1. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 5 Introduction to CPT ® and Place of Service Coding

2. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CURRENT PROCEDURE TERMINOLOGY (CPT)  Developed and published by the American Medical Association (AMA)  First published in 1966  Attempt to standardize terms for procedures  Link with diagnosis codes to establish medical necessity

3. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS) AND CPT  Adopted CPT in 1983  Used as part of Healthcare Procedure Coding System (HCPCS)  Mandated usage for Part B Medicare

4. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes E/M SECTION  Divided into broad services such as office visits, hospital visits, and consultations

5. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes E/M SECTION  Most categories are then divided into subcategories of services, such as new patient, established patient, initial hospital care, subsequent hospital care; initial pediatric care, subsequent pediatric care; and initial neonatal critical care, subsequent neonatal critical care.

6. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes E/M SECTION  The CPT coding system makes specific distinctions for place of service in the evaluation and management codes

7. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes OTHER SERVICES E/M SECTIONS  Prolonged services  Physician standby services  Other services not coded to POS

8. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes OFFICE VERSUS HOSPITAL SERVICES  Office services most reported  Hospital observation  Hospital inpatient  Emergency department

9. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CPT CATEGORIES  Category I  Category II  Category III

10. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CATEGORY I CODES  Procedure or services  Subject to lengthy approval process  Restricted to clinically recognized services

11. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CATEGORY II CODES  Optional tracking codes  Used for performance measurement  Developed to standardize collection of data  Use is optional  Newly approved codes are added twice a year via electronic distribution on the AMA website

12. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CATEGORY III CODES  Emerging technology  Temporary codes  Located following category II section

13. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CPT NOMENCLATURE Revised code. A triangle indicates that the code’s descriptor has changed. New code. This symbol indicates new to this edition

14. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CPT NOMENCLATURE New or revised text. These symbols enclose new or revised text other than the code’s descriptor. Add-on code. Describes secondary procedures only. Cannot be used as a primary code. +

15. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CPT MODIFIERS  Two-digit numeric indicators preceded by hyphen  Found in guidelines of Anesthesia section and Appendix A  Indicate that code description has been altered

16. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes MODIFIERS USED FOR EVALUATION AND MANAGEMENT CODING  21 Prolonged Evaluation and Management Service – used when the service provided is greater than the highest level described for the code range

17. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes MODIFIERS USED FOR EVALUATION AND MANAGEMENT CODING  24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period is used when the E/M service is not related to the reason for surgery and is provided within the postoperative tie period (global period) in the payer’s reimbursement.

18. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes MODIFIERS USED FOR EVALUATION AND MANAGEMENT CODING  25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service is used when the physician provides an E/M service in addition to another E/M service or procedure on the same day.

19. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes MODIFIERS USED FOR EVALUATION AND MANAGEMENT CODING  32 Mandated Services is used when it is requested by the payer.  52 Reduced Services is used when an E/M service is less extensive than the descriptor indicates

20. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes MODIFIERS USED FOR EVALUATION AND MANAGEMENT CODING  57 Decision for Surgery is used to indicate the visit was scheduled because a decision to have surgery was made and the patient was informed and counseled about the risks and outcomes.

21. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes TYPE OF PATIENT  New patient: Has not received professional services in past 3 years from a physician in the group practice  Established patient: Has received professional services in the same group practice

22. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes TYPE OF PATIENT  Referral: Transfer of total care or specific portion of care from one physician to another  Consultation: Occurs when a second physician, at the request of the patient’s physician or another appropriate source, examines the patient and renders an opinion.

23. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes LEVEL OF E/M SERVICE  Three to five levels available  Levels describe variations in skill, effort, time, and medical knowledge required for prevention, diagnosis, or treatment.

24. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes THREE KEY COMPONENTS IN E/M  Extent of history  Extent of examination  Extent of medical decision making

25. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes COMPONENTS OF E/M SERVICE  Extent of patient history documented  Extent of examination  Complexity of medical decision making  Nature of presenting problem  Coordination  Counseling  Time

26. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes EXTENT OF HISTORY  CC: Chief complaint- a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the visit/encounter, usually stated in the patient’s or guardian’s words

27. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes EXTENT OF HISTORY  HPI: History of present illness - a chronological description of the development of the patient’s illness from the first sign and/or symptom to the present.

28. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes EXTENT OF HISTORY  ROS: Review of systems - an inventory of body systems obtained through a series of questions asked by the physician.  PFSH: Past, family, and social history - includes a review of past medical experiences of the patient and the patient’s family.

29. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes EXTENT OF EXAMINATION  Problem focused  Expanded problem focused  Detailed  Comprehensive

30. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes COMPLEXITY OF MEDICAL DECISION MAKING  Number of possible diagnoses  Number of possible management options  Amount and/or complexity of medical records  Risk of complications or morbidity and/or mortality

31. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes ADDITIONAL COMPONENTS  Time  Counseling