Coding.

Coding

Coding TABLE OF CONTENTS Lessons 1. Coding Go 2. Diagnostic Coding Go
3. Procedural Coding Go TABLE OF CONTENTS

Lesson 1 – Coding Codes Represent diseases, injuries, procedures, and much more More precise then written descriptions Coding Codes are used to record patients' diagnoses and treatments. The coding system contributes to a more complete and accurate record of care for each patient. Codes can be all numbers, or they can be a combination of letters and numbers. They represent diseases, injuries, medical procedures, examinations, and equipment. Codes are easier to document and reference than written descriptions. They are also more precise, which makes them useful for transferring information between health care provider and insurance carrier. The codes are used to complete the insurance claim form, through which providers communicate with insurance carriers. Each claim form will have a separate code for each diagnosis and for each procedure.

Lesson 1 – Coding Diagnostic Codes Procedural Codes Updated annually
ICD-9-CM Procedural Codes CPT-4 HCPCS Updated annually Types of Codes Codes can be either diagnostic or procedural. Diagnostic codes represent the physician's diagnosis, or the reason for the patient's visit. They are organized in a manual called the International Classification of Disease, Clinical Modification. Currently, the United States is using the 9th Revision of this code set, called ICD-9-CM. Effective October 1, 2015, the United States will be switching to the 10th Revision of the code set, called the ICD-10-CM. Procedural codes represent the specific actions, such as tests, surgeries, or treatments that were taken in response to the diagnosis. There are two manuals of procedural codes. Both code sets are updated every year. One manual is published by the American Medical Association (AMA). It is called the Physician's Common Procedural Terminology, 4th Edition, or: CPT-4. The other manual was developed by the Centers for Medicare and Medicaid Services (CMS). This set of procedural codes is known as the Health Care Financing Administration's Procedural Coding System, or HCPCS. It features codes for services and durable medical equipment not found in the CPT manual.

Lesson 1 – Coding History – Diagnostic Coding
First system appeared at end of 17th century London Bills of Morality International Classification of Causes of Death History of Diagnostic Coding A standard system of coding first appeared at the end of the seventeenth century. Health practitioners in England categorized data on causes of death in a document called London Bills of Mortality. Over the next few centuries, this trend spread internationally. In the 1830s, the International List of Causes of Death reported data on causes of death around the globe. This document also was the first to show a standard organization: diseases were classified by anatomic location. In 1893, this organization became more evolved with the Bertillon Classification of Causes of Death, which later became known as the International Classification of Causes of Death. It was used as the standard classification system in North America until the mid-twentieth century.

Lesson 1 – Coding History – Diagnostic Coding (continued)
World Health Organization International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) History of Diagnostic Coding (continued) By 1948, the World Health Organization (WHO) was publishing reports on disease and causes of death in the International Classification of Disease. This document was used to index hospital records, categorizing them for medical research. In 1977, the United States began using the International Classification of Disease to code medical records according to diagnoses. This allowed diseases to be classified and studied. In 1979, this classification was modified for use in medical billing and insurance claims. This is the manual used in the medical office today: the International Classification of Disease, 9th Edition, Clinical Modification, or ICD-9-CM.

Lesson 1 – Coding History – Procedural Coding Appeared in the 1960’s
CPT: Level I of HCPCS Medicare requires HCPCS coding History of Procedural Coding Procedural coding appeared in the 1960s. The American Medical Association (AMA) recognized a need for classification of services for data collection and reimbursement. In response, it developed the CPT codes to standardize procedural terms. The current edition, the Physician's Common Procedural Terminology, 4th Edition, or CPT-4, was published in 1977. In 1983, CPT was included as Level I of the HCPCS system. HCPCS was developed as a procedural coding manual which contained codes not found in the CPT-4. The HCPCS and CPT-4 manuals work together as one system to provide procedural coding for claims and statistical data. The current edition of the Common Procedural Terminology, 4th Edition, or CPT-4, was published in The ICD code set is updated periodically to reflect changes in medicine and clinical practice. On October 1st, 2015, the ICD-9 code set will be replaces with the ICD-10-CM code set.

