Chapter 4 PROCEDURAL CODING

PROCEDURAL CODING Learning Objectives Identify the purpose and format of the Current Procedural Terminology (CPT). Name three key factors that influence the selection of Evaluation and Management codes. Recognize surgical packages and laboratory panels that are coded as single procedures. Describe the three levels of codes in the Health Care Financing Administration’s Common Procedure Coding System (HCPCS) and discuss when they should be used. Find correct procedure codes using CPT. Chapter 4

Key Terms Add-on code Attending physician Category II codes Category III codes Centers for Medicare and Medicaid Services (CMS) Code linkage Consultation Current Procedural Terminology (CPT) E/M code Established patient Global period Health Care Common Procedure Coding System (HCPCS) Main number Modifier Chapter 4

Key Terms New patient Panel Primary procedure Procedure code Referral Surgical package Unbundle Unlisted procedures Chapter 4

Introduction to Procedural Coding Procedure code(s) Detail the treatment and services provided to the patient by the provider, such as surgery and diagnostic tests, and medical services, such as examination to evaluate a patient’s condition. Use standardized, numeric codes. Chapter 4

Introduction to Procedural Coding Code Linkage The connection between a service and a patient’s condition or illness Establishes the medical necessity of the procedures. Chapter 4

Organization of The CPT Published by the American Medical Association (AMA). Currently in 4th edition. Published Yearly New codes added/old codes deleted Available as software, such as Encoder Pro Chapter 4

Organization of The CPT Category I Codes 5 Digits Numbers Organized into Six Sections Arranged in Numerical order, except for “Evaluation & Management” Each section open with “Guidelines” that apply to its procedure. Chapter 4

Organization of The CPT Codes divided into 6 Sections Section Range Of Code Evaluation and Management 99201-99499 Anesthesia 00100-01999 Surgery 10021-69990 Radiology 70010-79999 Pathology and Laboratory 80047-89356 Medicine 90281-99607 Chapter 4

Organization of The CPT Codes divided into 6 Sections - Cont Sections are divided into subsections They are further divided into headings according to the type of test, service, or body system. Code ranges on a page are found in the upper-right corner Sections are arranged in numerical order (exception E/M, & Anesthesia). Chapter 4

Organization of The CPT Procedure Codes are located by referring to: The CPT Index (an alphabetic index of procedures, organs and conditions) Main Terms are in Bold May be followed by descriptions and groups of indented terms. Codes are selected by reviewing each description and indented term under the main term. PERFORMANCE EXERCISE Figure 4-1 – Page 63 Chapter 4

The CPT Format/Symbols Special Symbols (highlight changes or special points)  new procedure  change in code’s description  new or revised information  add-on codes (procedures carried out in addition to other procedures) Chapter 4

The CPT Format/Symbols Special Symbols (highlight changes or special points) – Cont.  (Bullet inside a circle) next to a code means that the conscious sedation is a part of the procedure that the surgeon performs.  (Lightning Bolt) is used with vaccine codes that have been submitted to the Federal Drug Administration (FDA) and are expected to be approved for use soon. The Code can not be used until approved When approved the symbol is removed for the next printing of the CPT. Chapter 4

The CPT Format/Listings Numbering Written as XXXXX-XX 5 digits plus 2 digit modifiers when necessary Modifiers Always shown with hyphen Complete listing in Appendix A Appendix A details proper use Modifiers that pertain to each section are also listed in each section Chapter 4

The CPT Format/Listings Modifiers Show that some special circumstance applies to the service or procedure the physician performed. Example: -62 indicates two surgeons worked together, each performing part of a surgical procedure, during an operation. Each physician will be paid part of the amount normally reimbursed for that procedure code. -80 indicates that the service of a surgical assistant were used, and Each the assistant’s fee are a part of the claim. Chapter 4

Using the CPT(cont’d) The CPT Index Main Terms Modifying Terms Listed by procedure or service; organ or anatomic site; condition; or synonyms, eponyms, and abbreviations. Modifying Terms In parentheses ( ) Don’t affect the code selection Code ranges Commas separate codes (Non-Sequential) Hyphens show ranges of 3 or more codes (Sequential) Chapter 4

Using the CPT (cont’d) CPT format Common Entry Indented Material Notes appear in ( ) Chapter 4

