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Copyright © 2008 Delmar Learning. All rights reserved. CHAPTER 7 CPT Coding.

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Presentation on theme: "Copyright © 2008 Delmar Learning. All rights reserved. CHAPTER 7 CPT Coding."— Presentation transcript:

1 Copyright © 2008 Delmar Learning. All rights reserved. CHAPTER 7 CPT Coding

2 Copyright © 2008 Delmar Learning. All rights reserved. 2 Introduction Chapter 7: –Introduces assignment of Current Procedural Terminology –CPT: Services and procedure codes reported on insurance claims

3 Copyright © 2008 Delmar Learning. All rights reserved. 3 Overview of CPT CPT –Provides a list of identifying and descriptive codes for reporting procedures and medical services –Uniform language that describes medical, surgical procedures and services

4 Copyright © 2008 Delmar Learning. All rights reserved. 4 Overview of CPT CPT codes are used to report services and procedures Submitted as claims with linked ICD-9-CM codes –Codes justify need for service or procedure

5 Copyright © 2008 Delmar Learning. All rights reserved. 5 Overview of CPT Changes to CPT –CPT supports electronic data –Exchange (EDI), Computer-based patient –Record (CPR), or electronic medical –Record (EMC) and reference/research database

6 Copyright © 2008 Delmar Learning. All rights reserved. 6 Overview of CPT Improvements to CPT are underway In 2002 –AMA completed the CPT 5 Project, resulting in the establishment of three categories of CPT codes

7 Copyright © 2008 Delmar Learning. All rights reserved. 7 Overview of CPT Category 1 –Procedures/services identified by a five digit CPT code and descriptor nomenclature –Codes traditionally associated with CPT organized in six sections

8 Copyright © 2008 Delmar Learning. All rights reserved. 8 Overview of CPT Category 2 –Contain “performance measurements” tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A) –Codes located after Medicine section Use is optional

9 Copyright © 2008 Delmar Learning. All rights reserved. 9 Overview of CPT July 2007 –New program from Medicare utilizing these codes to justify documentation –“PQRI’s” will begin a project for physicians’ practices Will receive additional percentage of revenue for documentation compliance

10 Copyright © 2008 Delmar Learning. All rights reserved. 10 Overview of CPT Category 3 codes –Contain “emerging technology” temporary codes assigned for data purposes and assigned in alphanumeric with the letter in the last position

11 Copyright © 2008 Delmar Learning. All rights reserved. 11 Overview of CPT Field 0001T –Codes are located after Medicine section –Archived after five years unless accepted for placement

12 Copyright © 2008 Delmar Learning. All rights reserved. 12 CPT Sections Category I procedures and services –Evaluation and Management (E/M) 99201- 99499 –Anesthesia (00100-01999, 99100-99140) –Surgery (10021-69990)

13 Copyright © 2008 Delmar Learning. All rights reserved. 13 CPT Sections Radiology (70010-79999) Pathology and laboratory (80048-89356) Medicine (90281-99199, 99500-99602)

14 Copyright © 2008 Delmar Learning. All rights reserved. 14 CPT Sections CPT code number format –Five-digit number and description identifying each procedure and service listed in CPT

15 Copyright © 2008 Delmar Learning. All rights reserved. 15 CPT Sections CPT Appendices –CPT contains appendices located after the Medicine section and Index –Insurance specialist should become familiar with changes that affect the practice

16 Copyright © 2008 Delmar Learning. All rights reserved. 16 CPT Appendix Description Appendix A –Detailed description of each CPT modifier Appendix B –Annual CPT coding changes Added, deleted, revised CPT codes

17 Copyright © 2008 Delmar Learning. All rights reserved. 17 CPT Appendix Description Appendix C –Clinical examples for evaluation and Management (E/M) section codes Appendix D –Add-on codes

18 Copyright © 2008 Delmar Learning. All rights reserved. 18 CPT Appendix Description Appendix E –Codes exempt from modifier -51 reporting rules Appendix F –CPT codes exempt from modifier -63 reporting rules Appendix G –Summary of CPT codes that include moderate (conscious) sedation

19 Copyright © 2008 Delmar Learning. All rights reserved. 19 CPT Appendix Description Appendix H –Alphabetic index of performance measures by clinical condition or topic Serves as a crosswalk to the category II Appendix I –Genetic testing code modifiers

20 Copyright © 2008 Delmar Learning. All rights reserved. 20 CPT Appendix Description Appendix J –Electro diagnostic medicine listing of sensory, motor, and mixed nerves

21 Copyright © 2008 Delmar Learning. All rights reserved. 21 CPT Appendix Description There is also a table that indicates “type of study and maximum of studies” –Generally performed for needle electromyogram (EMG) –Nerve conduction studies –Other EMG studies

