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Introduction to CPT Coding for Physician Practices Gretchen L. Segado, MS, CPC Director of Reimbursement Compliance NYU School of Medicine 316 East 30.

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Presentation on theme: "Introduction to CPT Coding for Physician Practices Gretchen L. Segado, MS, CPC Director of Reimbursement Compliance NYU School of Medicine 316 East 30."— Presentation transcript:

1 Introduction to CPT Coding for Physician Practices Gretchen L. Segado, MS, CPC Director of Reimbursement Compliance NYU School of Medicine 316 East 30 th Street New York, NY (212) (212) fax NYU School of Medicine Coding and Reimbursement Seminar Series Presented by the Office of Reimbursement Compliance

2 What Is CPT-4? Systematic listing of procedures & services performed by physicians Five-digit codes for procedures or services Used to describe the physician’s services to a patient for diagnosis and treatment of the medical condition(s) Codes and descriptive terminology developed and copyrighted by AMA CPT Editorial Panel

3 Linkage Between ICD-9 & CPT CPT-4 represents the “WHAT” was done to the patient Procedure (EKG) ICD-9 represents the “WHY” it was done Medical Necessity (Chest Pain)

4 Organization of CPT Manual Text organized in 6 major sections Evaluation and Management ( ) Anesthesiology ( , ) Surgery ( ) Radiology ( ) Pathology and Laboratory ( ) Medicine ( )

5 Guidelines Presented at the beginning of each of the six sections Provide information necessary to appropriately interpret and report the procedures and services contained in that section In addition to guidelines, several subheadings or subsections also have special instructions unique to that section Reading the guidelines and notes are critical to using CPT correctly

6 CPT Symbols Revised CPT Code-Description has been substantially altered New CPT Code Codes that never stand alone Appears during the 1 st year that the text is revised or added Codes exempt from the 51 modifier, but that do not have designated add-on procedures or services

7 Format of the CPT-4 Developed as a stand-alone descriptions of the procedures To conserve space, some are not printed in their entirety but refer back to a common portion listed in a preceding entry** Example: 25100arthrotomy, wrist joint; for biopsy 25105for synovectomy 25105arthrotomy, wrist joint; for synovectomy **Commonly referred to as “Indented Codes”

8 Who can tell me what CPT Code reads? The book says 24102with synovectomy

9 What is the full description of each of these codes? 20600*arthrocentesis, aspiration &/or injection; small joint, bursa or ganglion cyst (e.g., Fingers, toes) 20605*intermediate joint, bursa or ganglion cyst (e.g., Temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa 20610*major joint or bursa (e.g., Shoulder, hip, knee joint, subacromial bursa

10 Example application of halo, including removal; cranial 20662pelvic 20663femoral

11 The Index-The Starting Point Listed procedures in alphabetical order at the back of the manual Index is organized by main terms There are 4 primary classes of main entries: – Procedure or service – Organ or anatomic site – Condition – Synonyms, eponyms or common abbreviation

12 CPT Index Procedure or service – Appendectomy Organ or anatomic site – Knee Condition – Renal Abscess Synonyms, eponyms or common abbreviation – Bucca (cheek) – BAER (Brainstem Auditory Evoked Potential) – Whipple Procedure

13 Use of CPT-4 Manual Select the name of the procedure or service that most accurately identifies the service performed: – Example: Surgery:operations and minor procedures Medicine:diagnostic or therapeutic procedure Radiology: radiographic study Any physician can use any code in the CPT book.

14 Important!!!!! The alphabetical index is NOT a substitute for the main text of the CPT Manual. Even if only one code appears, the user must refer to the main text to ensure that the code selection is accurate In short…NEVER CODE FROM THE

15 10 Steps to Basic CPT Coding 1. Read the source document. Never assume! 2. Using information in the record, analyze procedure statement provided by physician. Identify main term and modifying terms 3. Locate main term in the CPT index 4. Look for subterms indented below the main term 5. Jot down the tentative code range for each procedure.

16 10 Steps to Basic CPT Coding 6. Locate each tentative code in the book 7. Read any instructional notes and watch for diagnoses or specific procedures within code descriptions 8. Verify that the code matches the procedure statement provided in the record 9. Assign a modifier if necessary 10. Assign the code

17 Now it’s your turn to use what you’ve learned……. Identify the service or procedure performed Identify the organ involved Identify the condition or key word

18 Procedure/Organ/Key Word What is the code for a Whipple Procedure? 48150

19 Procedure/Organ/Key Word What is the code for an upper gastrointestinal endoscopy with biopsy? You can find the same code looking under any of the terms “gastrointestinal” “endoscopy” or “biopsy”

20 Procedure/Organ/Key Word What is the code for a synovectomy of the metacarpophalangeal joint? Common mistakes made: carpometacarpal joint vs metacarpophlangeal joint

21 Procedure/Organ/Key Word What is the code for removal of a foreign body in the nose? Need more information, was this done under anesthetic? Did they have to cut into nose?

