1. Basics of Procedural Coding
Chapter 19
Chapter 19
The Basics of Procedural Coding
Chapter 19 provides an overview of procedural coding in the medical office. Accurate coding procedures influence the reimbursement made to physicians by third-party payors, so the process must be approached carefully and codes assigned accurately.

2. Consider the following while reading this chapter:
What will the medical assistant find similar to ICD-9-CM as she or he performs procedural coding?
What will help in selecting the most specific and accurate CPT code?
What are the differences between coding for the CPT and coding for HCPCS?
What will be learned about the legal and compliance implications of improper coding?
Provide this overview for the chapter content.
Assign the study guide that corresponds with this chapter if not assigned in advance, as well as any additional assignments that are associated with this chapter.

3. What is Procedural Coding and How Is It Used?
Procedural or CPT coding is defined as the transformation of verbal descriptions of medical services and procedures into numeric or alphanumeric designations.
The medical assistant facilitates accurate medical recordkeeping and the efficient processing of insurance claims by using the CPT and HCPCS
CPT and HCPCS are used in the claims submission process to receive reimbursement from payors as well as to track physician productivity and provide statistical data.
Discuss the difference between diagnosis coding and procedural coding. Talk about the importance of reporting every procedure code that was used during medical treatment as well as how this affects the physician’s income. Then discuss how accurate coding can affect the medical assistant’s salary.

4. What is the Purpose of CPT Coding?
Encourage the use of standard terms and descriptors to document procedures in the medical record
Help communicate accurate information on procedures and services to agencies concerned with insurance claims
Provide the basis for a computer-oriented system to evaluate operative procedures
Contribute basic information for actuarial and statistical purposes
Talk about the need for a strong knowledge of medical terminology as well as anatomy and physiology when performing coding duties.
Discuss the reasons that even a small error in procedural coding can drastically change the physician’s reimbursement.

5. The CPT Code
The CPT code is a five-digit code also known as a Category I code. Category I codes are located in the Tabular Index (Main Text) of the CPT coding manual and are arranged by Section
Category II codes are optional codes used by providers to assist in measuring performance and outcomes. Category II codes include the letter F as the fifth digit.
Category III codes are temporary codes assigned for emerging and new technology, services and procedures that have not been officially added to the Main Text of the CPT manual. The fifth digit of the Category III code is the letter T.
Modifiers provide a way for providers to indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition.
Talk about the difference between each code category. Discuss modifiers and their difference in diagnostic and procedural coding.

6. Format of the CPT Coding Manual
Each procedure or service is represented by a five-digit numeric code – a type of medical shorthand that saves enormous amounts of time and effort and helps to ensure the accuracy of information
Discuss how often codes change and why they might change. Mention several of the codes that have remained the same for a length of time. Talk about why a code might be deleted completely.

7. CPT Content
Comprehensive instructions for use of the manual, including steps for coding
A complete Alphabetic Index
Main Text (Tabular Index)
Six sections
Guidelines and notes
Conventions
Thirteen appendixes
Discuss the place to start looking for the correct procedural code. Talk about the process from that starting point.

8. CPT Content
The Tabular Index is divided into six sections, with codes listed in numeric or alphanumeric order within each section.
Evaluation and Management (E&M)
Anesthesia
Surgery (all body systems)
Radiology
Pathology and Laboratory
Medicine
Define each section and provide examples from each. Determine the section in which the students would find office visits and other encounters with the physician.

9. Sections of the CPT Main Text
A section is a broad category in the main text of the CPT manual, and each of the six sections is divided by the general type of service
Evaluation and Management (E&M)
Anesthesia
Surgery
Radiology
Pathology and Laboratory
Medicine
Allow the students to suggest a type of surgery, x-ray, or laboratory procedure and turn to the section in the CPT Manual. Direct the students as they look for the correct, complete code for each of their suggestions. Work collectively as a class or allow the students to partner and work on several codes together.

10. Sections of the CPT Main Text
The subsection of the CPT manual is indented two spaces below a section, and usually describes:
Anatomic Site
Organ System
Categories are indented two additional spaces below the subsection, and generally refer to:
a specific procedure or service
can also be a more specific anatomical site
Direct the students to a selected page in the CPT manual and point out several subsections and several categories. Discuss the types of procedures found in both places. Talk about why such specificity is needed in procedural coding.

11. Sections of the CPT Main Text
The subcategory is indented two spaces below a category, and provides even more specificity about an anatomical site or the procedure or service performed.
Suggest several examples of subcategories and direct the students in locating them in the CPT Manual. Discuss the specificity of each.

