Surgery, Radiology, Pathology/Laboratory, and Medicine

Surgery, Radiology, Pathology/Laboratory, and Medicine
Chapter 6 CODING PROCEDURES Part II: Surgery, Radiology, Pathology/Laboratory, and Medicine Chapter 6

PROCEDURAL CODING PART II
Learning Objectives Define procedure code terminology. Explain the purpose of coding for professional services. List all subsections of Surgery section. Compare comprehensive codes and component codes. Chapter 6

Learning Objectives Distinguish between surgical package and Medicare global package rules. Describe two ways to code for multiple procedures. Demonstrate an understanding of surgical terminology. Explain situations in which modifiers are applied to surgical codes. Chapter 6

Performance Objective Locate a code in the Surgery section by using the index. Code scenarios presented in the worktext from all of CPT. Apply CPT and HCPCS Level II modifiers when appropriate. Chapter 6

Key Terms Endoscopy Add-on code Fixation Anesthesia
Bilateral Procedure Bundled Code Closed Fracture Closed Treatment Component Code Comprehensive Code Downcoding Elective Surgery Endoscopy Fixation Fracture Manipulation Global Surgery Policy Indented Code Open Fracture Open Treatment Percutaneous Treatment Professional Component (PC) Chapter 6

Key Terms Qualitative Analysis Quantitative Analysis
Test Panel Unbundling Upcoding Qualitative Analysis Quantitative Analysis Separate Procedures Stand-alone Codes Surgical Package Technical Component (TC) Chapter 6

Coding Procedures & Services Introduction to the Surgery Section (10040-69979)
Largest Section of the CPT Codebook 16 Subsections, divided according to Body Systems Guidelines are found at the beginning of the Surgery Sections. Subsection further divided into Categories based on Anatomic Site Subcategories are within each Category which list the type of procedure or condition. Chapter 6

How to Code Effectively You must be able to analyze a procedure description and identify various terms that will direct you to the correct code. To do this you must know the main categories under which services and procedures are listed according to their main term in the index. After the procedure, service, or condition is identified in the index, search for a subterm and a sub-subterm that further defines the procedure. Chapter 6

How to Code Effectively – Cont. When a code range is found, turn to the correct section and read all descriptions listed under the code range before selecting a code. Performance Exercise Table 6-2/Page 138 Chapter 6

How to Code Effectively Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Chapter 6

Coding Procedures & Services Introduction to the Surgery Section/(10040-69979) PERFORMANCE EXERCISE
Excision of tendon, finger, flexor, single (separate procedure), each 26180 How to Code Effectively Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Chapter 6

How to Code Effectively – Cont.
Coding Procedures & Services Introduction to the Surgery Section ( ) How to Code Effectively – Cont. Stand-alone Codes – are procedure codes that have a full description. Comes before the (;) Terminology after the (;) has a Dependent Status as the Subsequent Indented Entries Performance Exercise Figure 6-3/Page 138 Chapter 6

How to Code Effectively – Cont.
Coding Procedures & Services Introduction to the Surgery Section ( ) How to Code Effectively – Cont. Indented Codes – are listed after stand-alone codes whose descriptions have a dependent status. To read the description, you must first read the description of the stand-alone code that comes before the semicolon (;) and, then continue with the indented description listed by the subsequent code (indented code). Performance Exercise Figure 6-3/Page 138 Chapter 6

Integral Code Description One Code is part of another based on language used in the description Example 6-2/Page139 Parentheses ( ) further define & tell where other services are located Figure 6-4/Page 139 Chapter 6

Coding Steps Step 1 Become familiar with CPT codes
Step 2 Find the services listed on patient encounter form Step 3 Look up codes in index, then look up actual code Step 4 Determine appropriate modifiers Step 5 Record the procedure code on the insurance claim; PROOFREAD numbers Chapter 6

Coding from the Operative Report Read the Operative report thoroughly & code on documented operations Determine Bundled or Unbundled Procedures Never Code Verbal Procedures Coding Rule: “Not Documented, Not Done”! Chapter 6

Operative Report Date of Service: 5/17/03 Surgeon: Jeffrey Thompson, MD Assistant Surgeon: None Preoperative Diagnosis: RLQ pain, probable appendicitis Postoperative Diagnosis: Acute appendicitis Procedures Performed: Exploratory laparotomy, appendectomy Anesthesia: General Endotracheal Chapter 6

