Presentation on theme: "Medical Coding I – Week 1 Introduction CPT and HCPCS"— Presentation transcript:
1Medical Coding I – Week 1 Introduction CPT and HCPCS Robyn Korn, MBA, RHIA, CPHQ
2CPT History CPT – Current Procedural Terminology Published 1966 by AMA (American Medical Association)Until 1983 – only private insurers recognized CPT CodesHCPCS (Healthcare Common Procedure Coding System) developed using CPT
3HCPCS Level I – CPT Level II - National Codes Category I – Main sections of CPTCategory II – not mandatory; tracking codesCategory III – collect statistical data; temporary codesLevel II - National CodesUsed to bill for services not in Level I and supplies and equipment
4CPT Updated annually Notifications sent in early fall Effective January 1Coding changesAdditionsDeletionsChanges or revisions
5CPT StructureIntroduction – text, symbols, history and use of the bookMain body – 6 sectionsAppendices (A-N)Index
6Six Main Sections Evaluation and Management - 99201-99499 Anesthesia , 99100, 99150Surgery –Radiology –Pathology and Laboratory –Medicine – ,
7Main SectionEXAMPLE: Referencing the Surgery section of your book, you will see the following arrangement: (Section) Surgery (Subsection) Integumentary System (Subcategory) Skin, Subcutaneous and Accessory Structures (Heading) Incision and Drainage (Procedure) Incision and drainage of pilonidal cyst; simple
8Symbols New code Revised code New or revised text + Add-on code . Code includes moderate sedationNew codeRevised codeNew or revised text+ Add-on code
9Guidelines Beginning of each main section Define items necessary to interpret and report procedures in the sectionGuidelines are strictly followedCan also appear at the beginning of a subsection
10Index Subterms modify the main term Located at the back of the CPT ManualOrganized by Main termsProcedure or serviceOrgan or other anatomic siteConditionSynonyms, Eponyms or abbreviationsSubterms modify the main term
11Appendices A – Modifiers B – additions, deletions, revised codes C – Clinical ExamplesD – Add-on codesE - Exempt from -51F – Exempt from -63G - Moderate Sedation
12Appendices H – Alpha index of performance measures I – Genetic testing code modifiersJ – Electrodiagnostic Medicine Listing of sensory, motor and mixed nervesK – Products pending FDA ApprovalL – Vascular familiesM – Cross walk deleted codesN – Summary of resequenced codes
13ResequencingCodes are not deleted and renumbered to keep in numerical orderAids in data maintenance and integrityLimit number of additions and deletions# indicates code is out of order or has been resequenced
14CPT ModifierA CPT modifier is a two-digit code that is appended to the CPT code to indicate that a service or procedure has been altered for some reason, but it does not change the main definition of the code.Further describes the service performedLevel II HCPCS Modifier – two digit alphanumeric codeReference: Understanding Procedural Coding: A Worktext, 2nd edition , Bowie, Mary Jo
15Modifier Usage• A service or procedure has both a technical and professional component. • A service or procedure was performed by more than one physician. • A service or procedure was performed in more than one location.
16Modifier Usage• A service or procedure has taken more time to complete than routinely would occur. • A service or procedure was reduced or increased. • Only part of a procedure was completed. • A bilateral procedure was performed.
17Modifier Usage• A service or procedure was completed multiple times. • An unusual event occurred during the procedure. • An accompanying or adjunctive procedure was performed.
18Modifiers – Physician Services Third party payers use different instructions for reporting modifiers – review the instructions when billingModifiers that affect fee are listed firstImportant to learn pricing modifiers
19Modifiers – Hospital Outpatient Services Only some modifiers are approved for Ambulatory Surgery CenterSee Appendix A for current list
20CPT Level I Modifiers Definition of each modifier is in Appendix A Quick list is found on inside cover of CPT code bookCurrently there are 31 modifiers
21Frequent CPT Modifiers - 22 Unusual Procedural Services- 24 Unrelated Evaluation and Management Service, Same Physician, During Postoperative Period- 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
23Frequent CPT Modifiers -54 Surgical Care Only-55 Postoperative Management Only- 56 Preoperative Management Only- 57 Decision for Surgery
24Frequent CPT Modifiers -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period-59 Distinct Procedural Service
25Frequent CPT Modifiers -78 Return to the Operating Room for a Related Procedure during the Postoperative Period Level II (HCPCS/National) Modifiers-79 Unrelated Procedure or Service by the Same Physician during the Postoperative Period
26HCPCS Level II Modifiers Used with HCPCS Level II codesTwo digit alphanumericUse the website of insurance carriers and CMS for the use of these modifiersComprehensive list is in Appendix 2 of HCPCS code manualAmbulance origin and destination modifiers
27Case 1Marty went to the doctor’s office with a sore throat and an upset stomach. The doctor performed an exam and evaluation of Marty. In the course of the evaluation, Marty mentioned he was having some back pain. The doctor also evaluated this issue and performed an osteopathic manipulation on one body region. The doctor reported a with a __________modifier and a for the OMT.