22 Copyright © 2008 Delmar Learning. All rights reserved. 22 CPT Appendix Description Appendix L –List of vascular families that is intended to assist in selection of first, second, third, and beyond third-order branch arteries Appendix M –Crosswalk of deleted to new CPT codes

23 Copyright © 2008 Delmar Learning. All rights reserved. 23 CPT Symbols Symbols are located throughout CPT coding book Bullet located to left of a code number –Identifies new procedures and services added to CPT

24 Copyright © 2008 Delmar Learning. All rights reserved. 24 CPT Symbols Triangle located to left of a code number –Identifies a code description that has been revised

25 Copyright © 2008 Delmar Learning. All rights reserved. 25 CPT Symbols Horizontal triangles –Surround revised guidelines and notes –Not used for revised code descriptions –To save space in CPT Code descriptions are not printed in their entirety next to a code number

26 Copyright © 2008 Delmar Learning. All rights reserved. 26 CPT Symbols Plus sign –Identifies add-on codes –For procedures that are commonly, but not always, performed at the same time and by the same surgeon

27 Copyright © 2008 Delmar Learning. All rights reserved. 27 CPT Symbols Circle with a line through it –Identifies codes that are not to be used with modifier Bull’s-eye symbol –Indicates a procedure that includes moderate sedation

28 Copyright © 2008 Delmar Learning. All rights reserved. 28 Guidelines Located at beginning of the CPT section –Should be reviewed each year before attempting to code from this section Guidelines define and explain the assignment of codes, procedures, and services in a particular section

29 Copyright © 2008 Delmar Learning. All rights reserved. 29 Unlisted Procedures/Services Unlisted procedure or service –Codes are assigned when a procedure or service is performed by a provider for which there is no CPT code

30 Copyright © 2008 Delmar Learning. All rights reserved. 30 Unlisted Procedures/Services Special Report –When an unlisted procedure or service code is reported

31 Copyright © 2008 Delmar Learning. All rights reserved. 31 Unlisted Procedures/Services Special Report –Narrative document must accompany claim to describe nature and extent of the need of service or procedure Some practices place in Box 19 of CMS 1500 claim form the “unlisted code = the closest related code of XXXXX.”

32 Copyright © 2008 Delmar Learning. All rights reserved. 32 Unlisted Procedures/Services Notes –Instructional notes are found throughout

33 Copyright © 2008 Delmar Learning. All rights reserved. 33 Unlisted Procedures/Services Blocked unindented note: –Located below a subsection title and contains instructions that apply to all codes

34 Copyright © 2008 Delmar Learning. All rights reserved. 34 Unlisted Procedures/Services Indented parenthetical note: –Located below a subsection title, code description, or code description that contains an example Highlight and understand each of these notes

35 Copyright © 2008 Delmar Learning. All rights reserved. 35 CPT Modifiers Clarify services and procedures performed by providers Have always been reported on claims submitted for provider office services and procedures

36 Copyright © 2008 Delmar Learning. All rights reserved. 36 CPT Modifiers Coding tip: –List of all CPT modifiers with brief descriptions is located inside front cover of coding manual

37 Copyright © 2008 Delmar Learning. All rights reserved. 37 CPT Modifiers Documented history, examination, and medical decision making –Must “stand on its own” to justify reporting modifier -25 with the Evaluation and Management (E/M) code

38 Copyright © 2008 Delmar Learning. All rights reserved. 38 CPT Modifiers E/M service: –Must be “above and beyond” what is normally performed during a procedure

39 Copyright © 2008 Delmar Learning. All rights reserved. 39 Coding Procedures and Services Step 1: –Read introduction in CPT coding manual Step 2: –Review guidelines at beginning of each section Step 3: –Review procedure

40 Copyright © 2008 Delmar Learning. All rights reserved. 40 Coding Procedures and Services Step 4: –Refer to CPT index –Locate main term for procedure or service documented Main terms can be located by referring to the following:

41 Copyright © 2008 Delmar Learning. All rights reserved. 41 Coding Procedures and Services a. Procedure or service documented b. Organ or anatomic site c. Condition documented in the record d. Substance being tested

42 Copyright © 2008 Delmar Learning. All rights reserved. 42 Coding Procedures and Services e.Synonym (term with similar meaning) f.Eponym (procedures and diagnoses named for an individual) g.Abbreviation

43 Copyright © 2008 Delmar Learning. All rights reserved. 43 Coding Procedures and Services Step 5: –Locate sub terms and follow cross references Step 6: –Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements

44 Copyright © 2008 Delmar Learning. All rights reserved. 44 Coding Procedures and Services Step 7: –Assign applicable code number and any add- on (+) or additional codes needed to accurately classify statement being coded

45 Copyright © 2008 Delmar Learning. All rights reserved. 45 Surgery Section Surgery section is organized by body system –Some subsections are further subdivided by procedure categories

