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Chapter 61 Surgery, Radiology, Pathology/Laboratory, and Medicine Chapter 6 Part II: CODING PROCEDURES Part II:

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Presentation on theme: "Chapter 61 Surgery, Radiology, Pathology/Laboratory, and Medicine Chapter 6 Part II: CODING PROCEDURES Part II:"— Presentation transcript:

1 Chapter 61 Surgery, Radiology, Pathology/Laboratory, and Medicine Chapter 6 Part II: CODING PROCEDURES Part II:

2 Chapter 62 PART II 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.

3 Chapter 63 PART II PROCEDURAL CODING PART II 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.

4 Chapter 64 PART II PROCEDURAL CODING PART II 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.

5 Chapter 65 Key Terms Add-on code 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)

6 Chapter 66 Key Terms Qualitative Analysis Quantitative Analysis Separate Procedures Stand-alone Codes Surgical Package Technical Component (TC) Test Panel Unbundling Upcoding

7 Chapter 67 Introduction to the Surgery Section Largest Section Largest Section of the CPT Codebook 16 Subsections, 16 Subsections, divided according to Body Systems Guidelines Guidelines are found at the beginning of the Surgery Sections. SubsectionCategories Anatomic Site Subsection further divided into Categories based on Anatomic Site Subcategories Subcategories are within each Category which list the type of procedure or condition. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

8 Chapter 68 How to Code Effectively How to Code Effectively procedure descriptionidentify various terms You must be able to analyze a procedure description and identify various terms that will direct you to the correct code. main categories servicesprocedures main termindex. To do this you must know the main categories under which services and procedures are listed according to their main term in the index. procedure,service,condition index, subterm sub-subterm After the procedure, service, or condition is identified in the index, search for a subterm and a sub-subterm that further defines the procedure. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

9 Chapter 69 How to Code Effectively – How to Code Effectively – Cont. correct section and read all descriptions 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 Performance Exercise Table 6-2/Page 138 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

10 Chapter 610 How to Code Effectively How to Code Effectively Identify Main Term(s) Identify Main Term(s) in the Procedure Description of the Medical Record LocateMain Term(s) Locate Main Term(s) in the Index & Document Code Range TurnRead Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select Select the Correct Code Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

11 Chapter 611 Introduction to theSurgery Section/( ) PERFORMANCE EXERCISE Coding Procedures & Services Introduction to the Surgery Section/( ) PERFORMANCE EXERCISE Excision of tendon, finger, flexor, single (separate procedure), each How to Code Effectively How to Code Effectively Identify Main Term(s) Identify Main Term(s) in the Procedure Description of the Medical Record LocateMain Term(s) Locate Main Term(s) in the Index & Document Code Range TurnRead Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select Select the Correct Code

12 Chapter 612 How to Code Effectively How to Code Effectively – Cont. Stand-alone 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 Performance Exercise Figure 6-3/Page 138 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

13 Chapter 613 How to Code Effectively How to Code Effectively – Cont. Indented Indented Codes – are listed after stand-alone codes whose descriptions have a dependent status. before 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 Performance Exercise Figure 6-3/Page 138 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

14 Chapter 614 Integral Code Description One Code is part of another based on language used in the description Example 6-2/Page139 Example 6-2/Page139 ( )definetell located Parentheses ( ) further define & tell where other services are located Figure 6-4/Page 139 Figure 6-4/Page 139 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

15 Chapter 615 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

16 Chapter 616 Coding from the Operative Report Read Read the Operative report thoroughly & code on documented operations Determine Determine Bundled or Unbundled Procedures Never Never Code Verbal Procedures Coding Rule:“Not Documented, Not Done”! Coding Rule: “Not Documented, Not Done”! Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

17 Chapter 617 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( ) 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

18 Chapter 618

19 Chapter 619 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 Performance Exercise Figure 6-4/Page 141 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

20 Chapter 620 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. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

21 Chapter 621 Surgical Package 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 ExampleGlobal Period For Example, the Global Period for repairing a Tendon might be set at 15 days. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