28Case 1Case 1—Modifier 25Rationale: An Evaluation and Management Code (99213) and a procedure (OMT-98925) for the same day require a modifier to identify that two separate and distinct services were performed. Modifier 25 is reported with the E/M code.
29Case 2Dr. Albert is performing a complicated pyeloplasty on Kelly. Kelly was tolerating the procedure fairly well until her blood pressure began to drop dangerously low. After having trouble stabilizing her, Dr. Albert discontinued the procedure because he felt it would be too dangerous to continue. The doctor reported the part of the service he performed with a and a______modifier.
30Case 2Case 2—Modifier 53Rationale: Because of the extenuating circumstances of the drop in blood pressure, the doctor felt it was in the patient’s best interest to stop the procedure.
31Case 3Jamie South was out of town playing football two weeks ago, and he sustained a broken ankle. He was taken to the local hospital, and Dr. Books performed a closed treatment of trimalleolar ankle fracture with manipulation. Today he is being seen by Dr. Thompson for the postoperative care for the fracture treatment. Dr. Thompson should report code with modifier _______.
32Case 3Case 3—Modifier 55Rationale: Modifer 55 is appended to the code to report that the provider is completing postoperative management only.
33Case 4Mary Beth is a 19-day-old neonate, who weighs 3.2 kg and who is undergoing an arthrotomy with biopsy of the interphalangeal joint. The surgeon reports code with modifier ______.
34Case 4Case 4—Modifier 63Rationale: When a procedure is completed and the patient is a newborn and less than 4 kg, modifier 63 is appended to the procedure code.
35Case 5Dr. Cook is performing a pulmonary valve replacement. Dr. Samson is the assistant surgeon for the case. Dr. Cook reports code , whereas Dr. Samson should report _________.
36Case 5Case 5—Rationale: Modifier 80 is appended to the procedure code to report that the provider is the assistant surgeon for the case.
37Case 6Sam is a 10-year-old child who has had chronic ear infections for the last year. Today Dr. Abbes has decided that Sam needs to have tubes inserted into his ears. This is scheduled to occur in 3 weeks. Today’s visit was coded with appended with modifier ________.
38Case 6Case 6—Modifier 57Rationale: Modifier 57 denotes that the decision for surgery was made.
39Case 7James Tree is a patient at an intermediate care facility. Today he is being seen by Dr. Rip because of a state mandate for the resident to be seen every 6 months. Code was reported with modifier ______ to report the mandated service.
40Case 7Case 7—Modifier 32Rationale: When a service occurs because the service is mandated, modifier 32 is appended to the basic procedure code.
41Case 8Dr. Whoo interprets a MRI of the temporomandibular joint. This is reported with code 70336, appended with modifier ________.
42Case 8Case 8—Modifier 26Rationale: Modifier 26 is appended to the code to report that the provider completed the professional component of the procedure.
43Case 9Drs. Jones and Smith work as a surgical team to perform a double lung transplant with cardiopulmonary bypass. Dr Jones would report code 32854, and Dr. Smith would report code Is this correct?
44Case 9 Case 9—No, both should report 32854-66. Rationale: Since the providers worked as a team, modifier 66 would be reported by both providers.
45Case 10Dr. Jackson performed a therapeutic pneumothorax on Sally Small and reported code Later that same day, the procedure was repeated. How should the second procedure be reported?
46Case 10Case 10—Rationale: Modifier 76 would be appended to the procedure code to denote that the procedure was repeated.