46 Copyright © 2008 Delmar Learning. All rights reserved. 46 Surgery Section Incision Excision Introduction or removal Repair, revision, or reconstruction Grafts

47 Copyright © 2008 Delmar Learning. All rights reserved. 47 Surgery Section Suture Other procedures

48 Copyright © 2008 Delmar Learning. All rights reserved. 48 Code Surgeries Properly Three questions must be asked: –What body system was involved? –What anatomic site was involved? –What type of procedure was performed? Carefully read the procedure outlined in the operative report

49 Copyright © 2008 Delmar Learning. All rights reserved. 49 Evaluation and Management Evaluation and management –Located at the beginning of CPT because these codes describe services most frequently provided by physicians Before assigning E/M codes –Make sure you review guidelines and apply any notes

50 Copyright © 2008 Delmar Learning. All rights reserved. 50 Evaluation and Management For established patients –Two of three key components must be considered

51 Copyright © 2008 Delmar Learning. All rights reserved. 51 Evaluation and Management E/M code reported to a payer –Must be supported by documentation in the patient’s record

52 Copyright © 2008 Delmar Learning. All rights reserved. 52 Key Components E/M code selection is based on three key components: –Extent of history –Extent of examination –Complexity of medical decision making All key components must be considered when assigning codes for new patients

53 Copyright © 2008 Delmar Learning. All rights reserved. 53 Extent of Examination Physical examination is an assessment of the patient’s organ and body system/s

54 Copyright © 2008 Delmar Learning. All rights reserved. 54 Extent of Examination Categorized according to four types: –Problem focused examination –Expanded problem focused examination –Detailed examination –Comprehensive examination

55 Copyright © 2008 Delmar Learning. All rights reserved. 55 Complexity of Medical Decision Making Complexity of establishing a diagnosis and/or selecting a management option as measured by the: –Number of diagnoses or management options –Amount and/or complexity of data to be reviewed –Risk of complications and/or morbidity or mortality

56 Copyright © 2008 Delmar Learning. All rights reserved. 56 Patient’s Records Should Include Laboratory, imaging, and other test results that are significant to the management of the patient care List of known diagnoses as well as those that are suspected Opinions of other physicians who have been consulted

57 Copyright © 2008 Delmar Learning. All rights reserved. 57 Patient’s Records Should Include Planned course of action for the patient’s treatment Review of patient records obtained from other facilities

58 Copyright © 2008 Delmar Learning. All rights reserved. 58 History and Examination Determined by: –Straightforward –Low complexity –Moderate complexity –High complexity

59 Copyright © 2008 Delmar Learning. All rights reserved. 59 History and Examination Once the extent of history, extent of examination, and complexity of medical decision making are determined –Select the appropriate E/M code

60 Copyright © 2008 Delmar Learning. All rights reserved. 60 Presenting Problem CPT defines nature of the presenting problem as “a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.”

61 Copyright © 2008 Delmar Learning. All rights reserved. 61 Presenting Problems Minimal Self-limited or minor Low severity Moderate severity High severity

62 Copyright © 2008 Delmar Learning. All rights reserved. 62 Face-to-Face Time Amount of time the doctor spends with the family or the patient

63 Copyright © 2008 Delmar Learning. All rights reserved. 63 Unit/Floor Time Amount of time the doctor spends at the patient’s bedside and at the management of the patient’s care.

64 Copyright © 2008 Delmar Learning. All rights reserved. 64 E/M Time Claiming E/M on time you must have: –Total length of time for the encounter –Plus the length of time spent coordinating care and/or counseling patient –Issues discussed –Relevant history, exam, and medical decision making

65 Copyright © 2008 Delmar Learning. All rights reserved. 65 Observation Services Are furnished in a hospital outpatient setting –Patient is considered an outpatient They are reimbursed only when the doctor orders it

66 Copyright © 2008 Delmar Learning. All rights reserved. 66 Subcategories Include Observation care discharge services Initial observation care

67 Copyright © 2008 Delmar Learning. All rights reserved. 67 Hospital Inpatient Services E/M services provided to hospital inpatients, including partial hospitalization services.

68 Copyright © 2008 Delmar Learning. All rights reserved. 68 Subcategories Include Initial hospital care Subsequent hospital care Observation care services Hospital discharge services

69 Copyright © 2008 Delmar Learning. All rights reserved. 69 Consultations Type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem requested by another physician or other appropriate source.

70 Copyright © 2008 Delmar Learning. All rights reserved. 70 Criteria Consultation is requested by another doctor or provider Consultant renders an opinion or advice

71 Copyright © 2008 Delmar Learning. All rights reserved. 71 Criteria Consultant initiates diagnostic or therapeutic services. Requesting physician documents in the patient’s record, the request, and the need for the consultation.