Using the CPT(cont’d) Unlisted Procedures A service not listed in CPT Codes are located in guideline at beginning of each section of the CPT, except Anesthesiology. Unlisted codes for Anesthesiology can be found under the “Other Procedures” Subsection. Use as a last resort, then: A Detailed report must be attached to claim Chapter 4

Using the CPT(cont’d) Category II Codes Listed at the end of Category 1 (CPT Codes) Used to track performance measures for a medical goal such as reducing tobacco use. Reporting these codes are optional, because they are not paid. Alphabetic charter for the 5th digit (such as, 0002F for tobacco use, smoking, assessed) Chapter 4

Using the CPT(cont’d) Category III Codes Listed after the Category II codes. Are temporary codes for emerging technology, service, and procedures. If a Category III code exists for a service, it must be used, rather than an unlisted code. Alphabetic 5th digit (such as 0041T for urinalysis infectious agent detected) Chapter 4

Coding Evaluation and Management (E/M) Three Key Factors to determine the Level of Service: Extent of patient History Extent of Exam Complexity of Medical Decision Making Chapter 4

Coding Evaluation and Management (E/M) In addition to the level of service: Health Plans want to know if the Physician treated a New or Established Patient New or Established Patient NP - not seen before (or for 3 years) EP - seen within 3 years Chapter 4

Coding Evaluation and Management (E/M) Location of Service (POS) Location is important, because different procedural codes apply depending on where the procedures were performed. EXAMPLE: Procedures Code for services done in a physician office differ from those done in a hospital) Hospital Coding describe time as “Unit” or “Floor” time. The definition includes the physician’s time spent in the hospital unit or review medical records or talk with hospital staff about the patient’s care and time spent directly with the patient. Chapter 4

Referral & Consultation Patient is sent to another physician for examination and treatment Consultation The service performed by one physician for the purpose of advising an attending physician about a patient’s condition and care. Chapter 4

Types of Consultations Initial Consultation Is when the physician ask for consultation with another physician. Confirmatory Consultation Is when patient ask for consultation with another physician. Chapter 4

Coding Surgical Procedures Codes in the Surgery Section represent groups of procedures that include all routine elements, called a “Surgical Package” Surgical Package includes: Combination of Services included in a single procedure code for some surgical procedures in CPT Groups of services that should not be listed individually Payer assign a fee to these codes that reimburse all the services provided under them. Chapter 4

Coding Surgical Procedures Surgical package includes (Cont. ): The period of time that is covered for following-up care is referred to as the Global Period. Example of Global Period: A Global Period for repairing a “Tendon” may be set at 15 days. A Global Period for major surgery such as an appendectomy may be set at 100 days. After the Global Period ends, additional services that are provided can be reported separately for additional payment. Chapter 4

Coding Surgical Procedures Two type of services not included in a Surgical Package Complications or recurrences that arise after therapeutic surgical procedures. 2. Care for the condition for which a diagnostic surgical procedure is preformed. Routine follow-up care included in the code refers only to care related to recovery from the diagnostic procedure itself, not the condition Chapter 4

Coding Surgical Procedures When Health Plans pay for more than one surgical procedure performed on the same day for the same patient, they pay the full amount for the first listed surgical procedure. The Health Plan pay less than the full amount for the other procedures. For maximum payment for reimbursement with multiple procedures, the coder should list the procedure with the highest level code first. The other procedures are listed with the modifier -51 or modifier -59. Chapter 4

Coding Surgical Procedures Modifiers 51 Used for multiple procedures at the same body site or system. Modifiers 59 Indicates distinct procedures, each fully reimbursed, rather than multiply procedures. EXAMPLE: Modifier 59- is usually used when the surgeon performs procedures on two different body sites or organ systems, such as the excision of a lesion on the chest as well as the incision on drainage (I&D) of an abscess on the leg. Chapter 4

Coding Laboratory Procedures Organ/Disease-Oriented Panels listed in the Pathology & Laboratory section include: Tests frequently ordered together When tests are performed together, the code for the panel must be used, rather than listing them separately Do not unbundle the Panel Chapter 4

Coding Immunizations Coding Immunizations Two codes are required A Code for Injection A Code for Vaccine EXAMPLE: Influenza shot (the administration code 90471) is used for the injection. Along with one of the codes for the specific Vaccine, such as 90655, 90657, 90658, or 90660. Chapter 4

