2 Introduction Chapter 7: Introduces assignment of Current Procedural TerminologyCPT:Services and procedure codes reported on insurance claims
3 Overview of CPTCPTProvides a list of identifying and descriptive codes for reporting procedures and medical servicesUniform language that describes medical, surgical procedures and services
4 Overview of CPT CPT codes are used to report services and procedures Submitted as claims with linked ICD-9-CM codesCodes justify need for service or procedure
5 Overview of CPT Changes to CPT CPT supports electronic data Exchange (EDI), Computer-based patientRecord (CPR), or electronic medicalRecord (EMC) and reference/research database
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 Overview of CPT Category 1 Procedures/services identified by a five digit CPT code and descriptor nomenclatureCodes traditionally associated with CPT organized in six sections
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 sectionUse is optional
9 Overview of CPTJuly 2007New program from Medicare utilizing these codes to justify documentation“PQRI’s” will begin a project for physicians’ practicesWill receive additional percentage of revenue for documentation compliance
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 Overview of CPT Field 0001T Codes are located after Medicine section Archived after five years unless accepted for placement
12 CPT Sections Category I procedures and services Evaluation and Management (E/M)Anesthesia ( , )Surgery ( )
14 CPT Sections CPT code number format Five-digit number and description identifying each procedure and service listed in CPT
15 CPT Sections CPT Appendices CPT contains appendices located after the Medicine section and IndexInsurance specialist should become familiar with changes that affect the practice
16 CPT Appendix Description Appendix ADetailed description of each CPT modifierAppendix BAnnual CPT coding changesAdded, deleted, revised CPT codes
17 CPT Appendix Description Appendix CClinical examples for evaluation and Management (E/M) section codesAppendix DAdd-on codes
18 CPT Appendix Description Appendix ECodes exempt from modifier -51 reporting rulesAppendix FCPT codes exempt from modifier -63 reporting rulesAppendix GSummary of CPT codes that include moderate (conscious) sedation
19 CPT Appendix Description Appendix HAlphabetic index of performance measures by clinical condition or topicServes as a crosswalk to the category IIAppendix IGenetic testing code modifiers
20 CPT Appendix Description Appendix JElectro diagnostic medicine listing of sensory, motor, and mixed nerves
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 studiesOther EMG studies
22 CPT Appendix Description Appendix LList of vascular families that is intended to assist in selection of first, second, third, and beyond third-order branch arteriesAppendix MCrosswalk of deleted to new CPT codes
23 CPT Symbols Symbols are located throughout CPT coding book Bullet located to left of a code numberIdentifies new procedures and services added to CPT
24 CPT Symbols Triangle located to left of a code number Identifies a code description that has been revised
25 CPT Symbols Horizontal triangles Surround revised guidelines and notes Not used for revised code descriptionsTo save space in CPTCode descriptions are not printed in their entirety next to a code number
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 CPT Symbols Circle with a line through it Bull’s-eye symbol Identifies codes that are not to be used with modifierBull’s-eye symbolIndicates a procedure that includes moderate sedation
28 Guidelines Located at beginning of the CPT section Should be reviewed each year before attempting to code from this sectionGuidelines define and explain the assignment of codes, procedures, and services in a particular section
29 Unlisted Procedures/Services Unlisted procedure or serviceCodes are assigned when a procedure or service is performed by a provider for which there is no CPT code
30 Unlisted Procedures/Services Special ReportWhen an unlisted procedure or service code is reported
31 Unlisted Procedures/Services Special ReportNarrative document must accompany claim to describe nature and extent of the need of service or procedureSome practices place in Box 19 of CMS 1500 claim form the “unlisted code = the closest related code of XXXXX.”
32 Unlisted Procedures/Services NotesInstructional notes are found throughout
33 Unlisted Procedures/Services Blocked unindented note:Located below a subsection title and contains instructions that apply to all codes
34 Unlisted Procedures/Services Indented parenthetical note:Located below a subsection title, code description, or code description that contains an exampleHighlight and understand each of these notes
35 CPT Modifiers Clarify services and procedures performed by providers Have always been reported on claims submitted for provider office services and procedures
36 CPT Modifiers Coding tip: List of all CPT modifiers with brief descriptions is located inside front cover of coding manual
37 CPT ModifiersDocumented history, examination, and medical decision makingMust “stand on its own” to justify reporting modifier -25 with the Evaluation and Management (E/M) code
38 CPT Modifiers E/M service: Must be “above and beyond” what is normally performed during a procedure
39 Coding Procedures and Services Step 1:Read introduction in CPT coding manualStep 2:Review guidelines at beginning of each sectionStep 3:Review procedure
40 Coding Procedures and Services Step 4:Refer to CPT indexLocate main term for procedure or service documentedMain terms can be located by referring to the following:
41 Coding Procedures and Services a. Procedure or service documentedb. Organ or anatomic sitec. Condition documented in the recordd. Substance being tested
42 Coding Procedures and Services Synonym (term with similar meaning)Eponym (procedures and diagnoses named for an individual)Abbreviation
43 Coding Procedures and Services Step 5:Locate sub terms and follow cross referencesStep 6:Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements
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 Surgery Section Surgery section is organized by body system Some subsections are further subdivided by procedure categories
46 Surgery Section Incision Excision Introduction or removal Repair, revision, or reconstructionGrafts
