Chapter 6 Procedural Coding Lesson 4 Topic 2 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Procedure Coding Procedure coding: the transformation of written descriptions of procedures and professional services into numeric designations (code numbers). Procedure codes are a standardized method used to precisely describe the services provided by physicians and allied health professionals. CPT code book is published annually by the AMA. Discuss the differences between procedure coding and diagnosis coding. (procedure coding is for the services rendered to the patient during the encounter, while diagnosis coding is for the conditions ascribed to the patient.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Levels of Medicare HCPCS Coding Level I: The AMA CPT codes and modifiers (national codes) Level II: CMS-designated codes and alpha modifiers (national codes) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Current Procedural Terminology (CPT) Five-digit system for coding services Two-digit add-on modifiers Represents diagnostic and therapeutic services System of choice from CMS What is a “modifier?” (a two-digit add-on number placed after the usual procedure code number to indicate a procedure or service has been altered by specific circumstances) Are CPT codes used for outpatient or inpatient encounters? (outpatient) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Code Selection Formula Physician or provider service = CPT code Supplies = HCPCS national code Instructions to use from carrier = local code Integrative health care products = Alternative Billing Codes (ABCs) Have students differentiate between the three types of codes. (CPT is used for services provided, HCPCS are used for supplies or durable goods) Private insurance companies may not accept Level II HCPCS codes. Confirm with the carriers before submitting insurance claims using Level II HCPCS codes. ABCs are used for services that are considered alternative or complementary medicine. What would be an example of such services? (acupuncture, osteopathic medicine, etc. Answers will vary. See p. 163 of the textbook.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Methods of Payment Fee schedule Usual, customary, and reasonable Multiple schedules can be used Consistent charges and uniform application Usual, customary, and reasonable Three fees determine reimbursement Relative value scales or schedules Units (RVUs) based on median charges for all physician during a given time period Conversion factors translates units to dollars Explain the difference between fee schedule, UCR, and RVS payment methods. (A fee schedule is a listing of acceptable charge or established allowances for specific medical procedures; UCR uses three fees [usual, customary, reasonable] to determine reimbursement; RVS uses units based on median charges of all physicians during a given time period, and a conversion factor is used to translate the units into dollar fees for each service.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Format & Content of the CPT Main sections are divided into categories and subcategories according to Anatomic body system Procedure Condition Description Specialty CPT I is divided into eight code sections, with categories and subcategories. There are 13 appendices for extra information. See Fig. 6-3AB (pp. 167-168) for an example of the CPT format. Remember, CPT codes are considered Category I. Category II codes describe clinical components that may be included in E/M services and do not have an associated relative value. Category III codes are temporary codes used for tracking emerging technologies that do not yet have procedure code assignment in Category I. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

CPT Code Book Symbols CPT has conventions, similar to ICD-9-CM. See Fig. 6-4 (p. 169). Symbols indicate different types of codes and which instructions should be followed when assigning that code. Drill students by giving them examples and having them identify which symbol would be used to indicate your example. (Answers will vary.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Evaluation & Management Divided into three sections Office visits New patients Established Hospital visits Initial visit Subsequent visits Consultations E/M codes describe physician’s services involving the evaluation and management of a patient’s problem. What is the difference between a new and an established patient? (a new patient HAS NOT received professional services from a physician or a physician group practice in the past three years; an established patient HAS received professional services from a physician or a physician group practice in the past three years) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Elements of E/M Codes History Examination Medical decision making Nature of presenting problem Counseling Coordination of care Time History, examination, and medical decision making are considered “key components” of an E/M code. Nature of presenting problem, counseling, coordination of care, and time are considered “contributory factors.” Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Subsections of E/M Hospital inpatient services Consultation Critical care Pediatric and neonatal critical care Emergency care Preventative medicine For hospital inpatient services, the physician includes the services related to the admission that were provided in other settings (like the ED). What is a consultation? (services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation and treatment of a patient.) What is critical care? (direct delivery of medical care by a physician for a critically ill or injured patient.) Time is a key factor in critical care codes and must be documented in the patient record. The same definitions for critical care services apply for an adult, child, and neonate, despite the separate section for pediatric/neonatal critical care. Emergency care could include services rendered in an emergency department or an emergency visit in a physician office. Types of counseling may be considered preventative medicine. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Selecting an E/M Code Determine category Determine subcategory Note key components Note contributory factors Determine appropriate E/M level and code Documentation must be reviewed to determine the key components and the contributory factors. Different levels indicate complexity of the office visit (1 is least complex, 5 is most complex). See Example 6.6 (p. 177) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Evaluation & Management Fig. 6-5 (p. 175). Discuss each of the notes 1-6 from this figure to ensure understanding of the E/M section. (key components and contributory factors are identified to assign the correct E/M code) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

CPT Code Digit Analysis Example 6.6 (p. 177). All procedure codes are five digits. Discuss the breakdown of digits as shown in this slide. (the first two digits are the code book section, the fourth digit is the type of patient, and the fifth digit is the complexity level.) Explain whether a level 2 is more or less complex than a level 5 E/M code. (A Level 2 code is less complex than a Level 5 code.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Surgery Section Always start with the operative report Assign code for postoperative diagnosis Assign codes for additional diagnoses Attach documentation to the claim form Code only documented procedures Confirm all diagnosis and procedure codes Be sure to use appropriate modifiers Only attach documentation to the claim form if necessary, and note “attachment” in Block 19. Read through the report before coding to confirm any additional diagnoses. Surgical code descriptions may define a correct coding relationship wherein one code is part of another based on the language used in the description. See Example 6.7 (p. 178). Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Unlisted Procedures Codes assigned for unusual procedures Supporting documentation is required to justify the procedures Comprehensive list of unlisted codes is at the beginning of each section. See Example 6.10 (p. 182). Some payers do not reimburse for unlisted procedures. Check guidelines before submitting claims. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Unbundled Codes Unbundling: coding and billing numerous CPT codes to identify procedures usually described by a single code. Example 6.15 and Example 6.16 (p. 185), Unbundling is considered fraud if it is done intentionally to gain increased reimbursement. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Unbundled Codes (cont’d.) Example 6.17 and Example 6.18 (p. 185) The use of outdated codes often inadvertently results in unbundling. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Downcoding and Upcoding Downcoding: when a coding system of an insurance carrier converts a code to reduce the level of codes on an insurance claim Upcoding: the deliberate manipulation of CPT codes for increased payment See Example 6.19 and Example 6.20 (p. 186). Is downcoding illegal? (Yes, in most states. When a payer receives a claim, the payer is allowed to pay or deny the claim. The claim should not be altered, but information can be clarified with the provider.) To prevent downcoding, make sure that the documentation form the provider supports the code that is being submitted. Is upcoding illegal? (Yes. It can be considered fraud or abuse in an external audit.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Modifiers Modifiers can indicate: A service or procedure has either a professional or technical component. A service or procedure was performed by more than one physician or in more than one location. A service or procedure has been increased or reduced. A service or procedure was provided more than once. Only part of a service was performed. An adjunctive service was performed. A bilateral procedure was performed. Unusual events occurred. Describe the types of services and procedures in which a modifier would be necessary. (A modifier is necessary when circumstances in which a procedure is performed differs in some way from that described in its usual five-digit code) See Example 6.21 (p. 188) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Steps for Effective Coding Always read the Introduction section at the beginning of the code book. Read the guidelines at the beginning of each of the six sections of the book. Read the notes and special subsection information throughout the Surgery, Radiology, Pathology, and Medicine sections. Use the index at the back of the book to locate a specific item by generalized code numbers, NOT by page numbers. Locate the code number in the code section and read through the narrative description to locate the most appropriate number to apply to the patient’s procedure. Explain why it is important to read the Introduction in the CPT code book. (There are rules and guidelines in the Introduction that affect code assignment.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Steps for Effective Coding (cont’d.) When trying to locate an E/M code, identify the place or type of service rendered. Then identify whether the patient is new or established and locate the category or subcategory. Review any guidelines or instructions pertaining to the category or subcategory. Read the descriptors of the levels of E/M service. Identify the requirements necessary for code assignment. Make sure the components necessary were performed by the physician and documented in the chart, and then assign the E/M code. Transfer the five-digit code number to the claim form exactly as given for each procedure. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.