22 Chapter 622 Surgical Package Surgical Package – Cont. Global Period A Global Period for Major Surgery such as Appendectomy may be set at 100 days. Global Period After the Global Period ends additional services that are provided can be reported separately for additional payment. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

23 Chapter 623 Surgical Package Surgical Package – Cont. Surgical 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. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

24 Chapter 624 MedicareIncluded 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 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

25 Chapter 625 Medicare -Excluded Medicare Global Package - Excluded Initial Consultation or Evaluation Diagnostic Tests & Procedures Treatment required to stabilize a seriously ill patient before surgery (modifier –24) Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed (modifier –24) (modifier –78) 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. Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

26 Chapter 626 Follow-Up Days 0-day or 10-day Vary 0-day or 10-day for Minor Surgeries 45-day or 90-day 45-day or 90-day for Major Surgeries Relative Value Studies 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 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

27 Chapter 627 Modifier –51 Multiple Procedure Modifier –51 primary serviceprocedure 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 Appendix E – Appendix E – Summary of CPT Codes Exempt from Modifier 51 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

28 Chapter 628 Add-on Code (+) additional Procedure done with Primary Procedure Noted by a Cross (+) Symbol represents additional Procedure done with Primary Procedure Appendix D Found in Appendix D of CPT Can not billed without the primary procedure Can not billed without the primary procedure Add-on-Code Description start with: “in addition” “list separately Or “second lesion” Performance Exercise Performance Exercise Example 6-5/Example 6-6/Page 143 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

29 Chapter 629 Add-on Code – Cont. Bilateral Procedures - is one procedure performed on two sides. Two ways to Bill Once–50double List the Code Once with Modifier –50 & double the fee Twicesingle –50 List the Code Twice using a single fee & add the second listing with Modifier –50 Performance Exercise Performance Exercise Example 6-7/Page 143 Example 6-7/Page 143 Introduction to theSurgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

30 Chapter 630 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 Performance Exercise Example 6-8/Page 144 Example 6-8/Page 144 Introduction to the Surgery Section ( ) Coding Procedures & Services Introduction to the Surgery Section ( )

31 Chapter 631 Integumentary System First Subsection listed in the Surgery Section Skin 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.  a lesion followed by excision would be included in the excision procedure code, and not reported separately.  Biopsy of a lesion followed by excision would be included in the excision procedure code, and not reported separately. Surgery:Integumentary System ( ) Coding Procedures & Services Surgery: Integumentary System ( )

32 Chapter 632 Lesion – when coding removal of lesions note the: Anatomic Site Size, measured in centimeters Number of lesions removed excision, destructionparingshaving 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) Surgery:Integumentary System ( ) Coding Procedures & Services Surgery: Integumentary System ( )

33 Chapter 633 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 Surgery:Integumentary System ( ) Coding Procedures & Services Surgery: Integumentary System ( )

34 Chapter 634 Multiple Lesions Modifier –51 (Multiple Procedures) Read Read description & look for terms such as complicated, complex, more than, etc Watch (+) –51 Watch for Add-on-codes (+) VS Codes eligible for Modifier –51 & indented Codes Surgical Supplies (99070)HCPCS Level II Codes Bundled into Surgical Code (99070) or HCPCS Level II Codes Surgery:Integumentary System ( ) Coding Procedures & Services Surgery: Integumentary System ( )

35 Chapter 635 Breast Category Included within the Integumentary system because of the type of tissue involved. Each Breast Considered Separate Modifier –50 (bilateral) If procedure occur on both sides use Modifier –50 (bilateral) Performance Exercise Performance Exercise Example 6-9, 6-10 & 6-11/Page Surgery:Integumentary System ( ) Coding Procedures & Services Surgery: Integumentary System ( )

36 Chapter 636 Surgery:Integumentary System ( ) PERFORMANCE EXERCISE Coding Procedures & Services Surgery: Integumentary System ( ) PERFORMANCE EXERCISE Breast reconstruction with free flap Preoperative placement of needle localization wire, breast: 19290