Lesson 1 – Coding ICD Codes ICD-9 code: 123.45 ICD-10 code: S52- 201A
International Classification of Diseases (ICD) Supervised by United Nations’ World Health Organization ICD-9 code: ICD-10 code: S A ICD Codes The International Classification of Diseases, or ICD, codes are published by the United States Department of Health and Human Services. This publication is supervised on an international level by the United Nations' World Health Organization (WHO). The ICD code set is used in the medical office to provide diagnostic codes. The ICD-9-CM code set is numeric digits long. The majority of ICD-9 codes begin with a number, and there are only two types of codes that start with a letter: V-codes and E-codes. The rest of the ICD-9 codes are all numeric. The first three characters refer to the category of disease or diseases. The last two digits, which come after the decimal point, are modifiers that make the code more specific. An ICD-9 code looks like: The ICD-10-CM code set is 3-7 characters long. Each ICD-10 code starts with a letter, and there are three characters before a decimal point, just like the ICD-9 codes. Each additional character after the decimal point adds more information to the disease or condition represented by the first three characters. This means that the more characters that an ICD-10 code has, the more specific it is. An ICD-10 code looks like this: S52-201A.

Lesson 1 – Coding CPT Codes Example: 99213-25
Current Procedural Terminology (CPT) Diagnostic, therapeutic, and surgical codes Used by medical providers Example: CPT Codes The Current Procedural Terminology, or CPT, provides diagnostic, therapeutic, and surgical codes for all services that medical staff may perform. The CPT data are used by medical providers to report the procedures they performed to the patient’s insurance carrier. The CPT codes are also used for reimbursement. All CPT codes are 5 numbers long. If the doctor needs to add more information or modify the CPT code, they can add a modifier which is two extra digits added to the end of the code. An example of a CPT code with a modifier looks like this:

Lesson 1 – Coding HCPCS Codes Required for Medicare Part B claims
Health Care Financing Administration’s Common Procedure Coding System (HCPCS) Level I codes: CPT Level II: HCPCS National Codes Required for Medicare Part B claims HCPCS Codes HCPCS is the code set maintained by the Centers for Medicare and Medicaid Services (CMS). CMS requires the use of HCPCS codes on its claims, and only accepts CPT codes when there is no HCPCS code that is available. HCPCS codes are known as Level II codes, or HCPCS National codes. These codes represent a variety of medical services, supplies, drugs, and durable medical equipment not found in CPT codes. HCPCS is the required method of reporting for all Medicare Part B claims.

Lesson 1 – Coding Purpose of coding
Keep statistical data within office Communicate with insurance carriers Reimburse health care provider Purpose of Coding Currently, the medical office uses ICD, CPT, and HCPCS coding for two reasons. One is to keep statistical data within the office. The other is to communicate with insurance carriers. For each covered procedure performed, an insurance carrier must reimburse, or pay back, the health care provider. The amount should cover the cost of performing the procedure. That is why it is so important to code the procedure correctly. Because the procedure must relate back to the diagnosis for medical necessity, the diagnosis must also be coded correctly. Modifiers help to further specify the diagnosis and procedure. Using modifiers can change the level, or amount, of reimbursement. If a procedure is very complex, its modifier will indicate a higher level of reimbursement. Being as specific as possible, or coding to the highest level of specificity, will ensure proper reimbursement.

Lesson 1 – Coding Coding Updates: All code sets are updated annually
ICD code updates effective October 1st CPT and HCPCS effective January 1st Coding Updates Both ICD, CPT, AND HCPCS code sets are updated annually, meaning that each year some of the codes change. The ICD code updates are effective October 1st of each year, and the CPT and HCPCS codes are effective January 1st of each year. There are a few code changes each year. Some codes are delete, some added, and other are changed to more accurately reflect the physician’s services.

