1. MEDICAL Billing and Coding TEMBC Education Explicit Intentional Instruction

2. CURRENT PROCEDURAL TERMINOLOGY Overview of CPT The CPT Manual Modifiers CPT-Category I Codes CPT-Category II Codes CPT-Category III Codes Unlisted CPT Codes HCPCS Level II Codes

3. Overview of CPT CPT (current procedural terminology) refers to a listing of terms and identification codes in order to report or claim medical services and procedures that have been performed by health care professionals. The intention of coding is to provide a uniform language in order to describe medical, diagnostic and surgical services and procedures, therefore providing an effective norm for communication between physicians and health care professionals, patients and third parties. The CPT Editorial Panel, comprised of 17 members, is authorized by the American Medical Association Board of Trustees to revise, modify and update codes, descriptors, guidelines and rules and maintaining the CPT code set. Application of CPT codes and guidelines is essential to an efficient collection processing system. As of now, the only implementation guidelines that covered entities such as physicians and other health care professionals are required to follow are the rules for the ICD-9-CM code set.

4. Definition Medical Billing and Coding Healthcare providers are reimbursed based on these codes submitted on CMS-1500 claim forms for the procedures and services rendered. Reporting of correct codes is essential as incorrect coding can result in wrongful reimbursement or even penalties for physicians for submitting inappropriate claims. There are 3 types of CPT Codes: Category I (consists of six main sections) Codes for Evaluation and Management Codes for Anesthesia Codes for Surgery Codes for Radiology Codes for Pathology and Laboratory Codes for Medicine Category II Performance measurement Category III Emerging technology

5. THE CPT MANAUAL The CPT manual contains three categories of codes. Category I codes, also called regular CPT codes, are the major pat of the CPT manual, containing codes beginning with the code 00100 and ending with code 99607. These codes are used to report the physician’s services. All Category I codes are numeric and are divided into six sections: Evaluation and Management Services Anesthesia Surgery Radiology Pathology and Laboratory Medicines The CPT manual Category II codes are meant to measure the performance of certain services. Use of Category II codes is not mandatory for coding purpose. Category III codes are codes for new and emerging technology, procedures and services. The codes representing the services listed in Category III can be incorporated into regular CPT codes if approved by the FDA.

6. THE CPT MANUAL After Category III codes the CPT manual contains a list of appendices, ranging form A to M. Appendix A – list of 2 digit CPT codes which are called modifiers Appendix B -summary of additions, revisions, and deletions in the CPT manual Appendix C – list of clinical examples to ensure understanding of CPT codes Appendix D –summary of add-on codes Appendix E – summary of CPT codes which are excluded form modifier 51 Appendix F – list of modifier 63 excluded procedures Appendix G – of moderate (conscious) sedation codes Appendix H – alphabetic index of performance measures by clinical condition or topic Appendix I – genetic testing modifiers Appendix J – electro-diagnostic medicine listing of sensory, motor and mixed nerves Appendix K- codes pending FDA approval Appendix L – listing of vascular families Appendix M – list of deleted CPT codes

7. THE CPT MANUAL Modifiers Modifiers are added to regular CPT codes to show the circumstances that cause changes form the exact code description of regular CPT codes or toss how additional information to insurance companies so that the correct amount will be reimbursed according to the service rendered. Ad on Codes All Category I CPT codes with a +symbol are add-on codes. Certain procedures of CPT are commonly carried out in addition to primary procedures performed. These additional procedures are designated as add-on codes. Add-on codes are never reported as a primary code or as a standalone code, and are all excluded from appending modifier 51. Moderate Sedation Moderate Sedation is a technique of providing medication for anxiety and discomfort relief during medical procedures. In contrast to general anesthesia where the patient is completely unconscious, patients that are receiving moderate sedation are semiconscious but comfortable. Codes that are listed with a bull’s eye symbol are CPT codes where the amount for overate sedation is included in that code and an additional code for moderate sedation is not required.

8. THE CPT MANUAL CPT Manual Index The CPT manual provides an extensive index at the end which is organized by main terms. Each main term is standalone or followed by two to three sub-term entries. There are four classes of main term entries which are based on: Name, procedure, or service Name of organ or anatomic site Condition Synonyms, eponyms, and abbreviations When using the CPT index to search for codes, it is recommended to see the complete code description to accurately assign codes for procedures. If the CPT index search provides a range of codes, it is best to search all codes in the given range in order to assign the correct code.

9. MODIFIERS 22 Increased Procedural Services work required to provide service is substantially greater than what is typically required 23 Unusual Anesthesia procedure that usually requires no or local anesthesia that must be performed under general anesthesia because of usual circumstances 24 Unrelated Evaluation and Management Service by Same Physician during Postoperative Period physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason, or reason, unrelated to the original procedure 25 Significant, Separately Identifiable Evaluation and Management Service by Same Physician on Same Day of the Service Procedure patient’s condition required a significant, separately identifiable evaluation and management service above and beyond another service provided, or beyond usual preoperative and postoperative care associated with the procedure 26 Professional Component certain procedures are a combination of a physician component and a technical component.