37 Chapter 637 Musculoskeletal System Arranged according to Anatomic Site “General”Procedures Subcategories “General” first Category Contain Procedures & Subcategories for different Anatomic Sites. “Head” “Toe” Remaining Categories Start from the “Head” to the “Toe” Subcategories Under Each Anatomic Category Include: Incision Excision Introduction/Removal Surgery: Musculoskeletal System ( ) Coding Procedures & Services Surgery: Musculoskeletal System ( )

38 Chapter 638 Subcategories Under Each Anatomic Category Include: Fracture/Dislocation Arthrodesis Amputation Unlisted Procedures Fractures are: Open(Compound Fracture) Open/skin broken by the fragmented bone (Compound Fracture) Closed Closed/skin is not broken PercutaneousOpenedClosed Percutaneous/neither Opened or Closed Surgery: Musculoskeletal System ( ) Coding Procedures & Services Surgery: Musculoskeletal System ( )

39 Chapter 639 Coding Treatment of a Fracture Locate the Anatomic Site “Fracture and/or Dislocation” Find Subcategory “Fracture and/or Dislocation” Then find the appropriate code Description of Fractures are either: “With Manipulation” or “Without Manipulation” Surgery: Musculoskeletal System ( ) Coding Procedures & Services Surgery: Musculoskeletal System ( )

40 Chapter 640 Surgery: Musculoskeletal System ( ) Coding Procedures & Services Surgery: Musculoskeletal System ( ) Other Descriptive Terms Are: “Internal Fixation” “External Fixation”

41 Chapter 641 Surgery: Musculoskeletal System ( ) Coding Procedures & Services Surgery: Musculoskeletal System ( )  Fracture Manipulation is: The manual stretching or applying pressure or traction to realign the broken (fractured) bone. “reduction”. Referred to as “reduction”.  Fixation – is the use of hardware (instrumentation) to keep a bone in place. internally  It can be applied internally (e.g., plates, rod, pin) or  Externall  Externally (e.g., pins that comes thru the skin to the outside to keep the fractured bone from moving).

42 Chapter 642 Surgery: Musculoskeletal System ( ) Coding Procedures & Services Surgery: Musculoskeletal System ( )  Fracture Follow-up Period:  The surgical package rule applies.  All fracture code carry a 90-day follow-up  All fracture code carry a 90-day follow-up period. period. Performance Exercise Example 6-12/Page Example 6-13/Page 147

43 Chapter 643 Surgery: Musculoskeletal System ( ) PERFORMANCE EXERCISE Coding Procedures & Services Surgery: Musculoskeletal System ( ) PERFORMANCE EXERCISE Closed treatment of mandibular fracture; without manipulation Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone

44 Chapter 644 Respiratory System 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) Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( )

45 Chapter 645 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 Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( )

46 Chapter 646 Endoscopy Procedures Diagnostic Endoscopy Surgical Endoscopy Endoscopies Named for body area being explored e.g., brochial tube/bronchoscopy Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Performance Exercise Example 6-14/Page 149

47 Chapter 647 Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) PERFORMANCE EXERCISE Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) PERFORMANCE EXERCISE Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) 31622

48 Chapter 648 Cardiovascular System Cardiovascular System Organized by Anatomic Site Then by Type of Procedure Procedures Include: Procedures Include: Heart & Blood Vessels, including Pacemaker Implantation and Coronary Artery Bypass Graft (CABG) For Additional Studies Refer to: Medicine Sections Under: For Additional Studies Refer to: Medicine Sections Under: Cardiovascular/Therapeutic Services for: Cardiography, Echocardiography, Cardiac Catheterization & Other Vascular Studies Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) Coding Procedures & Services Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( )

49 Chapter 649 Surgery: Respiratory, Cardiovascular, Hemic & Lymphatic Systems - ( ) PERFORMANCE EXERCISE 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 Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography 92975

50 Chapter 650 Digestive System Digestive System 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 Surgery: Digestive System ( ) Coding Procedures & Services Surgery: Digestive System ( )

51 Chapter 651 Digestive System Digestive System Endoscopic Procedures used through-out subsection (i.e. Laparoscopy Incision) Endoscopic procedures are coded according to the anatomic site examined Notes Rectum: Endoscopy Notes defining proctosigmoidoscopy, sigmoidoscopy & colonoscopy are included under Rectum: Endoscopy Surgery: Digestive System ( ) Coding Procedures & Services Surgery: Digestive System ( )