Lesson 2 – Diagnostic Coding
Diagnostic codes Physician’s diagnosis Aid in insurance claims process Verify medical necessity Diagnostic Coding Diagnostic codes are codes that refer to the physician's diagnosis. These codes are used to record and track statistical health care data. Diagnostic codes aid in the insurance claims process. The actual amount of payment received from the insurance company is based on the procedure. However, the diagnostic code will indicate why the procedure was performed. For instance, if a provider bills an insurance carrier for putting an arm in a cast, but the diagnosis does not show a broken arm, the carrier may deny payment for lack of medical necessity. The medical appropriateness of a procedure is based on its relation to the diagnosis. Accurate diagnostic coding is important to both the financial and the legal status of the medical practice. Improper coding can result in reduced reimbursement from insurance carriers. If improper codes are the result of fraud or abuse, civil or criminal penalties can be assigned.

Primary diagnosis Most significant Always entered first Secondary diagnosis Entered in order determined by the specialized coding guidelines Always entered after primary diagnosis Primary and Secondary Diagnoses Many times, patients have more than one diagnosis. The primary diagnosis is the one that required the most resources or was primarily responsible for the services performed. A secondary diagnosis is one that coexists with the primary condition and may affect its treatment. Up to eleven secondary diagnoses may also be entered on a claim. The order of the secondary diagnoses codes is determined by the specialized coding guidelines for each type of diagnosis reported on the claim. A secondary diagnosis should not be reported unless it is relevant to that day’s treatment or service.

ICD manual volumes: Volume 1 – Tabular Index Volume 2 – Alphabetic Index Volume 3 – Procedures: Tabular Index and Alphabetic Index Volumes of the ICD The ICD manual is divided into three volumes: Volume 1 - Tabular Index. Volume 1 is a list of diagnostic codes in numeric order. Volume 2 - Alphabetic Index. Volume 2 is an alphabetic listing of all known diagnoses. Volume 3 - Procedures: Tabular Index and Alphabetic Index. Volume 3 lists procedures performed in an inpatient setting. Volume 3 is not used in the medical office, as it is only used for reporting inpatient hospital procedures. Outpatient medical coding only requires the use of the first two volumes.

ICD: Volume 2 Alphabetical listing of all know diagnoses Section 1: The Index to Diseases Section 2: Table of Drugs and Chemicals Section 3: Index to External Causes of Injury and Poisoning Volume 2 of the ICD It depends on the manufacturer, but Volume 2 usually comes before Volume 1 in the ICD manual. When coding from the ICD, the diagnosis must be referenced in Volume 2 first. Volume 2 of the ICD lists all known diagnoses. It is separated into three sections: Section 1: The Index to Diseases Section 2: Table of Drugs and Chemicals Section 3: Index to External Causes of Injury and Poisoning

Organization Main terms Nonessential modifiers Essential modifiers Qualifiers Organization of Volume 2 Volume 2 is organized alphabetically by main terms. The main term refers to the most general term in a diagnosis. Listed with each main term will be: Nonessential modifiers, which can provide alternate terms or further specificity Essential modifiers, which must be added to increase the level of specificity Qualifiers, which can be added to increase the specificity of essential modifiers A code is associated with each diagnosis in Volume 2. However, the code must be cross-referenced in Volume 1. Never code rom Volume 2 without verifying the code in the Tabular list (Volume 1).

Main Terms Diseases Conditions Eponyms Never parts of the body Main Terms Main terms in the index are listed in bold. They are not indented. Many conditions can be found in more than one place in Volume 2. Conditions may be searchable by more than one main term. Main terms can be: Diseases Conditions Eponyms Main terms are not, however, parts of the body. For instance, if a patient has been diagnosed with a rash on the face, the main term will be rash, not face. See the example in the image on the left. Eponyms can also be main terms. An eponym is a disease, procedure, or syndrome named after a person. An example is Crohn's Disease, diagnosed by Dr. Burrill Bernard Crohn in Crohn's Disease is also known as regional enteritis. This diagnosis could be found in Volume 2 under Crohn or under enteritis.