22 Procedure/Organ/Key Word How would you bill for a removal of a pylenoidal cyst? Do I need more information to code it correctly? If so, where do I get the info? Is it simple? extensive? complicated? Answer:

23 Procedure/Organ/Key Word Endoscopic biopsy of the urethra – This is a tricky one….beware Answer:52204

24 Procedure/Organ/Key Word Exploration of a penetrating wound of the abdomen Answer:20102

25 Procedure/Organ/Key Word Exploration of nasolacrimal duct with tube insertion Answer:68815

26 Procedure/Organ/Key Word Exploration of the knee with removal of a nail Answer:27310

27 Appendices Appendix AModifiers Appendix BSummary of additions, deletions and revisions Appendix CUpdate to short descriptor Appendix DClinical examples supplement Appendix ESummary of add on codes Appendix FSummary of CPT codes exempt from modifier -51

28 Global Surgery Components Preoperative visits - beginning with the day before the day of surgery for major procedures and the day of the surgery for minor procedures – Document pre-op evaluation/exam in medical record – Document pre-op evaluation in op report

29 What is the “Global” Period? Also known as the global surgical package No one standard definition Per CPT guidelines, The following services are always included in addition to the operation per se: local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;

30 What is in the Global Period? subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical); immediate postoperative care, including dictating operative notes, talking with the family and other physicians; writing orders; evaluating the patient in the post-anesthesia recovery area; typical postoperative follow-up care.

31 Examples of Services Included in the Global Period Removal of staples 10 days after a surgical procedure A visit with a patient prior to surgery to answer any last minute questions A post-operative visit in the office to check on wound healing

32 Examples of Services NOT Included in the Global Package The visit where the decision to perform a procedure or surgery was made, even if on the same day as the procedure A visit during the post-op period for a problem unrelated to the surgery

33 Example of Global Payment CPT code coronary artery bypass, vein Only; 3 coronary venous grafts Allowed payment (80%) = $2,001.40

34 National Correct Coding Initiative Commonly known as CCI Purpose: – Develop a correct coding methodologies – Control improper coding that leads to inappropriate increased in payment in Part B – Promote correct coding nationwide – Assist physicians in correctly coding their services for payment

35 Definitions in the Correct Coding Initiative Correct Coding means the reporting of a group of procedures with the appropriate comprehensive codes. Unbundling is the billing of multiple procedure codes for a group of procedures that are covered by a single comprehensive code. Mutually Exclusive Codes are those codes that represent services that cannot reasonably be performed in the same session

36 Types of Unbundling Fragmenting one service into component parts and coding each as a separate service. Reporting separate codes for related services when one comprehensive code includes all related services. Breaking out bilateral procedures when one code is appropriate.

37 Types of Unbundling Down coding a service in order to use an additional code when one higher code level, more comprehensive code is appropriate. Separating a surgical approach from a major surgical service.

38 Examples of Bundled Services Component Codes Cystourethroscopy, with urethral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiological service. – Bundled services: Bladder irrigation, simple, lavage &/or instillation Cystoeruthroscopy (separate procedure) Catheterization, urethra, simple

39 Examples of Bundled Services Mutually Exclusive Codes Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; cervical 63040Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical First code would be paid and the second denied without use of an appropriate modifier

40 Separate Procedures – Services “should not be reported in addition to code for total procedure or service of which it is considered an integral component” – If the service is performed independently, unrelated or distinct from other procedures provided at the time, it may be reported by itself or in addition to other services by attaching modifier -59 (indicates service is distinct, independent procedure)

41 Example of Separate Procedures Example: Enterolysis (freeing intestinal adhesion) (separate procedure) (Do not report in addition to 45136) is included in 45136Excision of ileoanal reservoir with ileostomy

42 Add-on Codes – Carried out in addition to a primary procedure Exempt from -51 modifier CPT descriptors - “list separately in addition to primary procedure” or “each additional” Must never be reported as a stand-alone code

43 Examples of Add-on Codes Suture of digital nerve, hand or foot; one nerve each additional digital nerve (list separately in addition to code for primary procedure) Open tmt and/or reduction of vertebral fx and/or dislocation(s), posterior approach, one fx vertebrae or dislocated segment; lumbar each additional fractured vertebrae or dislocated segment (list separately in addition to code for primary procedure)

44 In Summary Learned CPT Nomenclature (how to read the book) – Reading the guidelines – Use of Symbols, Appendices, Indexes Learned never to code from the index Learned the importance of linking CPT with an appropriate diagnosis (ICD-9) code Learned about Correct Coding Initiative

45 Coming soon.. An Advanced E&M/Chart Auditing Workshop Seminar Series Classes on – ICD-9 Coding – Billing for Non-physician Practitioners – How to Use Modifiers – Evaluation and Management Coding A Special Session on Advance Beneficiary Notices Sign up for classes via the School of Medicine Calendar at – Select Department Calendars, Find Compliance Office under “miscellanous” category


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