19 Procedure Coding.

19 Procedure Coding

Learning Outcomes (cont.)
19.1 List the sections of the CPT manual, giving the code range for each. 19.2 Describe briefly each of the CPT’s general guidelines. 19.3 List the types of E/M Codes within the CPT. 19.4 List the areas included in the Surgical Coding Section.

Learning Outcomes (cont.)
19.5 Locate a CPT code using the CPT manual. 19.6 Explain how to locate a HCPCS code using the HCPCS coding manual 19.7 Explain the importance of code linkage in avoiding coding fraud

Introduction Procedural coding Code “linkage” with diagnostic codes
Translate medical procedures and services into codes Explains what services were provided Code “linkage” with diagnostic codes Maximum reimbursement This chapter introduces the language of procedural coding which is the translation of medical terms for procedures and services provided to patients into code numbers selected from standardized procedural coding systems. Procedural coding explains to third-party payers the services patients received from the provider. This chapter also introduces “linking” of diagnosis codes with procedure codes to explain the medical necessity of each procedure or service performed. Accurate procedure codes plus accurate and appropriate diagnosis codes equal the maximum appropriate reimbursement to the physicians in your medical office.

The CPT Manual Procedure code Current Procedural Terminology (CPT)
Medical procedures and services Based on encounter form or patient record Current Procedural Terminology (CPT) HIPAA-required code set Published by the AMA Updated annually Use the appropriate CPT based on date of service Learning Outcome: List the sections of the CPT manual, giving the code range for each. Procedure codes – represent medical procedures and medical services to evaluate a patient’s condition. CPT Manual – a reference manual published by the American Medical Association The most commonly used system of procedure codes. HIPAA-required code set translates descriptions for physicians and other provider healthcare-related procedures into 5-digit codes. Updated yearly Date of service determines which manual is used

Organization of the CPT Manual
Section Range of Codes Evaluation and Management 99201 – 99499 Anesthesiology 00100 – 01999 99100 – 99140 Surgery 10021 – 69990 Learning Outcome: List the sections of the CPT manual, giving the code range for each. Because Evaluation and Management (or E/M codes) are used so frequently, they are placed in the front of the manual for easy reference. Otherwise, the sections are listed in numeric order by code range. Radiology 70010 – 79999 Pathology and Laboratory 80048 – 89356 Medicine 90281 – 99602 99500 – 99602

Organization of the CPT Manual (cont.)
Manual Introduction General instructions Information about common Prefixes Suffixes Word roots Guidelines for each section Learning Outcome: List the sections of the CPT manual, giving the code range for each. The Introduction to the CPT manual gives the user Important general instructions for the use of CPT. Information regarding common prefixes, suffixes, and word roots found within the manual. Pay close attention to the guidelines found at the beginning of each new section, as these provide important overall information for coding in each section.

Sections Guidelines at beginning Categories  headings Page Section name Subsection name Subheading Category Learning Outcome: List the sections of the CPT manual, giving the code range for each. The CPT’s sections are divided into categories, which in turn, are further divided into headings according to the type of test, service, or body system. Each page also gives you other important information, including: Section Name – used by CPT to denote each chapter Subsection Name – the area within the section detailing the body system you are in. Subheading – describes the body area for the body system you are looking at. Category – describes the procedure area

Excellent! Apply Your Knowledge Match CPT section to number range
ANSWER: Evaluation and management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine (except for Anesthesia) Learning Outcome: List the sections of the CPT manual, giving the code range for each. Excellent!

General CPT Guidelines
Code format 5-digit numeric code Stand-alone unless description contains a semicolon Add-on codes Additional procedures Indicated by plus sign (+) Indented codes Learning Outcome: Describe briefly each of the CPT’s general guidelines CPT Code Format 5-digit numeric codes Most codes are stand-alone codes with the complete description listed next to the appropriate code. Exception to this rule is the code description containing a semicolon, which is followed by a code with an indented description. The indented description means that you refer back to the previous code description, reading the information prior to the semicolon and adding the indented code information after the colon to complete the description. Add-on codes Codes that indicate procedures that are usually carried out in addition to another procedure. A plus sign (+) is used to indicate add-on codes Always used with a primary code Appendix D contains a complete listing of all add-on codes in the manual. Read the description of the “parent code” to the semicolon, and replace the information following the semicolon with the information found in the indented code description. Closed treatment of radial shaft fracture; without manipulation with manipulation

Symbols Used in CPT Code description has been revised A new code
Codes are out of numeric sequence New or revised text information Learning Outcome: Describe briefly each of the CPT’s general guidelines Blue triangle – tells the user the code description has been revised in some way from last year. Red dot – denotes a new code for this edition of CPT. The # sign Introduced in 2010, # is used to note codes that are out of numeric sequence. This was done so code numbers would not be “reshuffled” every year. Each code is also found in red, in its “proper numeric place” with directions telling the coder in what code range to locate the out-of-sequenced code. Triangles pointing toward each other Triangles pointing toward each other with text between them denote new or revised text information. You may also see them used for the out-of-sequence coding information.