Nonessential Modifiers Alternate terminology Aid with specificity Essential Modifiers Necessary for claim reimbursement Qualifiers Used for more accurate reporting when needed Not necessary for selection Modifiers and Qualifiers The main terms are followed by modifiers. There are two kinds of modifiers: essential and nonessential. On the left is an example of a category from Volume 2. Nonessential modifiers are found in Volume 2. They appear in parentheses directly after the main terms. These modifiers may give alternate terminology or help to add specificity, but they are not necessary for code selection. Essential modifiers are found in Volume 2 indented under the main term. They modify the main term by describing the site of a diagnosis, its cause, or its specific type. For instance, think again of the rash. Once rash is located as a main term, essential modifiers underneath will list the different kinds of rashes. Essential modifiers are, as the name suggests, required. If a main term has any essential modifiers underneath it, insurance carriers will not accept the code without a modifier. The claim will be returned. Qualifiers will appear indented underneath essential modifiers. Each qualifier increases specificity. They should be used if they more accurately describe the diagnosis. Before assigning a code, assistants should read through all qualifiers. They are not required if they do not apply. See the example on the left. Under the essential modifier rose, the qualifiers are epidemic and of infants. They are to be used if they apply. If not, reference the code for rose only.

Symbols in Volume 2 of ICD Black box with checkmark Inward-facing triangles Triangle Circle Symbols in Volume 2 of the ICD There are several symbols in the ICD which may alert the assistant to recent changes. Because the manual is updated every year, these changes are frequent. There are certain symbols that will alert the assistant to changes within the ICD manual. These symbols will depend on the publisher of the specific manual that you are using, but they will all give extra hints on proper coding. A term followed by a black box with a checkmark indicates that an additional modifier will be required for the code. The assistant must refer to Volume 1 to select the correct modifier. If text is enclosed within inward-facing triangles, it has been updated in the current release. A triangle beside a term or modifier indicates a revised code. A circle beside a term or modifier indicates it has been newly added in the current release.

17 Sections in Volume 1 of ICD-9- CM Divided by anatomic system or type of condition Volume 1 of the ICD-9-CM Volume 1 of the ICD-9-CM is divided into 17 sections. The sections are divided by anatomic system or type of condition, as follows: Infectious and Parasitic Diseases Neoplasms Endocrine, Nutritional, & Metabolic Diseases & Immunity Disorders Diseases of the Blood and Blood-Forming Organs Mental Disorders Nervous System and Sense Organs Diseases of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Complications of Pregnancy, Childbirth, and the Puerperium Diseases of the Skin and Subcutaneous Tissue Diseases of the Musculoskeletal System & Connective Tissue Congenital Anomalies Certain Conditions Originating in the Perinatal Period Symptoms, Signs, and Ill-Defined Conditions Injury and Poisoning

ICD-9-CM Supplementary Sections V Codes Physician visits for reasons other than a new illness E Codes External causes of primary diagnosis Volume 1 Supplementary Sections There are also two supplementary sections in Volume 1: V Codes and E Codes. The first supplement is titled V Codes: Supplementary Classification of Factors Influencing Health Status and Contact with Health Services. V Codes are used when a patient visits the physician for a reason other than a new illness, such as to receive a vaccination or a preventive service. For instance, well baby check-ups and annual physical examinations are coded with V Codes. V Codes are also used when treating ongoing diseases that are already diagnosed, such as performing chemotherapy for cancer. The second supplement is titled E Codes: Supplementary Classification of External Causes of Injury and Poisoning. E Codes describe external causes of injuries, poisonings, or adverse effects. For example, if someone is injured in an auto accident, an E Code can supplement the diagnosis of the injury by describing the accident. Within each supplemental section, codes are ordered numerically.