12. Appendixes appendixes found in the CPT are as follows:
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 A: Modifiers. This appendix lists all the two-digit numeric or alphanumeric codes used to increase specificity and provide additional information about certain procedures and services.
Appendix B: Summary of Additions, Deletions, and Revisions. At each annual update of the CPT, this appendix lists, for easy reference, all changes made to the CPT from the previous year.
Appendix C: Clinical Examples. These are helpful narrative examples that aid the selection of the correct and most specific level of E&M codes.
Appendix D: Summary of CPT Add-on Codes. These are codes for services and procedures that require more than one code to describe the service or procedure fully or to identify a procedure performed concurrently with another procedure.
Appendix E: Summary of CPT Codes Exempt from Modifier -51. This appendix lists all procedures and services exempt from the use of modifier -51. Modifier -51 (99051) is the multiple procedures modifier. When multiple procedures are performed at the same session by the same provider, the primary procedure is reported and the additional procedure or service is identified by appending modifier -51 to the procedure or service code. This is done only when the primary procedure code does not include the additional procedure in its description.
Appendix F: Summary of CPT Codes Exempt from Modifier -63. This appendix lists all procedures exempt from the use of modifier -63. Modifier -63 is used to report procedures performed on infants weighing less than 4 kg to identify the increased complexity common with these patients. Category I codes that state specifically “exempt from modifier -63” do not require this modifier.

13. Appendixes
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 G: Summary of CPT Codes that Include Moderate (Conscious) Sedation. This appendix lists all procedure codes that include conscious sedation as part of the code description, which eliminates the need to code the sedation separately.
Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or Topic. These codes are the Category II codes used by providers tracking and measuring performance and outcomes.
Appendix I: Genetic Testing Code Modifiers. This appendix lists all modifiers and their descriptions that are unique to genetic testing.
Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves. This appendix is a list of each sensory, motor, and mixed nerve conduction study code. It is used to assist in accurate use of codes 95900, 95903, and
Appendix K: Product Pending FDA Approval. This appendix is a list of vaccine products for which FDA approval is pending and for which Category I codes already have been assigned .
Appendix L: Vascular Families. This appendix lists the vascular system, grouped by families, beginning at the aorta and ending at the termination point of each vessel. The appendix is designed to assist in coding for the Cardiology subsection of the Surgery and Medicine sections.

14. Beginning the Coding Process
The steps for using the CPT manual actually begin with the medical documentation:
Encounter form, also known as a superbill, fee slip, or charge ticket
History and physical report (H&P)
Discharge summary
Operative report
Pathology report
Discuss each document used in the coding process. Talk about where the documents are found in the medical record or what department at a hospital might control the document.

15. Beginning the Coding Process
The basic steps in medical coding are to:
read
analyze
abstract the procedure or service documented
compare it with the encounter form, operative report, or other documentation
Explain that the document must be read carefully to make certain that all services and/or procedures have been recorded so that they can be charged to the patient.
The term abstract, used as a verb in this context, means to create an outline or summary of information from a text or record. In procedural coding, an abstract is created to find all the procedures and services performed during a patient encounter and to ensure that nothing has been omitted or added to the encounter form or charge ticket that is not documented in the patient’s medical record.
The abstracted data then are broken down into main terms and modifying terms. A main term usually is the primary procedure or service performed; a modifying term further defines or add information to a main term.

16. Using the Alphabetic Index to Search
Begin the search by using one or all of the four primary classifications (or types) of main and modifying term entries:
Procedure or service
Organ or anatomic site
Condition, illness, or injury
Eponym, synonym, abbreviation, or acronym
Stress to students that the alphabetic index is to be used only to begin the search for the procedural code. Students should never code straight from the alphabetic index.

17. Steps for Using the Alphabetic Index
Abstract the procedures and/or services performed from the medical documentation.
Determine the main and modifying terms from the abstracted information.
Select the most appropriate main term to begin the search in the Alphabetic Index.
Select modifying term(s), if needed, once the main term is located to narrow down the search.
If no main or modifying term produces an appropriate code or code range, repeat steps 2, 3, and 4, using a different main term.
Find code or code ranges that include all or most of the medical record procedure or service description.
Disregard any code or code range containing additional descriptions or modifying terms not found in the abstracted information or the medical documentation.
Write down the code or code ranges that best match the medical documentation.
Provide a medical record and choose a procedure or service to code. Using the steps above, guide the students through each item to arrive at the most accurate and specific procedure code.

18. Steps for Using the Main Text
Turn to the Main Text and find the first code or code range found while searching the Alphabetic Index.
Compare the description of the code with the medical documentation. Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation.
Read the guidelines and notes for the section, subsection, and code to ensure there are no contraindications to the use of the code.
Evaluate the conventions, especially add-on codes (+) and exemption from modifier -51.
Determine if there are special circumstances that require the use of a modifier.
Determine if a Special Report is required.
Record the CPT code selected in the medical record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form.
Provide a medical record and choose a procedure or service to code. Using the steps above, guide the students through each item to arrive at the most accurate and specific procedure code.