Chapter 6

Decision for Surgery - Criteria to Evaluate Is patient new or established? Is the E/M service significant and separately identifiable from the procedure? What is the time lapse from the time the decision is made for surgery to the time when the procedure is performed? Performance Exercise Figure 6-4/Page 141 Chapter 6

Decision for Surgery -57 (Modifier) – An E/M service that resulted in the initial decision to perform the surgery. -25 (Modifier) - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Chapter 6

Surgical Package is a combination of services included in a single procedure code for some surgical procedures in the CPT. Governmental Programs & Insurance Companies assign fees to surgical package codes that reimburse all services provided under them. The period of time that is covered for follow-up care is referred to as the Global Period. For Example, the Global Period for repairing a Tendon might be set at 15 days. Chapter 6

Surgical Package – Cont. A Global Period for Major Surgery such as Appendectomy may be set at 100 days. After the Global Period ends additional services that are provided can be reported separately for additional payment. Chapter 6

Surgical Package – Cont. Surgical Package Includes Combination of Services Global Period Surgical Procedures Anesthesia Related E/M Encounter Postoperative Care Private Carriers May have an individual policy on what is included in the package. Chapter 6

Medicare Global Package - Included Preoperative E/M Services Intraoperative Services Postoperative Visits Complications after surgery without addition trips to the operating room Anesthesia Supplies necessary for performance of the procedure Chapter 6

Medicare Global Package - Excluded Initial Consultation or Evaluation Diagnostic Tests & Procedures Treatment required to stabilize a seriously ill patient before surgery Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed (modifier –24) Related Procedures for postoperative complications that requires a return trip to the operating room (modifier –78) Immunosuppressive Therapy after transplant surgery For services performed in a physician’s office, separate payment may be made for splints and casting supplies, and a surgical tray. Page 142 Chapter 6

Follow-Up Days Vary 0-day or 10-day for Minor Surgeries 45-day or 90-day for Major Surgeries Most States use Relative Value Studies fee schedule for Worker’s Compensation cases List the follow-up days allowed for most surgical procedures Federal Register Published annually List follow-up days for Medicare Services Chapter 6

Multiple Procedure Modifier –51 Report the primary service or procedure (identified by the highest dollar value listed) Identify all additional services or Procedures by appending code(s) with modifier –51 or use the separate five-digit modifier 09951 Appendix E – Summary of CPT Codes Exempt from Modifier 51 Page Chapter 6

Add-on Code Noted by a Cross (+) Symbol represents additional Procedure done with Primary Procedure Found in Appendix D of CPT Can not billed without the primary procedure Add-on-Code Description start with: “in addition” “list separately Or “second lesion” Performance Exercise Example 6-5/Example 6-6/Page 143 Page Chapter 6

Add-on Code – Cont. Bilateral Procedures - is one procedure performed on two sides. Two ways to Bill List the Code Once with Modifier –50 & double the fee List the Code Twice using a single fee & add the second listing with Modifier –50 Performance Exercise Example 6-7/Page 143 Page Chapter 6

Assistant At Surgery Modifiers -80 Assistant surgeon -81 Minimum Assist Surgeon -82 Assistant surgeon (when qualified resident surgeon not available) -62 Two Surgeons -66 Surgical Team The Surgeon who assist is usually paid a fee of 16 to 30 percent of the allowed fee of the primary Surgeon. Performance Exercise Example 6-8/Page 144 Page Chapter 6

Benign versus Malignant
Coding Procedures & Services Surgery: Integumentary System ( ) Integumentary System First Subsection listed in the Surgery Section Contains Procedures performed on the Skin Benign versus Malignant Neoplasm – must indicate benign or malignant Claim Form – should be delayed until the Pathology report can confirm or deny Benign vs Malignant Lesion – is any discontinuity of the skin Biopsy – performed for the purpose of determining the morphology (shape, form, & structure) is reported separately. Biopsy of a lesion followed by excision would be included in the excision procedure code, and not reported separately. Page Chapter 6