Nervous System Chapter Three chapters Supplementary section Additional chapter Volume 1 of the ICD-10-CM Volume 1 of the ICD-10-CM manual is very similar to the ICD-9-CM, except that the nervous system chapter has been separated into three chapters as follows: Nervous System, Eye and Adnexa, and Ear and Mastoid Process. The supplementary sections that were V-Codes in ICD-9 are included as additional chapter in ICD-10-CM.

E Codes Secondary diagnosis only Does not affect reimbursement Check with carrier Using E Codes E Codes should never be the primary diagnosis. First, diagnose from one of the first seventeen sections. Then find the external cause of that symptom or condition in the E Codes. E Codes do not affect the level of reimbursement, but they may indicate who is responsible for paying. For instance, if someone is injured on the job, an E Code indicating an industrial accident may be used to indicate Workers' Compensation liability. Some third-party carriers prefer that E Codes are not used on the claim. Before coding from this section, be sure the third-party allows it.

Volume 1 – Symbols and Formatting Three-digit category codes Four-digit subcategory codes Five-digit sub- classification codes Yellow highlight – unspecified Gray highlight – other Blue highlight - manifestation Symbols and Formatting in Volume 1 of the ICD-9-CM In Volume 1, three-digit category codes are listed in numeric order. Modifying terms are formatted similarly to Volume 2. Four-digit subcategory codes and five-digit sub-classification codes will be indented underneath. If a fourth or fifth digit is required for a code, there will be an indicator box to the left of the code heading. The other symbols used in Volume 1 are the same as those used in Volume 2. Volume 1 also uses a color-coded highlighting system to make certain types of codes easier to recognize: Text highlighted in yellow indicates an unspecified code. This means that the diagnosis was not further specified in the physician's clinical notes. Assistants must never code anything that is not documented in the medical record. Text highlighted in gray indicates a code specifying "other." This indicates that the diagnosis was more specific, but there is no code that exactly matches that specificity. Text highlighted in blue indicates a manifestation code. A manifestation is an illness or condition caused by an underlying illness or condition. For example, if a patient is suffering from pneumonia due to anthrax exposure, the pneumonia is a manifestation of the anthrax poisoning. A manifestation code should always be a secondary diagnosis. When coding, read through the entire category. There might be a more informative, more specific, or more correct code. The symbols and highlighting of the ICD manual will vary by publisher, so it is important to be familiar with the specific type of book you are using.

Determine physician’s diagnosis Superbill Determining the Diagnosis The first step to diagnostic coding is to determine the physician's diagnosis. If an office uses a superbill, or encounter form, determining the diagnosis can be easy. The physician will check off the diagnosis from the list provided on the superbill. However, the assistant should still ensure that the selected code is the most appropriate for the information documented in the patient's medical record. Sometimes the assistant may have to determine the diagnosis from a physician's clinical notes. In this case, the assistant must first translate the physician's handwriting. Then, the assistant must locate the physician's diagnosis in the notes. Finally, the assistant determines the correct diagnosis. With more doctors using electronic medical records now than ever before, it will not be as difficult to determine the doctor’s handwriting, as everything is typed into the computer system. When entering a code, do not disregard the zeroes. If zeroes are present in the manual, they must be included with the code. For example, if a code is , the assistant must write If a code is 045.3, the assistant must write

Coding diseases and conditions Find noun in diagnosis Modifiers go from general to specific Trial and error Coding Diseases and Conditions Although adjectives can be main terms, it is best to find the noun in the diagnosis and look it up as the main term first. For example, let's say a physician diagnoses the patient with nocturnal angina. Angina is the condition, and nocturnal further describes it. The assistant should look up angina. Then, the assistant would scan through the modifiers below to find the term nocturnal. Here's another example. The physician diagnoses the patient with an open fracture of the clavicle shaft. The clavicle, or collarbone, shaft is an anatomic part, so it will not be the main term. The assistant would first look up fracture. There will be numerous modifiers and qualifiers under this term. Modifiers should be found from the more general to the more specific. This fracture is of the clavicle shaft. The first modifier will be clavicle. Then look for the part of the clavicle: the shaft. Below shaft, there will be a qualifier that specifies open. Finding diseases and conditions in the index can be a process of trial and error. Here is a third example. Let's say the physician diagnoses a patient with a cardiac contusion. The assistant looks up cardiac as the main term. Cardiac is present as a main term in the index. However, contusion is not listed as a modifier. The assistant should look up contusion and see if it has cardiac as a modifier.