19. Surgery coding
There are some guidelines and notes related to surgery coding that must be considered when researching and selecting a procedure or service code:
Surgical Package Definition
Follow Up Care for Diagnostic Procedures
Materials Supplied by the Physician
Surgical Destruction
Discuss the importance of reviewing the current years’ procedural coding guidelines inside the CPT Manual. Since coding is updated annually, changes may take effect that will lower the physician’s reimbursement if not coded correctly.

20. Surgery Coding Endoscopy X-ray Imaging/Fluoroscopy
Excision of Lesions – Benign or Malignant
Repair (Closure)
Musculoskeletal System
Respiratory System
Maternity Care and Delivery
Talk about each item and make certain students understand the meaning of each term. Explain that surgery may involve more than one code and provide examples.

21. Understanding Evaluation and Management
The first two steps in choosing an E&M code are:
Identifying the place of service (POS)
Identifying the patient status
Determining the level of service provided
There are three components for determining the level of service for E&M:
history
examination
medical decision making
four contributing factors:
counseling
nature of the presenting problem
coordination of care
time
Explore the E&M pages in the CPT Manual and discuss the categories. Talk about recent changes in this section of the coding manual, including consultation changes.

22. Anesthesia Coding STEPS FOR ANESTHESIA CODING
Read the medical documentation to determine what procedure or service was provided.
Determine the anatomic site or organ system involved.
In the Alphabetic Index, go to the heading “Anesthesia” and find the code or code range that includes all or most of the medical record procedure or service.
Write down the code or code range found in the Alphabetic Index, under the Anesthesia heading, that best matches the medical documentation.
Turn to the Main Text, Anesthesia Section, and find the code or code range found while searching the Alphabetic Index.
Read the guidelines and notes for the section, subsection, category, or subcategory.
Evaluate the conventions, especially add-on codes (+) and modifier -51 exemptions.
Document the code selected.
Determine the Basic Unit Value from the Relative Value Guide.
Determine the patient’s physical status and document the appropriate modifier.
Determine if any qualifying circumstance modifier should be used. If yes, document the modifier.
Determine the total anesthesia time, divide by 15 (minutes), and document the time.
Select the appropriate geographic conversion factor.
Calculate the charge for the anesthesia service using the anesthesia formula.
Document the anesthesia charge and the code in the medical record and on the encounter form or charge ticket.
Explain that anesthesia coding is different from any other coding in the way anesthesia services are billed. Discuss the standard formula for payment of anesthesia services: Basic units + Time units + Modifying units (B + T + M). Discuss the two factors that affect the formula: any qualifying circumstances and the patient’s physical status.

23. Healthcare Common Procedure Coding System (HCPCS)
Steps for Using HCPCS Codes
Read the medical documentation to determine what procedures or services were provided.
Determine the main and modifying terms from the abstracted information.
Select modifying term(s) if needed once the main term is located.
Select the most appropriate main term to begin the search in the Alphabetic Index.
If no modifying term produces an appropriate code or code range, repeat steps 2 and 3 using a different main term classification.
Find code or code ranges that include all or most of the medical record procedure or service description.
Disregard any code or code range containing additional descriptions or modifying terms not found in the medical record.
Write down the code or code ranges that best match the medical documentation.
Turn to the Main Text and find the first code or code range found while searching the Alphabetic Index.
Compare the description of the code with the medical documentation. Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation.
Read the guidelines for the section, subsection, and code to ensure there are no contraindications to the use of the code.
Evaluate the HCPCS manual conventions.
Determine if there are special circumstances that require the use of a modifier.
Record the HCPCS code selected in the medical record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form.
HCPCS is a collection of codes and descriptions that represents procedures, supplies, products, and services not covered by or included in the CPT. Explain that HCPCS codes are updated annually. They are designed to promote standardized reporting and statistical data collection on medical supplies, products, services, and procedures.

24. Compliance and Legal Issues
Medical assistants should also ensure that proper precautions are taken to avoid incorrect coding, data entry errors, and false claims submissions.
Downcoding, in which lower level codes are used even when the diagnostic statement indicates a higher level procedure or service, usually affects reimbursement only by lowering the amount received, but may have civil and criminal penalty implications if it is done to disregard insurance policy restrictions or preexisting condition clauses.
Upcoding, on the other hand, in which a procedure or service code is used that is of a higher level than is supported by the medical documentation, can result in civil and criminal penalties, including fines, loss of privileges as a participating provider, and even prison time.
Talk about the difference between downcoding and upcoding, and provide several examples for clarification. Discuss the legal issues involved in downcoding and upcoding.