72 Copyright © 2008 Delmar Learning. All rights reserved. 72 Criteria Consultant’s opinion, advice, and any services rendered are documented in the patient’s record –These are reported to the requesting physician or source

73 Copyright © 2008 Delmar Learning. All rights reserved. 73 Subcategories Include Office or other outpatient consultations Inpatient consultations

74 Copyright © 2008 Delmar Learning. All rights reserved. 74 Emergency Department Services Are given in a hospital setting that is open 24 hours to provide services that are not scheduled.

75 Copyright © 2008 Delmar Learning. All rights reserved. 75 Critical Care Services When a doctor provides services to someone who is critically ill or injured. The doctor should document the total time spent delivering critical care services –Excluding time for allowable services

76 Copyright © 2008 Delmar Learning. All rights reserved. 76 Neonatal A neonate is a newborn up until 28 days, and an infant is 29 days to a year old.

77 Copyright © 2008 Delmar Learning. All rights reserved. 77 Subcategories Inpatient pediatric critical care Inpatient neonatal critical care Continuing intensive care services

78 Copyright © 2008 Delmar Learning. All rights reserved. 78 Nursing Facility Services Are provided at nursing facilities: –Skilled nursing, intermediate care, and long- term care

79 Copyright © 2008 Delmar Learning. All rights reserved. 79 Subcategories Initial nursing facility care Subsequent nursing facility care Nursing facility discharge services Other nursing facility services

80 Copyright © 2008 Delmar Learning. All rights reserved. 80 Prolonged Services May be reported when a doctor’s services involving patient contact are considered beyond the usual service in either an inpatient or outpatient setting.

81 Copyright © 2008 Delmar Learning. All rights reserved. 81 Subcategories Prolonged physician service with direct face-to-face Prolonged physician services without face-to-face Physician standby services

82 Copyright © 2008 Delmar Learning. All rights reserved. 82 Newborn Care Includes services provided to newborns in a variety of health care settings.

83 Copyright © 2008 Delmar Learning. All rights reserved. 83 Qualifying Circumstances for Anesthesia When situations or circumstances make anesthesia administration more difficult and increases the patient’s risk factor.

84 Copyright © 2008 Delmar Learning. All rights reserved. 84 Physician Status Modifiers Each “status modifier” –Reported with an anesthesia code to indicate the patient’s condition at the time anesthesia was administered.

85 Copyright © 2008 Delmar Learning. All rights reserved. 85 Modifiers P1 –Normal health P2 –Mild systemic disease P3 –Severe systemic disease

86 Copyright © 2008 Delmar Learning. All rights reserved. 86 Modifiers P4 –Severe systemic disease that is a constant threat to life P5 –Not expected to survive without the operation P6 –Declared brain-dead and whose organs are being removed for donor purposes

87 Copyright © 2008 Delmar Learning. All rights reserved. 87 Anesthesia Time Units Be sure to record the time with the anesthesiologist Anesthesia time unit is one 15-minute increment

88 Copyright © 2008 Delmar Learning. All rights reserved. 88 Calculating Anesthesia Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesia Nonmonitored interval time Recovery room time Routine postoperative evaluation by the anesthesiologist or CRNA

89 Copyright © 2008 Delmar Learning. All rights reserved. 89 Separate Procedure Follows a code explanation identifying procedures that are an important part of an additional procedure or service.

90 Copyright © 2008 Delmar Learning. All rights reserved. 90 Complete Procedure When the word “complete” is established in the code definition –One code is reported to “completely” explain the procedure performed

91 Copyright © 2008 Delmar Learning. All rights reserved. 91 Pathology and Laboratory Organized according to the kind of pathology or laboratory procedure performed

92 Copyright © 2008 Delmar Learning. All rights reserved. 92 Pathology and Laboratory Subsections Organ or disease oriented panels Drug testing Therapeutic Drug Assays Consultations (Clinical Pathology) Urinalysis, chemistry, hematology and coagulation immunology Microbiology

93 Copyright © 2008 Delmar Learning. All rights reserved. 93 Pathology and Laboratory Subsections Anatomic pathology Cytopathology and cytogenetic studies Surgical pathology Transcutaneous procedures Other procedures Reproductive medicine procedures

94 Copyright © 2008 Delmar Learning. All rights reserved. 94 National Correct Coding Initiative To encourage national correct coding, methodologies, and manage the improper assignment of codes.

95 Copyright © 2008 Delmar Learning. All rights reserved. 95 National Correct Coding Initiative Incorrect coding –Results in inappropriate repayment of Medicare Part B claims –Centers for Medicare and Medicaid Services implemented the National Correct Coding Initiative

96 Copyright © 2008 Delmar Learning. All rights reserved. 96 NCCI Coding Policies Analysis of standard medical and surgical practice Coding conventions included in CPT Coding guidelines developed by national medical specialty societies Local and national coverage determinations Review of current coding practices


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