V Codes Contact with health services for reason other than new injury or illness Family history Coding V Codes Remember that V Codes are used to describe contact with health services for reasons other than a new injury or illness. Vaccinations and screenings fall into this category. If a patient comes into the office for a influenza vaccination, there is no diagnosis of a condition. But, a diagnostic code still must be coded on the claim form. V Codes are also used to describe factors that may influence a patient's health status, such as family history. For example, if a physician orders a diagnostic test to detect asthma, the physician must give the reason as a V Code. The reason may be that the patient has a family history of asthma. Looking up V Codes in the index is similar to looking up any other diagnosis. For the influenza vaccination, the assistant should look up vaccination first. Then, find influenza as a modifier below. In this case, though, the assistant could also find the code by looking up influenza first. Looking up the V Code for a family history of asthma may be trickier. The assistant may look up the term asthma. While it is present as a main term, the modifier history is not present. Instead, the assistant should look up history. There will be numerous modifiers for history: they are first split into personal and family. Below the family modifier, find the qualifier that reads asthma.

Lesson 3 – Procedural Coding
Procedural codes Medical Surgical Diagnostic Five digits Modifiers Procedural Coding The CPT-4 and HCPCS are used for procedural coding. Procedural codes represent the procedure performed in response to the physician's diagnosis. Procedural codes are used to describe services, procedures, and supplies. The services and procedures can be medical, surgical, or diagnostic. A diagnostic procedure is not the same as a diagnosis. A diagnostic procedure is a procedure that helps the physician diagnose the patient. For example, X-rays and MRIs are diagnostic procedures. Procedural codes are five digits long. Modifiers of up to two digits may be required after the five-digit code. Modifiers are used to give further details related to the procedure. It may indicate the complexity of the service or note what part of the service was performed. The modifier may increase or decrease the amount, or level, of reimbursement owed to the practice.

Coding the claim form Determine reimbursement levels Related to diagnostic code Documentation may be needed Coding the Claim Form Insurance carriers use procedural codes to determine reimbursement levels. The procedural code on the claim must be related to the diagnostic code. If the procedure is not medically necessary in relation to the diagnosis, the claim will be denied. Insurance carriers also want to be sure that the procedure was coded correctly. Sometimes, further documentation will be needed.

Levels of procedural coding Level I: CPT-4 Level II: HCPCS National Codes Level III: Local Codes Levels of Procedural Coding HCPCS is organized into three levels: Level I: CPT-4 Level II: HCPCS National Codes Level III: Local Codes CPT codes were adopted as part of the HCPCS procedural coding system. The CPT-4 makes up Level I of HCPCS. These codes are five digits, followed by two modifying digits, as needed. While the CPT-4 codes are considered to be a part of the HCPCS system, they are published separately. Level II is made up of HCPCS National Codes. They were developed to cover procedures and services not included in the CPT, including prescription drugs, and durable medical equipment. They are required on Medicare and Medicaid claims. Level III of HCPCS is made up of local codes. These codes are no longer used for Medicare reporting.

CPT-4 Introduction Six main sections Twelve appendices Index Parts of the CPT-4 The CPT-4 is divided into the following parts: Introduction Six main sections Twelve appendices (A - L) Index

Introduction Layout and formatting Symbols Add-on codes, modifiers, and place of service codes Resources and references Introduction to the CPT-4 The introduction of the CPT-4 provides information on using the manual. The introduction shows the layout and formatting of the main sections. This includes a description of all the symbols used. It also summarizes the appropriate use of add-on codes, modifiers, and place of service codes. Finally, it points assistants in the direction of further resources and references. Assistants might find these resources helpful to learn more about the coding system and to stay current on coding practices. All coders should be familiar with the introduction. It is useful to both new and experienced coders. Because the introduction can change in each year's updates, it is useful to go over the text each year.