HCPCS Codes The Health Care Financing Administration’s Common Procedure Coding System (HCPCS), was developed by the Health Care Financing Administration (HCFA) for use in coding services for Medicare Patients. Level 1 – Duplicates the CPT Level II - issued by CMS in Medicare Carrier Manual Supplies, drugs, durable medical equipment 5 characters plus modifiers; alphanumeric Chapter 4

Five Steps to Procedural Coding Step 1 Become familiar with CPT codes Step 2 Find the services listed on patient encounter form Step 3 Look up codes in index, then look up actual code Step 4 Determine appropriate modifiers Step 5 Record the procedure code on the insurance claim; PROOFREAD numbers Chapter 4

Five Steps to Procedural Coding Step 1 Become familiar with CPT codes Read the information and main section guidelines and notes. Pay attention to modifiers for each section, because they specify the exact nature of a procedure being reported Chapter 4

Five Steps to Procedural Coding Step 2 Find the services listed on patient encounter form Check the patient’s encounter form to see what services were performed. For E/M procedures look for clues as to the type of that were involved. history, examination, and decision making The encounter may also indicate the amount of time the physician spent with the patient. Chapter 4

Five Steps to Procedural Coding Step 3 Look up the procedure code Select a specific procedure or service, organ, or condition. Find the procedure code in the CPT’s Index. ie., to find the code for “dressing change”: First look in the alphabetic index for the procedures Then turn to the procedure code in the body of the CPT to be sure the code accurately reflect the service performed The procedure code 15852 explains the dressing change for “other than burns” and “under anesthesia (other than local)”. Chapter 4

Five Steps to Procedural Coding Step 4 Determine appropriate modifiers. In the section’s guidelines and notes, find the Modifiers that elaborate on details of the procedure being coded If multiple modifiers are required, use the five-digit main number and the modifier. Then list additional modifiers Chapter 4

Five Steps to Procedural Coding Step 5 Record The procedure code on the insurance claim form. If the patient has more than one diagnosis on a single claim form the Primary diagnosis or the Principal procedure is listed first. If secondary procedures are performed, match up each procedure with its correspondence diagnosis. Chapter 4

False, dx codes are written that way. Quiz CPT means _________ ________ ________. Current Procedural Terminology A ___________ is a 2-digit code that describes special circumstances. modifier The Level of Service helps determine the ___________. E/M code Supplies and drugs are coded using ________. HCPCS Procedure codes are written as 3 digits, a decimal, and 2 digits. (T/F) False, dx codes are written that way. Chapter 4

Excision of tendon, finger, flexor, single (separate procedure), each PERFORMANCE EXERCISE Excision of tendon, finger, flexor, single (separate procedure), each 26180 How to Code Effectively Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Chapter 6

Breast reconstruction with free flap PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Breast reconstruction with free flap 19364 Preoperative placement of needle localization wire, breast: 19290 Chapter 6

Closed treatment of mandibular fracture; without manipulation PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Closed treatment of mandibular fracture; without manipulation 21450 Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone. 26607 Chapter 6

PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 31231 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) 31622 Chapter 6

PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract 33414 Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography 92975 Chapter 6

Repair of palate; up to 2 cm PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Repair of palate; up to 2 cm 42180 Laparoscopy, surgical, appendectomy 44970 Chapter 6

Biopsy, prostate; needle or punch, single or multiple, any approach PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Biopsy, prostate; needle or punch, single or multiple, any approach 55700 Biopsy of ovary, unilateral or bilateral (separate procedure) 58900 Aspiration of bladder by needle 51000 Chapter 6

61107 Biopsy of Cornea 65410 PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device 61107 Biopsy of Cornea 65410 Chapter 6

Radiologic examination; forearm, two views PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Radiologic examination; forearm, two views 73090 Ultrasound, transvaginal 76830 Chapter 6

Acute hepatitis panel 80074 Insulin antibodies 86337 PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Acute hepatitis panel 80074 Insulin antibodies 86337 Chapter 6

Measles and rubella virus vaccine, live for subcutaneous use PERFORMANCE EXERCISE Identify Main Term(s) in the Procedure Description of the Medical Record Locate Main Term(s) in the Index & Document Code Range Turn to the Correct Section of the CPT & Read all Description listed in the Code Range Select the Correct Code Lyme disease vaccine, adult dosage, for intramuscular use 90665 Measles and rubella virus vaccine, live for subcutaneous use 90708 Chapter 6