52 Chapter 652 Surgery: Digestive System ( ) PERFORMANCE EXERCISE Coding Procedures & Services Surgery: Digestive System ( ) PERFORMANCE EXERCISE Repair of palate; up to 2 cm Laparoscopy, surgical, appendectomy 44970

53 Chapter 653 Urinary System 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 Surgery: Urinary, Male Genital & Female Genital Systems ( ) Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( )

54 Chapter 654 Male Genital System Male Genital System Divided by Anatomic Categories of Penis, Testis, Spermatic Cord, Prostate, etc Lesions Lesions May have specific code assigned Surgery: Urinary, Male Genital & Female Genital Systems ( ) Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( )

55 Chapter 655 Male Genital System – Cont. Male Genital System – Cont. Interset Surgery Interset Surgery “Male Genital System” Is a Subsection following “Male Genital System” Consist of only 2 Codes – Intersex survey; male to female – Female to male Surgery: Urinary, Male Genital & Female Genital Systems ( ) Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( ) Performance Exercise Example 6-15/Page 150

56 Chapter 656 Female Genital System/Maternity Care & Delivery 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 Surgery: Urinary, Male Genital & Female Genital Systems ( ) Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( )

57 Chapter 657 Incision & Drainage (I&D) Integumentary System Codes in the subsection with notes directing you to the Integumentary System for specific I&D procedures Read Code Description 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 Performance Exercise Figure 6-17/Page 150 Table 6-3/Page 151 Surgery: Urinary, Male Genital & Female Genital Systems ( ) Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( )

58 Chapter 658 Maternity Care & Delivery Maternity Care & Delivery Subsection following the Female Genital System Includes: Antepartum, Vaginal Delivery & Cesarean Delivery Delivery After Previous Cesarean Delivery Delivery After Previous Cesarean Delivery Category following Cesarean Delivery Referred to as VBAC, or vaginal birth after cesarean Abortion Abortion Last Category within the subsection Performance Exercise Performance Exercise 6-17/Page 150Table 6-3/Page 151 Example 6-17/Page 150 & Table 6-3/Page 151 Surgery: Urinary, Male Genital & Female Genital Systems ( ) Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems ( )

59 Chapter 659 Surgery: Urinary, Male Genital & Female Genital Systems/ ( ) PERFORMANCE EXERCISE Coding Procedures & Services Surgery: Urinary, Male Genital & Female Genital Systems/ ( ) PERFORMANCE EXERCISE Biopsy, prostate; needle or punch, single or multiple, any approach Biopsy of ovary, unilateral or bilateral (separate procedure) Aspiration of bladder by needle 51000

60 Chapter 660 Nervous System Nervous System Central Peripheral Code in subsections deals with both Central & Peripheral Nervous System Procedures Procedures Brain, spinal cord, & all types of nerves Organized by Anatomic site & then Procedure Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( ) Coding Procedures & Services Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( )

61 Chapter 661 Eye & Ocular Adnexa/Auditory System Eye & Ocular Adnexa/Auditory System Includes Surgical Codes of the Eye & related visual structures. Modifier –50 Modifier –50 (bilateral procedure) appended all procedures when done on both eyes. “previous eye surgery” Extensive Notes such as “previous eye surgery” are found through-out this subsection Auditory System/Subsection Auditory System/Subsection Divided into categories of External Ear, Middle Ear, Inner Ear & Temporal Bone Middle Fossa Approach Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( ) Coding Procedures & Services Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( )

62 Chapter 662 Operating Microscope Operating Microscope Last subsection of the Surgical section for use of a operating microscope when the surgical code does not contain the microscope as an inclusive component) 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 Code used in all Surgery Subsections where Microscope needs to be coded (i.e breast reconstruction) Surgery: Operating Microscope (69990) Coding Procedures & Services Surgery: Operating Microscope (69990)

63 Chapter 663 Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems ( ) PERFORMANCE EXERCISE 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 Biopsy of Cornea 65410