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 Evaluation and Management Located at the beginning of CPT because these codes describe services most frequently provided by physiciansBefore assigning E/M codesMake sure you review guidelines and apply any notes
50 Evaluation and Management For established patientsTwo of three key components must be considered
51 Evaluation and Management E/M code reported to a payerMust be supported by documentation in the patient’s record
52 Key Components E/M code selection is based on three key components: Extent of historyExtent of examinationComplexity of medical decision makingAll key components must be considered when assigning codes for new patients
53 Extent of ExaminationPhysical examination is an assessment of the patient’s organ and body system/s
54 Extent of Examination Categorized according to four types: Problem focused examinationExpanded problem focused examinationDetailed examinationComprehensive examination
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 optionsAmount and/or complexity of data to be reviewedRisk of complications and/or morbidity or mortality
56 Patient’s Records Should Include Laboratory, imaging, and other test results that are significant to the management of the patient careList of known diagnoses as well as those that are suspectedOpinions of other physicians who have been consulted
57 Patient’s Records Should Include Planned course of action for the patient’s treatmentReview of patient records obtained from other facilities
58 History and Examination Determined by:StraightforwardLow complexityModerate complexityHigh complexity
59 History and Examination Once the extent of history, extent of examination, and complexity of medical decision making are determinedSelect the appropriate E/M code
60 Presenting ProblemCPT 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 Presenting Problems Minimal Self-limited or minor Low severity Moderate severityHigh severity
62 Face-to-Face TimeAmount of time the doctor spends with the family or the patient
63 Unit/Floor TimeAmount of time the doctor spends at the patient’s bedside and at the management of the patient’s care.
64 E/M Time Claiming E/M on time you must have: Total length of time for the encounterPlus the length of time spent coordinating care and/or counseling patientIssues discussedRelevant history, exam, and medical decision making
65 Observation Services Are furnished in a hospital outpatient setting Patient is considered an outpatientThey are reimbursed only when the doctor orders it
66 Subcategories Include Observation care discharge servicesInitial observation care
67 Hospital Inpatient Services E/M services provided to hospital inpatients, including partial hospitalization services.
68 Subcategories Include Initial hospital careSubsequent hospital careObservation care servicesHospital discharge services
69 ConsultationsType 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 Criteria Consultation is requested by another doctor or provider Consultant renders an opinion or advice
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 CriteriaConsultant’s opinion, advice, and any services rendered are documented in the patient’s recordThese are reported to the requesting physician or source
73 Subcategories Include Office or other outpatient consultationsInpatient consultations
74 Emergency Department Services Are given in a hospital setting that is open 24 hours to provide services that are not scheduled.
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 servicesExcluding time for allowable services
76 NeonatalA neonate is a newborn up until 28 days, and an infant is 29 days to a year old.
77 Subcategories Inpatient pediatric critical care Inpatient neonatal critical careContinuing intensive care services
78 Nursing Facility Services Are provided at nursing facilities:Skilled nursing, intermediate care, and long-term care
80 Prolonged ServicesMay be reported when a doctor’s services involving patient contact are considered beyond the usual service in either an inpatient or outpatient setting.
81 Subcategories Prolonged physician service with direct face-to-face Prolonged physician services without face-to-facePhysician standby services
82 Newborn CareIncludes services provided to newborns in a variety of health care settings.
83 Qualifying Circumstances for Anesthesia When situations or circumstances make anesthesia administration more difficult and increases the patient’s risk factor.
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 Modifiers P1 P2 P3 Normal health Mild systemic disease Severe systemic disease
86 ModifiersP4Severe systemic disease that is a constant threat to lifeP5Not expected to survive without the operationP6Declared brain-dead and whose organs are being removed for donor purposes
87 Anesthesia Time UnitsBe sure to record the time with the anesthesiologistAnesthesia time unit is one 15-minute increment
88 Calculating Anesthesia Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesiaNonmonitored interval timeRecovery room timeRoutine postoperative evaluation by the anesthesiologist or CRNA
89 Separate ProcedureFollows a code explanation identifying procedures that are an important part of an additional procedure or service.
90 Complete ProcedureWhen the word “complete” is established in the code definitionOne code is reported to “completely” explain the procedure performed
91 Pathology and Laboratory Organized according to the kind of pathology or laboratory procedure performed
92 Pathology and Laboratory Subsections Organ or disease oriented panelsDrug testingTherapeutic Drug AssaysConsultations (Clinical Pathology)Urinalysis, chemistry, hematology and coagulation immunologyMicrobiology
93 Pathology and Laboratory Subsections Anatomic pathologyCytopathology and cytogenetic studiesSurgical pathologyTranscutaneous proceduresOther proceduresReproductive medicine procedures
94 National Correct Coding Initiative To encourage national correct coding, methodologies, and manage the improper assignment of codes.
95 National Correct Coding Initiative Incorrect codingResults in inappropriate repayment of Medicare Part B claimsCenters for Medicare and Medicaid Services implemented the National Correct Coding Initiative
96 NCCI Coding PoliciesAnalysis of standard medical and surgical practiceCoding conventions included in CPTCoding guidelines developed by national medical specialty societiesLocal and national coverage determinationsReview of current coding practices