Symbols Used in CPT (cont.)
Does not require modifier of 51 FDA approval pending Moderate (conscious) sedation is included in the procedure Learning Outcome: Describe briefly each of the CPT’s general guidelines Circle with diagonal line. Modifier 51 exempt codes are those where the multiple procedure modifier does not apply. Appendix E of the CPT manual lists the modifier 51 exempt codes. Additionally, modifier 51 is never appended to a designated add-on code. Lightning bolt Is used to denote vaccines pending FDA approval. Appendix K in the CPT manual lists the vaccines affected by this symbol. Bull’s-eye The bull’s-eye symbol denotes moderate (conscious) sedation and means it is understood that conscious sedation is necessary for the procedure performed and so is included in the procedure. It cannot be billed separately. Appendix G lists all codes that include moderate (conscious) sedation.

Modifiers Up to three per procedure Indicate that special circumstance applies Appendix A Section guidelines Learning Outcome: Describe briefly each of the CPT’s general guidelines Modifiers Use of a modifier shows that one or more special circumstance applies to the service or procedure the physician performed. Up to three two-digit modifiers per procedure may be assigned to the five-digit main code. Modifiers are written in column 24D on the CMS-1500 Claim Form Appendix A explains the proper use of each modifier. Some section guidelines also discuss the use of modifiers within the individual section. Refer to Table 19-2 Common CPT Modifiers.

Category II, III, And Unlisted Procedure Codes
Category II – supplemental tracking codes Category III – temporary codes Unlisted codes code not yet assigned Include a description of service or procedure Check with payers regarding use Learning Outcome: Describe briefly each of the CPT’s general guidelines Category II codes – optional, supplemental tracking codes used to track healthcare performance measures, like programs and counseling to avoid tobacco use. Category III codes – “temporary” CPT codes for emerging technology, services, and procedures. Category II and III codes are both found directly after the last of the Medicine Codes in the CPT manual. If available, they should be used instead of the unlisted codes. Unlisted procedure codes are used for new services or procedures that have not yet been assigned codes in CPT. When these codes are used, which is rare, a procedure or service description should be sent with the claim submission. Some payers, including Medicare and Medicaid, prefer the use of HCPCS codes so check to learn each payer’s preferences.

Coding Terminology Bundled codes Concurrent care Critical care
More than one physician If different specialties, not considered duplication Bundled codes Read description carefully Do not unbundle Critical care Provided to unstable patients Documentation Learning Outcome: Describe briefly each of the CPT’s general guidelines Bundled codes Consist of any code that includes more than one procedure in its description. Read code descriptions carefully Do not intentionally unbundle procedures into component codes when a bundled procedure code is available. Concurrent care Similar care being provided by more than one physician and occurs when a patient is hospitalized and multiple specialists are caring for the patient. Because of the differing specialties, the care is not considered to be duplication of services. Critical care Provided to unstable, critically ill patients. Physician’s documentation must be explicit regarding the time spent with the patient. The patient need not be in a critical care or intensive care bed in order for the codes to be used but his/her condition must be critical in nature.

Coding Terminology (cont.)
Consultations Must have request, record of findings and recommendations, and report Verify if payer is accepting these codes Counseling – use codes if history or physical is not done Learning Outcome: Describe briefly each of the CPT’s general guidelines Consultations Provided at the request of other healthcare providers 3R’s must be present – request (from another physician), record (documentation) of findings and recommendations, and report to the referring physician. Medicare stopped accepting consultation codes; comparable inpatient and outpatient E/M service codes are used instead. Many commercial payers have also begun denying consultation codes, so again, know each payer’s rules and regulations before submitting claims to the payers. Counseling Part of E/M services, but if a complete history and physical exam does not take place, counseling codes may be used. Used when discussing with the patient and family questions or concerns regarding Diagnostic results and recommendations Prognosis Risks and benefits of options Instructions for treatment and/or follow-up; importance of compliance Risk factor reduction Patient/family education

Coding Terminology (cont.)
Downcoding Reimbursement on a lower code level than submitted Lack of documentation most common cause Unbundling Upcoding Learning Outcome: Describe briefly each of the CPT’s general guidelines Downcoding Reimbursement is based on a code level lower than the one submitted by the provider. This can occur for several reasons: The coding system used by the insurer and provider do not match. Always verify the code set accepted by the payer. If a workers’ compensation carrier bases payment on a RVS, the carrier may convert a CPT code to the lowest paying code within the system. Documentation on a case does not “back up” the level of code used on the claim. This is the most common cause of downcoding in medical offices. Be sure your provider’s documentation is specific enough to back up the level of code used. Unbundling – breaking a bundled code into its component parts for higher reimbursement and is not allowed. Upcoding Coding a procedure or service at a higher level to receive greater reimbursement. Code creep, overcoding, and overbilling – fraudulent practices when done knowingly or repeatedly.