64 Chapter 664 Radiology Section Radiology Section Include Nuclear Medicine & Diagnostic Ultrasound Subsections/References are: Subsections/References are: X-ray index Diagnostic Radiology/X-ray index Ultrasound index Diagnostic Ultrasound/Ultrasound index Radiation Therapy index Radiation Oncology/Radiation Therapy index Nuclear Medicine index Nuclear Medicine/Nuclear Medicine index Radiology Section ( ) Coding Procedures & Services Radiology Section ( )

65 Chapter 665 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. physician professionaltechnical  When the physician performs both the professional & technical component there is know need to modify the Code. Radiology Section ( ) Coding Procedures & Services Radiology Section ( )

66 Chapter 666 Professional & Technical Components – cont. Modify Procedures Modifier -26 Modifier -26/professional element used when the physician performs only the professional component Modifier –TC Modifier –TC/technical element used only when billing for technical component Performance Exercise Performance Exercise Example 6-18/Page 152 Example 6-18/Page 152 Radiology Section ( ) Coding Procedures & Services Radiology Section ( )

67 Chapter 667 Professional & Technical Components Cont. Combination Coding procedural code book that is used to completely describe a procedure performed. 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 Radiology Section ( ) Coding Procedures & Services Radiology Section ( )

68 Chapter 668 Radiology Procedure Radiology Procedure When a radiology procedure is performed from the required combined services: Radiology Section A Code from the Radiology Section describes the Procedure Surgery Section A Code from the Surgery Section describe the Combination Procedure Performance Exercise Performance Exercise Example 6-19/Page 153 Example 6-19/Page 153 Radiology Section ( ) Coding Procedures & Services Radiology Section ( )

69 Chapter 669 Radiology Section ( ) PERFORMANCE EXERCISE Coding Procedures & Services Radiology Section ( ) PERFORMANCE EXERCISE Radiologic examination; forearm, two views Ultrasound, transvaginal Injection procedure for knee arthrography Surgery 27370&Radiology Surgery & Radiology 73580

70 Chapter 670 Pathology & Laboratory Pathology & Laboratory Codes listed according to type of Test performed (i.e., Hematology Tests, Urinalysis, etc.) Test Panels “Organ or Disease Oriented Panels” Listed under first subsection “Organ or Disease Oriented Panels” Single Code 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 Pathology & Laboratory ( ) Coding Procedures & Services Pathology & Laboratory ( )

71 Chapter 671 Qualitative/Quantitative Analysis Qualitative Analysis presence Qualitative Analysis test may determines the presence of an agent within the body Quantitative Analysishow much Quantitative Analysis measures how much of the agent is within the body Pathology & Laboratory ( ) Coding Procedures & Services Pathology & Laboratory ( )

72 Chapter 672 Surgical Pathology Alphabetical Order Arranged according to Levels/In Alphabetical Order Level I/ ( which means the way the specimen looks to the naked eye before it is prepared for microscopic study.) 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/ (it identification of tissue in the absence of disease) Level II/Gross & Microscopic Exam (it identification of tissue in the absence of disease) Level III through Level VI/ ( Exam of diseased tissue and each level requires additional work of the pathologist. Level III through Level VI/Gross & Microscopic Exam ( Exam of diseased tissue and each level requires additional work of the pathologist. Pathology & Laboratory ( ) Coding Procedures & Services Pathology & Laboratory ( )

73 Chapter 673 Pathology & Laboratory ( ) PERFORMANCE EXERCISE Coding Procedures & Services Pathology & Laboratory ( ) PERFORMANCE EXERCISE Acute hepatitis panel Insulin antibodies 86337

74 Chapter 674 Medicine Section Medicine Section PhysicianSpecialties List of codes used by Physician of different Specialties in conjunction with codes from different sections of the CPT Diagnostic & Therapeutic Services Diagnostic & Therapeutic Services that are not surgically invasive are listed in this section, including many specialized testing Notescarefully read before coding a subsection, category or subcategory Notes in this section should be carefully read before coding a subsection, category or subcategory Documentation Documentation may be included with the claim form to justify the use of the code Medicine Section ( ) Coding Procedures & Services Medicine Section ( )