Coding Procedures & Services Surgery: Integumentary System (10000-19999)
Lesion –when coding removal of lesions note the: Anatomic Site Size, measured in centimeters Number of lesions removed Process used to remove the lesion (excision, destruction, paring, shaving) Morphology (appearance of specimen’s shape and structure used to determine benign or malignant status) Page 145 Chapter 6

Repair of Lacerations Simple Closure – Superficial; involving the epidermis, dermis, or subcutaneous tissue. Intermediate Closure – Requires layered closure of deeper subcutaneous tissue in addition to the simple closure. Complex Closure – Requires more than one layered closure; debridement, scar revision, extensive undermining, stents, or retention sutures Page 145 Chapter 6

Multiple Lesions Modifier –51 (Multiple Procedures) Read description & look for terms such as complicated, complex, more than, etc Watch for Add-on-codes (+) VS Codes eligible for Modifier –51 & indented Codes Surgical Supplies Bundled into Surgical Code (99070) or HCPCS Level II Codes Page Chapter 6

Breast Category Included within the Integumentary system because of the type of tissue involved. Each Breast Considered Separate If procedure occur on both sides use Modifier –50 (bilateral) Performance Exercise Example 6-9, 6-10 & 6-11/Page Page Chapter 6

Coding Procedures & Services Surgery: Integumentary System (10000-19999) PERFORMANCE EXERCISE
Breast reconstruction with free flap 19364 Preoperative placement of needle localization wire, breast: 19290 Chapter 6

Coding Procedures & Services Surgery: Musculoskeletal System (20000-29999)
Arranged according to Anatomic Site “General” first Category Contain Procedures & Subcategories for different Anatomic Sites. Remaining Categories Start from the “Head” to the “Toe” Subcategories Under Each Anatomic Category Include: Incision Excision Introduction/Removal Page 147 Chapter 6

Subcategories Under Each Anatomic Category Include: Fracture/Dislocation Arthrodesis Amputation Unlisted Procedures Fractures are: Open/skin broken by the fragmented bone (Compound Fracture) Closed/skin is not broken Percutaneous/neither Opened or Closed Page 147 Chapter 6

Coding Treatment of a Fracture Locate the Anatomic Site Find Subcategory “Fracture and/or Dislocation” Then find the appropriate code Description of Fractures are either: “With Manipulation” or “Without Manipulation” Page 147 Chapter 6

Other Descriptive Terms Are:
Coding Procedures & Services Surgery: Musculoskeletal System ( ) Other Descriptive Terms Are: “Internal Fixation” “External Fixation” Page 147 Chapter 6

Fracture Manipulation is: The manual stretching or applying pressure or traction to realign the broken (fractured) bone. Referred to as “reduction”. Fixation – is the use of hardware (instrumentation) to keep a bone in place. It can be applied internally (e.g., plates, rod, pin) or Externally (e.g., pins that comes thru the skin to the outside to keep the fractured bone from moving). Page 147 Chapter 6

Fracture Follow-up Period:  The surgical package rule applies.  All fracture code carry a 90-day follow-up period. Page 147 Performance Exercise Example 6-12/Page 147 Example 6-13/Page 147 Chapter 6

Coding Procedures & Services Surgery: Musculoskeletal System (20000-29999) PERFORMANCE EXERCISE
Closed treatment of mandibular fracture; without manipulation 21450 Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone. 26607 Chapter 6

Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Respiratory System Organized by Anatomic Site Then by Type of Procedure Includes procedures of the nose, sinuses, larynx (voice box), trachea (windpipe), bronchial tubes, lungs, and pleura (membrane that surrounds the lung) Page 148 Chapter 6

Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Endoscopy – is the insertion of a flexible fiber-optic tube, called scope, through a small incision into a body cavity or into a natural body opening, such as the ears, nose, mouth, vagina, etc. Diagnostic Endoscopy – is done for the purpose of visualization and determination of the disease process. Diagnostic Endoscopy is always included in a surgical endoscopy and may not be billed separately Page 148 Chapter 6

Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Endoscopy Procedures Diagnostic Endoscopy Surgical Endoscopy Endoscopies Named for body area being explored e.g., brochial tube/bronchoscopy Page 148 Performance Exercise Example 6-14/Page 149 Chapter 6

Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) PERFORMANCE EXERCISE Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 31231 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) 31622 Chapter 6

Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Cardiovascular System Organized by Anatomic Site Then by Type of Procedure Procedures Include: Heart & Blood Vessels, including Pacemaker Implantation and Coronary Artery Bypass Graft (CABG) For Additional Studies Refer to: Medicine Sections Under: Cardiovascular/Therapeutic Services for: Cardiography, Echocardiography, Cardiac Catheterization & Other Vascular Studies Page 149 Chapter 6

Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) PERFORMANCE EXERCISE Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract 33414 Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography 92975 Chapter 6

Coding Procedures & Services Surgery: Digestive System (40000-49999)
Organized by Anatomic Site Start with Lip & Mouth Then continues thru the Rectum and Anus Major Organs of the digestive system include: Stomach Intestines/small/large Liver, Pancreas & Gallbladder Page 149 Chapter 6

Coding Procedures & Services Surgery: Digestive System (40000-49999)
Endoscopic Procedures used through-out subsection (i.e. Laparoscopy Incision) Endoscopic procedures are coded according to the anatomic site examined Notes defining proctosigmoidoscopy, sigmoidoscopy & colonoscopy are included under Rectum: Endoscopy Page 149 Chapter 6

Repair of palate; up to 2 cm
Coding Procedures & Services Surgery: Digestive System ( ) PERFORMANCE EXERCISE Repair of palate; up to 2 cm 42180 Laparoscopy, surgical, appendectomy 44970 Chapter 6

Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems (50000-58999)
Urinary System Organized by Anatomic Site & Type of Procedure Include organs such as Kidney, Ureter & Bladder Endoscopies include: Renal Endoscopy, Ureteral endoscopy, Cystoscopy, Urethroscopy & Cystourethroscopy Urodynamics Separate subcategory found under Bladder Urodynamics procedure measure how well the bladder stores and holds urine as well as the rate at which urine moves out of the bladder Page 149 Chapter 6

Male Genital System Lesions
Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( ) Male Genital System Divided by Anatomic Categories of Penis, Testis, Spermatic Cord, Prostate, etc Lesions May have specific code assigned Page 150 Chapter 6

Interset Surgery Consist of only 2 Codes
Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( ) Male Genital System – Cont. Interset Surgery Is a Subsection following “Male Genital System” Consist of only 2 Codes 55970 – Intersex survey; male to female 55980 – Female to male Page 150 Performance Exercise Example 6-15/Page 150 Chapter 6

Female Genital System/Maternity Care & Delivery
Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( ) Female Genital System/Maternity Care & Delivery Organized by Anatomic Site Subsection starts with the external genitalia Then progress upward thru the female genital system to the uterus, fallopian & uterine tubes & conclude with the ovary The last category is In Vitro- Fertilization Page 150 Chapter 6

Incision & Drainage (I&D)
Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( ) Incision & Drainage (I&D) Codes in the subsection with notes directing you to the Integumentary System for specific I&D procedures Read Code Description to determine surgical approach is Vaginal or abdominal Many codes include bilateral descriptions as well as a variety of procedures bundled together and routinely performed at same time of the operative session. Performance Exercise Figure 6-17/Page 150 Table 6-3/Page 151 Page 150 Chapter 6

Maternity Care & Delivery
Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( ) Maternity Care & Delivery Subsection following the Female Genital System Includes: Antepartum, Vaginal Delivery & Cesarean Delivery Delivery After Previous Cesarean Delivery Category following Cesarean Delivery Referred to as VBAC, or vaginal birth after cesarean Abortion Last Category within the subsection Performance Exercise Example 6-17/Page 150 & Table 6-3/Page 151 Page 150 Chapter 6

Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems/ ( ) PERFORMANCE EXERCISE Biopsy, prostate; needle or punch, single or multiple, any approach 55700 Biopsy of ovary, unilateral or bilateral (separate procedure) 58900 Aspiration of bladder by needle 51000 Chapter 6

Nervous System Procedures
Coding Procedures & Services Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( ) Nervous System Code in subsections deals with both Central & Peripheral Nervous System Procedures Brain, spinal cord, & all types of nerves Organized by Anatomic site & then Procedure Page 150 Chapter 6

