Location AMA Website performance Alphanumeric

41. Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Category III Codes— New Technology Temporary codes—up to _ years Identify emerging technology, services, and procedures Located after _______ section Alphanumeric (0019T) –May or may not receive future _______ I code status 5 Medicine Category

42. Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Category III Codes Category __ codes have not been approved and have no proven clinical effectiveness Usage order –Use __________ code instead of unlisted code –Use unlisted code if no Category III code III Category III

43. Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Special or Written Report Indicates: Nature Extent Need Time Effort _________ Used Photos and medical journal articles if relevant Equipment

44. Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. The Index! Used to locate service/procedure terms and codes Speeds up code location Like a dictionary First entries and last entries

45. Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CPT Index Figure: 13.18

46. Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Presentation of Codes in Index Single code: 38115 Multiple codes: 26645, 26650 - Note ______ Range of codes: 22305-22325 - Note ______ comma hyphen

47. Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 1._______________ : repair, excision 2.___________: median nerve, elbow 3._________________ : cleft lip, clot 4.________ : toe and interphalangeal joint 5._______ : Jones procedure, Heller operation 6.__________: ECG, PEEP (Pressure Breathing, Positive) Location Methods with Examples Abbreviation Service/procedure Anatomic site Condition or disease Synonym Eponym

48. Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Always Reference index Locate code in __________ of CPT Read the entire _________ and any _____ main portion description notes

49. Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. “See” in Index Cross-reference terms –“Look here for code” Index: Stem, Brain: See Brainstem

50. Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. HCPCS Healthcare Common Procedure Coding System Developed by Centers for Medicare and Medicaid Services (____) –Formerly _____ HCPCS developed in ____ CPT did not contain all codes necessary for Medicare services reporting CMS HCFA 1983

51. Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Levels of Codes Level I: ___ Level II: HCPCS, also known as national codes Level III: Local codes ( __________ ) due to HIPAA CPT phased out

52. Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Level III, Local Codes Developed by Medicare carriers for use at local level Varied by locale Discontinued December 31, 2003 –Some codes incorporated into HCPCS Level I and II

53. Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Level II: _______ Codes Codes for wide variety of providers –Physicians –Dentists –Orthodontists –Temporary codes for Medicare National (Cont’d…)

54. Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Level II: National Codes (…Cont’d) Codes for wide variety of services –Specific drugs –______________________ (DME) –Ambulance services Durable medical equipment

55. Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. HCPCS Gains Popularity Many payers require Each year increased number of HCPCS codes –J0585—Botox, per unit

56. Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Format Begins with ____, followed by four ____ –Example: E0618, apnea monitor Each letter represents group of codes –Example: “_” codes used to report drugs and dosage letterdigits J

57. Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Temporary Codes Certain letters (_, K, _, S, H, T) indicate temporary codes –Example: K0006 heavy duty wheelchair Code books published every ______ –But codes added, deleted, and revised throughout the year –Notified through carrier bulletins GQ January

58. Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Coverage Just because item/service has HCPCS code does NOT mean service covered –Example: –V5130, _______ _________ –Not covered under Medicare From Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, editors: Cummings Otolaryngology-Head & Neck Surgery, ed 4, Philadelphia, 2005, Mosby. binaural hearing aid

59. Slide 59 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Where HCPCS Are Used _________ settings –Including outpatient departments in hospital Level I and II used to report outpatient services to certain payers Outpatient

60. Slide 60 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. HCPCS Index Directs to specific codes Do not code directly from index Reference main portion text before assigning code See Figure 13.22 in textbook (Cont’d…)

61. Slide 61 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. HCPCS Index Alphabetical order (Cont’d…) (…Cont’d) Figure: 13.22 Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders.

62. Slide 62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. HCPCS Index Main text display (…Cont’d) Figure: 13.27 Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders.

63. Slide 63 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. HCPCS Modifiers ___ and ______ modifiers used with both HCPCS and CPT codes Figure: 13.25 CPT HCPCS Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders.

64. Slide 64 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Anatomical Modifiers F1Left hand, second digit __Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit FA Left hand, thumb __Right hand, thumb F6Right hand, second digit F7Right hand, third digit __Right hand, fourth digit F9Right hand, fifth digit F2 F5 F8

65. Slide 65 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Often Used HCPCS Modifiers __ Left __ Right Example: Right kidney biopsy, 50200-RT Left kidney biopsy, 50200-LT LT RT

66. Slide 66 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Ambulance Modifiers Origin and destination used in combination: –First letter: _____ –Second letter: _________ –Example: R = Residence H = Hospital RH: origin (first letter) residence and destination (second letter) hospital Origin Destination

67. Slide 67 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Table of Drugs Listed by generic name Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders. Figure: 13.26

68. Slide 68 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Durable Medical Equipment DME Used with chronic disabling condition Medicare and Medicaid pay for some DME items Physician must attest to need using _________________ Necessity Certificate of Medical

69. Slide 69 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Home Oxygen Therapy Medicare may also pay for oxygen with certain medical conditions Physician must complete form (CMS-___) attesting to medical necessity 484

70. Slide 70 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)