1. Chapter 4
PROCEDURAL CODING

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. Organization of The CPT
Codes divided into 6 Sections
Section
Range Of Code
Evaluation and Management
Anesthesia
Surgery
Radiology
Pathology and Laboratory
Medicine
Chapter 4

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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
Chapter 4

33. 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

34. 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

35. 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

36. 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

37. 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 explains the dressing change for “other than burns” and “under anesthesia (other than local)”.
Chapter 4

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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