Eye & Ocular Adnexa/Auditory System
Coding Procedures & Services Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( ) Eye & Ocular Adnexa/Auditory System Includes Surgical Codes of the Eye & related visual structures. Modifier –50 (bilateral procedure) appended all procedures when done on both eyes. Extensive Notes such as “previous eye surgery” are found through-out this subsection Auditory System/Subsection Divided into categories of External Ear, Middle Ear, Inner Ear & Temporal Bone Middle Fossa Approach Page 151 Chapter 6

Coding Procedures & Services Surgery: Operating Microscope (69990)
Last subsection of the Surgical section Has only one code ( for use of a operating microscope when the surgical code does not contain the microscope as an inclusive component) Code used in all Surgery Subsections where Microscope needs to be coded (i.e breast reconstruction) Chapter 6

Coding Procedures & Services Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( ) PERFORMANCE EXERCISE Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device 61107 Biopsy of Cornea 65410 Chapter 6

Coding Procedures & Services Radiology Section (70000-79999)
Include Nuclear Medicine & Diagnostic Ultrasound Subsections/References are: Diagnostic Radiology/X-ray index Diagnostic Ultrasound/Ultrasound index Radiation Oncology/Radiation Therapy index Nuclear Medicine/Nuclear Medicine index Page 152 Chapter 6

Professional & Technical Components Professional Components Tests/Procedures performs by Physician such as interpreting an Electrocardiogram (ECG), reading an X-ray, or making an observation and determination using a microscope. Technical Component The use of equipment and its operators that perform the test or procedure, that is, the ECG machine and technician, radiography machine and technician and microscope technician. When the physician performs both the professional & technical component there is know need to modify the Code. Page 152 Chapter 6

Professional & Technical Components – cont. Modify Procedures Modifier -26/professional element used when the physician performs only the professional component Modifier –TC/technical element used only when billing for technical component Performance Exercise Example 6-18/Page 152 Page 152 Chapter 6

Professional & Technical Components Cont. Combination Coding - Is a code from one section of the procedural code book combined with a code from another section that is used to completely describe a procedure performed. Services that maybe combined are: Injection of contrast materials Placement of catheters Placement of guidewires Placement of stents Page 152 Chapter 6

Radiology Procedure When a radiology procedure is performed from the required combined services: A Code from the Radiology Section describes the Procedure A Code from the Surgery Section describe the Combination Procedure Performance Exercise Example 6-19/Page 153 Page 152 Chapter 6

Radiologic examination; forearm, two views
Coding Procedures & Services Radiology Section ( ) PERFORMANCE EXERCISE Radiologic examination; forearm, two views 73090 Ultrasound, transvaginal 76830 Injection procedure for knee arthrography Surgery & Radiology 73580 Chapter 6

Coding Procedures & Services Pathology & Laboratory (80000-89999)
Codes listed according to type of Test performed (i.e., Hematology Tests, Urinalysis, etc.) Test Panels Listed under first subsection “Organ or Disease Oriented Panels” Single Code that groups Lab Tests which are frequently done together. To use a Panel Code, all test listed within the panel must be performed Page 153 Chapter 6

Qualitative/Quantitative Analysis Qualitative Analysis test may determines the presence of an agent within the body Quantitative Analysis measures how much of the agent is within the body Page 153 Chapter 6

Surgical Pathology Arranged according to Levels/In Alphabetical Order Level I/Gross Exam only (which means the way the specimen looks to the naked eye before it is prepared for microscopic study.) Level II/Gross & Microscopic Exam (it identification of tissue in the absence of disease) Level III through Level VI/Gross & Microscopic Exam (Exam of diseased tissue and each level requires additional work of the pathologist. Page 153 Chapter 6

Coding Procedures & Services Pathology & Laboratory (80000-89999) PERFORMANCE EXERCISE
Acute hepatitis panel 80074 Insulin antibodies 86337 Chapter 6

Coding Procedures & Services Medicine Section (90000-99199)
List of codes used by Physician of different Specialties in conjunction with codes from different sections of the CPT Diagnostic & Therapeutic Services that are not surgically invasive are listed in this section, including many specialized testing Notes in this section should be carefully read before coding a subsection, category or subcategory Documentation may be included with the claim form to justify the use of the code Page 153 Chapter 6