75 Chapter 675 Drugs & Injections (90782, 90783, 90784, & 90799) 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 NDC (national drug code) A NDC (national drug code) may be used to specify the drug, dosage, and the manufacturer HCPCS Level II Code HCPCS Level II Code may be used to specify the injected drug Medicine Section ( ) Coding Procedures & Services Medicine Section ( )

76 Chapter 676 Special Services, Procedures, and Reports “Miscellaneous Services” Additional codes are found under the category “Miscellaneous Services” Special Services & Reports Codes provide physician with means of identifying Special Services & Reports that are an addition to basic services provided Two commonly used codes are: – Handling and/or conveyance of specimen – Supplies and materials (except spectacles) Medicine Section ( ) Coding Procedures & Services Medicine Section ( )

77 Chapter 677 Medicine Section ( ) PERFORMANCE EXERCISE Coding Procedures & Services Medicine Section ( ) PERFORMANCE EXERCISE Lyme disease vaccine, adult dosage, for intramuscular use Measles and rubella virus vaccine, live for subcutaneous use 90708

78 Chapter 678 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 “Fraud” Claim Audit Considered “Fraud” if done intentionally for increased reimbursement (Can result in Claim Audit) Coding Terminology Coding Procedures & Services Coding Terminology

79 Chapter 679 Unbundling Examples are: Fragmenting Fragmenting one service into component parts and coding each component as if it were a separate service Example 6-20/156 Example 6-20/156 Comprehensive Codes Reporting separate codes for related services when one Comprehensive Codes includes all related services Example 6-21/156 Example 6-21/156 Bilateral Procedures Coding Bilateral Procedures as two codes when one code is inclusive Example 6-22/156 Example 6-22/156 Coding Terminology Coding Procedures & Services Coding Terminology

80 Chapter 680 Unbundling Examples Cont. Surgical Approach Separating a Surgical Approach from a major surgical service that includes the same approach Example 6-23/156 Example 6-23/156 Downcoding occurs when: Coding System The Physician Coding System does not match the Coding System of the Insurance Company receiving the Claim Example 6-24/156 Example 6-24/156 Coding Terminology Coding Procedures & Services Coding Terminology

81 Chapter 681 Upcoding Upcoding Deliberate manipulation of CPT Codes for increased payment prepayment, postpayment or stop alert screens Upcoding can be spotted in Insurance Carrier’s software screens, such as the prepayment, postpayment or stop alert screens Coding Terminology Coding Procedures & Services Coding Terminology

82 Chapter 682 Code Edits (Software) Code Edits (Software) Correct Coding Initiative (CCI) 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 private payers, other Federal programs and State Medicare programs. Similar software is used by private payers, other Federal programs and State Medicare programs. Coding Terminology Coding Procedures & Services Coding Terminology

83 Chapter 683 Coding Terminology Coding Procedures & Services Coding Terminology Code Edits (Software) – Cont. 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: Code Edit Examples are: Comprehensive/Component Edits Separate Code Edits Mutually Exclusive Code Edits

84 Chapter 684 Coding Terminology Coding Procedures & Services Coding Terminology Type of Code Edits 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 never indentedand the basis for its description appears before the semicolon (;) Comprehensive Codes are never indented and the basis for its description appears before the semicolon (;)

85 Chapter 685 Coding Terminology Coding Procedures & Services Coding Terminology Type of Code Edits – Type of Code Edits – Cont. Component Code before 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 is indented Component Code is indented Should be used only be used if both portions of the service were performed Performance Exercise Performance Exercise Example 6-25/157 Example 6-25/157

86 Chapter 686 Coding Terminology Coding Procedures & Services Coding Terminology 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 Performance Exercise Example 6-26/157 Example 6-26/157

87 Chapter 687 Coding Terminology Coding Procedures & Services Coding Terminology 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 Performance Exercise Example 6-27/157 Example 6-27/157

88 Chapter 688 Illegal or Unethical Coding follow Coding Guidelines & Individual Coding Policies from various Insurance Carriers 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 Figure 6-6A & B - Page 160 & 161 Appendix A Complete List of Modifier/in Appendix A Coding Terminology Coding Procedures & Services Coding Terminology


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