Main sections E & M Anesthesia Surgery Radiology Pathology/Laboratory Medicine E & M codes Place of service Patient status Level of service Main Sections of the CPT-4 The main body of the CPT-4 is made up of six sections: Evaluation & Management (E & M) Anesthesia Surgery Radiology Pathology & Laboratory Medicine Assistants should read each section's guidelines before coding from that section. The first main section, Evaluation and Management (E & M), will be used often. It is used to classify the patient and the type of visit. Office visits almost always use an E & M code. E & M codes identify: Place of service Patient status Level of service provided Patient status refers to whether the patient is new to the office or an established patient. Level of service refers to the type of office visit. Contributing factors to level of service include counseling, coordination of care, and nature of the problem. The introductory guidelines of this section are particularly important. They will explain how to determine a patient's status and give criteria for determining the level of service.

Index Alphabetically by main terms Always cross-reference Index of the CPT-4 The index of the CPT-4, located at the very back of the manual, is similar to Volume 2 of the ICD-9-CM. It is organized alphabetically by main terms. The index is the first place the assistant should look for appropriate procedural codes. However, coding should never come from the index alone. The code or code ranges provided in the index should always be cross-referenced in the main section.

Thirteen appendices Between the tabular section and the index Appendices The CPT-4 has thirteen appendices, located before the index: Appendix A - Modifiers Appendix B - Summary of Additions, Deletions, and Revisions Appendix C - Clinical Examples Appendix D - Summary of CPT Add-on Codes Appendix E - Summary of CPT Codes Exempt From Modifier 51 Appendix F - Summary of CPT Codes Exempt From Modifier 63 Appendix G - Summary of CPT Codes That Include Moderate (Conscious) Sedation Appendix H - Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I - Genetic Testing Code Modifiers Appendix J - Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix K - Product Pending FDA Approval Appendix L - Vascular Families Appendix M - Crosswalk to Deleted CPT Codes

CPT-4: Main Terms Procedure or service Anatomic site Condition Synonyms, eponyms, and abbreviations CPT-4 Index: Main Terms The CPT-4 Index is the first place to look up a procedure. Like Volume 2 of the ICD-9-CM, the CPT-4 Index is organized alphabetically by main terms. The four types of main terms that can be found in the index are: Procedure or service Anatomic site Condition Synonyms, eponyms, and abbreviations Notice that unlike the ICD-9-CM, the CPT-4 manual includes anatomic sites as main terms.

Subterms Indented under main terms More specific CPT-4 Index: Subterms Subterms will also be found in the CPT-4 index, indented under the main terms. They can indicate a more specific procedure. Being specific will lead to more accurate code selection. Remember to always cross-reference codes from the index with the codes in the main sections. If given multiple codes or a range of codes, all codes included should be investigated to find the most appropriate. Also, pay close attention to notes or special instructions. Determine the most specific and the most correct code.

CPT-4: Index Alphabetically by main terms Codes or ranges of codes Cross-references Format of the CPT-4 Index The CPT-4 index looks much like a phone book. It is laid out in columns and organized alphabetically, by main terms. For many main terms, there are subterms indented underneath. For each term, there is a code or range of codes given. Unlike the ICD-9-CM index, there are no symbols. There are, however, cross-references. A cross-reference will be indicated by the word "see" in italics after a term. If the instruction is given to see another term, the assistant should investigate that term and its subterm as well before looking up the code or codes in the main section.