Drugs & Injections Five Codes (90782, 90783, 90784, & 90799) in the subsection: “Therapeutic, Prophylactic or Diagnostic Injections”, which: Represents all subcutaneous, intramuscular, intra-arterial, and intravenous injections Insurance may require additional information on the substance being injected and communicated by: Listing the name, amount, & strength of the medication A NDC (national drug code) may be used to specify the drug, dosage, and the manufacturer HCPCS Level II Code may be used to specify the injected drug Page 154 Chapter 6

Special Services, Procedures, and Reports Additional codes are found under the category “Miscellaneous Services” Codes provide physician with means of identifying Special Services & Reports that are an addition to basic services provided Two commonly used codes are: 99000 – Handling and/or conveyance of specimen 99070 – Supplies and materials (except spectacles) Page 154 Chapter 6

Measles and rubella virus vaccine, live for subcutaneous use
Coding Procedures & Services Medicine Section ( ) PERFORMANCE EXERCISE Lyme disease vaccine, adult dosage, for intramuscular use 90665 Measles and rubella virus vaccine, live for subcutaneous use 90708 Chapter 6

Coding Procedures & Services Coding Terminology
Bundled Code Single Procedure Code used to report group of related procedures Unbundling The practice of using numerous CPT Codes to identify procedures normally covered by a single code Also known as: Itemizing, Exploding, Charges, Fragmented Billing or Surgery, or A La Carte Medicine Considered “Fraud” if done intentionally for increased reimbursement (Can result in Claim Audit) Page Chapter 6

Unbundling Examples are: Fragmenting one service into component parts and coding each component as if it were a separate service Example 6-20/156 Reporting separate codes for related services when one Comprehensive Codes includes all related services Example 6-21/156 Coding Bilateral Procedures as two codes when one code is inclusive Example 6-22/156 Page Chapter 6

Unbundling Examples Cont. Separating a Surgical Approach from a major surgical service that includes the same approach Example 6-23/156 Downcoding occurs when: The Physician Coding System does not match the Coding System of the Insurance Company receiving the Claim Example 6-24/156 Chapter 6

Upcoding Deliberate manipulation of CPT Codes for increased payment Upcoding can be spotted in Insurance Carrier’s software screens, such as the prepayment, postpayment or stop alert screens Page 157 Chapter 6

Code Edits (Software) Correct Coding Initiative (CCI) – was implemented by Medicare on 01/01/96 Contain a code edit system consistent with Medicare policies Its function is to eliminate improper reporting of CPT Codes. When online edit is performed, the computer software program checks: Codes on an Insurance Form Detect improper code submissions Similar software is used by private payers, other Federal programs and State Medicare programs. Page 157 Chapter 6

Code Edits (Software) – Cont. Code edits will help you obtain maximum reimbursement for each service rendered Will also Help to avoid denials, lowered reimbursement & possible audit Code Edit Examples are: Comprehensive/Component Edits Separate Code Edits Mutually Exclusive Code Edits Page 157 Chapter 6

Type of Code Edits Comprehensive/Component Edits Single Procedural code that describes or covers two or more CPT component codes that are bundled together as one unit Comprehensive Codes are never indented and the basis for its description appears before the semicolon (;) Page 157 Chapter 6

Type of Code Edits – Cont. Component Code The portion of a service described before the semicolon (;) of a CPT comprehensive code, together with the portion of a service described by the indented (component) code Component Code is indented Should be used only be used if both portions of the service were performed Performance Exercise Example 6-25/157 Page 157 Chapter 6

Separate Procedure Code Edits Integral part of a large procedure and does not need a separate code, unless performed independently and not immediately related to other service Performance Exercise Example 6-26/157 Page 157 Chapter 6

Mutually Exclusive Code Edits Procedures that meet any of the following criteria: Code combinations that are restricted by the guidelines outlined in CPT Procedures that cannot be reasonably done during the same session Procedures that represent medically impossible or improbable code combinations Procedures that represent two methods of performing the same service Performance Exercise Example 6-27/157 Page 157 Chapter 6

Illegal or Unethical Coding To avoid Illegal Or unethical coding: follow Coding Guidelines & Individual Coding Policies from various Insurance Carriers Modifiers Additional Modifiers: Figure 6-6A & B - Page 160 & 161 Complete List of Modifier/in Appendix A Page Chapter 6

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