10. MODIFIERS 27 Multiple Outpatient Hospital Evaluation and Management Encounters on Same Date for hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct evaluation and management encounters 32 Mandated Services services related to mandated consultation and/or related services 47 Anesthesia by Surgeon regional or general anesthesia provided by surgeon 50 Bilateral procedure bilateral procedures that are performed at the same operative session 51 Multiple Procedures Multiple procedures other than evaluation and management services, are performed at the same session by the same provider Primary procedure is reported as listed, additional procedure identified by modifier 51 52 Reduced Services Under certain circumstances a procedure or service is partially reduced or eliminated at the physician’s discretion 53 Discontinued Procedure Under certain circumstances the physician can elect to terminate a diagnostic or surgical procedure

11. MODIFIERS 54 Surgical Care Only one physician performs surgical procedure and another physician provides preoperative and/or postoperative management 55 Postoperative Management Only One physician performed the postoperative management and another physician performed the surgical procedure 56 Preoperative Management Only One physician performed the preoperative cane and evaluation and another physician performed the surgical procedure 57 Decision for Surgery Evaluation and management service resulting in the initial decision to perform the surgery 58 Staged or Related Procedure or Service by same physician during postoperative period performance or a service or procedure during the postoperative procedure or for therapy following the surgical procedure 59 Distinct Procedural Service Under certain circumstances it may be necessary to indicate that a procedure or service was distinct or independent from other non evaluation and management services performed on the same day

12. MODIFIERS 62 Two surgeons two surgeons work together as primary surgeons performing distinct part(s) of a procedure 63 Procedure performed on infants less than 4kg procedures performed on neonates and infants up to 4kg may involve significantly increased complexity and physician work 66 Surgical Team Under some circumstances highly complex procedures require the concomitant services of several physician, often of different specialties 73 Discontinued Outpatient Hospital/Ambulatory Surgery Center Procedure prior to the administration of anesthesia 74 Discontinued Outpatient Hospital/Ambulatory Surgery Center Procedure after the administration of anesthesia 77 Repeat Procedure by another physician procedure or service was repeated subsequent to original procedure or service 78 Unplanned return to the operating/procedure room by same physician 79 Unrelated procedure or service by same physician during postoperative period 80 Assistant Surgeon 81 Minimum Assistant Surgeon

13. MODIFIERS 82 Assistant Surgeon When qualified resident surgeon is not available 90 Reference Laboratory (outside) laboratory procedures are performed by a party other than the treating or reporting physician 91 Repeat Clinical Diagnostic Laboratory Test in the course of treatment it may be necessary to repeat same laboratory test on same day in order to obtain subsequent test results 92 Alternative Laboratory Platform Testing Laboratory testing is performed using a kit or transportable instrument 99 Multiple Modifiers Under certain circumstances two or more modifiers may be necessary to completely describe a service

14. CPT-CATEGORY I CODES CPT Category I codes are the common 5-digit codes which describe a procedure or service. To be considered a Category I code. CPT requires that the procedure or service is widely accepted in the medical community, the the FDA (Food and Drug Administration) approval of a drug or device associated with the procedure is documented or approaching within a specific CPT cycle and that the procedure or service has proven clinical efficacy. These codes are also known as HCPCS Level I codes and are created and maintained by the CPT Editorial Panel and are released each year, with implementation January 1 st. Once a procedure is approved as a Category I code, the code is referred to the RUC (relative Value Update committee for a valuation recommendation. The RVU (relative value unit) assignment for a particular code is determined by the practice expense, amount of work and malpractice expense associated with the procedure. The RUC makes a recommendation to CMS (Center for Medicare and Medicaid Services) on physician work and practice expense ‘direct inputs’. It is CMS that makes the final determination on the assignment of RVUs. Medicare payment is then determined by multiplying these RVUs by a conversion factor. The RVUs assigned are published annually in the Federal Register in the “Medicare Physician Fee Schedule”.

15. CPT-CATEGORY I CODES The 6 main sections of Category I codes are: 1.Evaluation and Management – code range 99201-99499 2.Anesthesia – code range 00100-01999, 99100-99150 3.Surgery code range: 10021-69990 4.Radiology code range: 70010-79999 5.Pathology and Laboratory code range 80047-89298 6.Medicine code range 90281-99199, 99500 -99607

16. CPT-CATEGORY II CODES Category II codes are performance measurement codes with alphanumeric code designations and are optional. These codes are used to indicate the performance of certain services or test results which contribute to quality patient care, and were established to decrease the need to audit charts manually for this information. An example for Category II codes are services that are typically included in evaluation and management services or that are a component or another service. Because these codes are optional, reporting of Category II codes is not required for correct coding and may used for informational purposes only with no payment associated with these codes. Category II codes may also describe results from radiology or clinical laboratoty tests and other procedures, identified processes intended to address patient safety practice or services reflecting compliance with feral or state law. Category II codes are published bi-annually, Jnuary 1 st and July 1 st.

17. HCPCS LEVEL II CODES The Healthcare Common Procedure Coding System, known as HCPCS, is set of codes used by Medicare and monitored by the Centers for Medicare and Medicaid Services, known as CMS. HCPCS is based on the Current Procedural Terminology (CPT) that was developed by the American Medical Association. The codes are numbers that are assigned to every service or procedure a physician or healthcare professional provides to a patient, including medical, diagnostic or surgical services. Such coding is necessary for Medicare, Medicaid as well as other health insurance programs in order to ensure that claims are processed in order and consistency. There are two sets of codes in the HCPCS. The first set is known as HCPCS Level I codes, which are based and identical to the CPT Category I codes. HCPCS Level II codes are used by medical suppliers other than physicians, such as durable medical equipment or ambulance services and are alphanumeric. As these are generally not costs to pass through a physician’s office, these must be handled by Medicaid or Medicare differently as an insurance company would.