HCPCS Level II 17 Main sections Index of Main Terms Table of Drugs HCPCS Level II Level II of HCPCS is structured much like the other coding manuals: 17 main sections Index of Main Terms Table of Drugs HCPCS Level II codes are supplementary to codes in the CPT-4. If something cannot be found in the CPT-4, it is likely in the HCPCS Level II. For example, HCPCS is often used to code durable medical equipment. As with the other indexes, the Index of Main Terms is organized alphabetically. Office assistants should look for codes in this section first.

CPT-4 Main Sections Numerically ordered Symbols Inward-facing triangles Triangle Circle Circle with diagonal line Circle with a dot Cross Lightning bolt Format of CPT-4 Main Sections Much like the ICD-9-CM, the main sections of the CPT-4 are numerically ordered. After a code or range of codes is found in the index, the assistant should look up those codes in the main sections. Read through all codes noted in the index to find the most appropriate one to the procedure. There are also symbols used in the main sections: If text is enclosed within inward facing triangles, that text has been recently added or revised. If a code has a triangle next to it, it has been recently revised. If a code has a circle next to it, it has recently been added. If a code has a circle with a diagonal line through it, it is exempt from Modifier -51. If a code has a circle with a dot in it, that indicates moderate sedation. If a code has a cross next to it, that indicates an add-on code. If a code has a symbol that looks like a lightning bolt, that means that FDA approval of that product or service is still pending.

Coding procedures Main terms can be anatomic sites More terms to choose from Coding Procedures Unlike in the ICD-9-CM, main terms in the CPT-4 can be anatomic sites. This gives the assistant many more terms in a procedure to choose from when referencing the index. This can be helpful, especially when the first term chosen has numerous subterms. As with the ICD-9-CM, the assistant should try to look up the most specific main term first. For example, let's say the physician's procedure notes read: Repair of nail bed. The assistant could look up repair. However, repair has many columns of subterms. If the assistant looks up nail bed, which is more specific, there will be fewer subterms. The assistant will be easily able to find the subterm specifying repair.

Coding procedures Ranges of codes Read through all Coding Procedures (continued) Also unlike the ICD-9-CM, the exact code for a procedure is not always given in the index. Sometimes, code ranges are given instead. Assistants must read through all codes within the range and select the most appropriate one. For example, let's say the physician's procedure notes read: Complete radiologic examination of the skull. Radiology refers to medical imaging, such as MRIs and X-rays. Because radiological exams can be conducted on every part of the body, it is more specific to look up skull. Scanning through the subterms under skull, the assistant will find X-ray. The assistant must know that an X-ray is a radiological exam. Knowledge of medical terminology is important. Because there are many types of X-rays for the skull, the index here lists a code range for the assistant to investigate. The final code should specify that the exam was complete.

Modifiers How procedure was performed More than one physician More than one place Unusual events Modifiers Modifiers in the CPT-4 manual have a different purpose than the modifiers in the ICD-9-CM; they do not further specify what the procedure is. Rather, modifiers change the code description to give more information about how the procedure was performed. Also unlike the ICD-9-CM, codes in the main sections will not indicate whether or not a modifier is needed. It is up to the assistant to determine whether or not a modifier would be appropriate to add. All modifiers are listed on the inside front cover of the manual. Also, Appendix A gives descriptions and uses of each of those modifiers. Always use a modifier when: A procedure is performed by more than one physician A procedure is performed in more than one place Unusual events occur during a procedure There are other cases when modifiers will be needed. Modifying terms must be used correctly. Be sure to read the coding manual guidelines, and reference Appendix A if necessary.

Downcoding Vague code Reimbursement at lowest level Downcoding Reimbursement from insurance carriers is based on procedural codes entered on the claim form. For the insurance carrier to approve reimbursement, the procedure must be medically necessary and appropriate to the diagnosis. This is why specific coding is so important. If the insurance carrier finds the procedural code to be vague or ambiguous, it will be downcoded. This means the code will be reduced to its most basic form, and reimbursement will be made at the lowest possible level. If this occurs, the medical office may lose money.

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