1. Comprehensive Medical Assisting, 3rd Ed Unit Three: Managing the Finances in the Practice Chapter 15 – Outpatient Procedural Coding

2. Health Care Procedural Coding System (HCPCS)
Level I
Current Procedural Terminology (CPT)
Level II
Coding system used to standardize identification of products, supplies, and services not included in the CPT codes
Level III
Local codes
No longer in use

3. Physician’s Current Procedural Terminology (CPT)
Complete listing of medical terms and codes for standardized coding
New version available every October
Providers are required to used the updated codes the following January
Insurance company benefits
Easy communication among companies
Easy comparison of reimbursable amounts
Faster claims processing

4. Performing Procedural Coding
Layout of CPT-4
Sections
Evaluation and management
Anesthesia
Surgery
Radiology
Pathology and laboratory
Medicine
Sections followed by
Explanations and listings of Category I and Category II codes
Appendices
Alphabetic index

5. Performing Procedural Coding
Reading Descriptors

6. Performing Procedural Coding
Place of Service Codes for Professional Claims (Table 15.1)
Place of Service Code
Physician’s office 11
Patient’s home 12
Assisted living facility 13
Urgent care facility 20
Inpatient hospital 21
Outpatient hospital 22
Emergency room, hospital 23
Ambulatory surgical center 24
Skilled nursing facility 31
Hospice

7. Performing Procedural Coding
Section Guidelines
Each section begins with guidelines and a listing of procedures for that particular field
Unlisted Procedures and Special Reports
The beginning of each section contains unlisted procedures
When one is performed, a copy of the procedure report must be submitted with the claim

8. Evaluation and Management Codes
Five-digit numbers beginning with the number 9
Used the most frequently
Describe what a physician does when interacting with a patient

9. Key Components Elements that make up a patient’s visit
Two of three required for an established patient
Three of three required for a new patient
History, physical examination, and medical decision making

10. Key Component Elements
History
Four classification levels
Problem focused
Expanded problem focused
Detailed
Comprehensive
Provider must chose one based on the patient’s record

11. Key Component Elements
Examination
A systematic way of assessing the body
Level depends no how many body systems are examined

12. Key Component Elements
Medical Decision Making
Defined in CPT-4 as
Straightforward
Low complexity
Moderate complexity
High complexity
What must be done by a physician to establish a diagnosis

13. Key Component Elements
Time
Only a key component when half of the visit is spent counseling
Must be clearly documented

14. Other Categories of Evaluation and Management Codes
Includes
Observation codes
Hospital inpatient services, including initial care and subsequent care

15. Other Categories of Evaluation and Management Codes
Anesthesia Section
Five-digit code beginning with 0
Divided by anatomic site and specific type of procedure
Modifiers
Letters or numbers added to add detail to the code
Standard modifiers and physical status modifiers

16. Other Categories of Evaluation and Management Codes
Surgery Section
Organized by body systems
Begin with 1 thorough 6
Generally, surgeries are billed in packages that include
Surgical procedure
Normal, uncomplicated follow-up care
Digital block or topical anesthesia
Preoperative and postoperative visits are generally included

17. Other Categories of Evaluation and Management Codes
Radiology Section
Five-digit number beginning with 7
Four subsections
Diagnostic radiology and diagnostic imaging
Diagnostic ultrasonography
Radiation oncology
Nuclear medicine
Generally arranged by anatomic site from the top of the body to the bottom
Two codes should be given when a physician is involved

18. Other Categories of Evaluation and Management Codes
Pathology and Laboratory Section
Five-digit number beginning with 9
Divided into sections
Subsection
Automated multichannel tests

19. Other Categories of Evaluation and Management Codes
Medicine Section
Five-digit number beginning with 8
Divided into sections
Immunization injections
Other miscellaneous services and procedures

20. CPT-4 Modifiers Two formatting options
Five-digit code with the modifier following a hyphen
Certain sections of the CPT-4 have guidelines for how the modifiers should be added

21. Diagnostic-Related Groups (DRGs)
Inpatients categories according to the similarity of diagnosis, treatment, and length of stay
Used to determine reimbursements for Medicare patients’ inpatient services
Fees associated based on national average of all Medicare discharges and adjusted regional differences
Hospitals pay a set amount

22. Diagnostic-Related Groups (DRGs)
Coder selects DRG based on
Principal diagnosis
Surgeries
Complications and comorbid conditions

23. Resource-Based Relative Value Scale
Used as a basis for the fee schedule setting maximal fees for each service
Goals
To reduce Medicare Part B costs
To establish national standards for payment

24. End of Presentation