Excellent! Apply Your Knowledge
The insurance representative has questioned the codes listed on three patient forms that were submitted last year. When re-checking these forms the office medical assistant should: Excellent! ANSWER: Use the current book to validate accuracy of the codes Use last year’s book to validate accuracy of the codes Use next year’s book to validate accuracy of the codes Learning Outcome: Describe briefly each of the CPT’s general guidelines

Evaluation and Management Services
E/M codes Used by all physicians New patient vs. established patient New patients – require more time Established patient – seen within 3 years Learning Outcome: Describe briefly each of the CPT’s general guidelines E/M codes Used by any physician in any medical specialty. Divided by patient status of new patient versus established patient. A physician will spend more time with a new patient. Existing patient – a patient has been seen by a physician of the same specialty in the same practice within 3 years New patient – the patient has not been seen in the practice within the last 3 years Refer to Table 19-3 E/M Code Breakdown with Code Ranges.

Evaluation and Management Services (cont.)
Key factors that help determine level of service Extent of patient history taken Extent of examination conducted Complexity of medical decision making Learning Outcome: List the types of E/M Codes within the CPT. The E/M section guidelines explain how to code different levels of these services. These are the three key factors that need to be documented in the patient’s medical record. They will help determine the level of service.

Patient History Elements Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) Past, family and/of social history (PFSH) Coding descriptions Problem-focused Expanded problem- focused Detailed Comprehensive Learning Outcome: List the types of E/M Codes within the CPT. Patient History When coding, the history is described using one of the following terms: Problem-focused – limited to chief complaint and brief history of present problem. Expanded problem-focused – includes the chief complaint, brief history of current problem, and a “problem-pertinent” review of systems. Detailed – focuses on the chief complaint, but includes an extensive history of current problem and extended review of systems and pertinent past, family, and/or social history. Comprehensive – the most complex of the histories, all four components are documented.

Physical Exam Elements Constitutional exam Body areas (BA) Organ systems (OA) Coding description Problem-focused Expanded problem- focused Detailed Comprehensive Learning Outcome: List the types of E/M Codes within the CPT. Physical Exam The physical exam has three elements: The constitutional exam Body areas (BA) Organ systems (OA) Coding descriptions: Problem-focused – exam is limited to the body area or organ system directly related to the chief complaint. (1 BA or OS) Expanded problem-focused – limited exam of the affected body area or organ system and any other symptomatic or related BA or OS. (2–7 limited BA or OS) Detailed – includes an extended exam of the affected body area and any other related, symptomatic BA or OS. (2-7 extended BA or OS) Comprehensive – the most extensive exam, includes either a complete single- specialty exam or a complete multisystem examination. (8+ BA or OS)

Medical Decision-Making Elements for documentation Number of diagnoses and management options Amount or complexity of data to be reviewed Risk of complication or death if untreated Learning Outcome: List the types of E/M Codes within the CPT. Medical Decision-Making Probably the most difficult to document based on the complexity of the decision making by the provider about the patient’s care and diagnosis. Three elements must be documented to establish MDM Number of diagnoses or management options – minimal, limited, multiple, or extensive Amount or complexity of date to be reviewed – none or minimal, limited, moderate, or extensive Risk of complication or death if condition is untreated – minimal, low, moderate, or high

Complexity level Straightforward MDM Low-complexity MDM Moderate-complexity MDM High-complexity MDM Learning Outcome: List the types of E/M Codes within the CPT. Medical Decision-Making Complexity levels of medical decision making: Straightforward MDM – there are minimal diagnosis and management options with no or a minimal amount or complexity of data to be reviewed, and minimal risk to the patient of complication or death if the condition is left untreated. Low-complexity MDM – there are a limited number of diagnoses and management options with a limited amount/complexity of data to be reviewed and low risk of complication or death if the patient is not treated. Moderate-complexity MDM – there are multiple diagnoses and management options with a moderate amount and complexity of data to review. If not treated, the condition presents a moderate risk of complication or death to the patient. High-complexity MDM – the physician has extensive diagnoses and management options with an extensive amount and complexity of data for review. The patient is at high risk for complication and/or death if not treated.

Contributory factors in assigning codes Counseling Reason for encounter 50% or more of time Coordination of care Learning Outcome: List the types of E/M Codes within the CPT. Some E/M codes take three contributory factors into consideration when codes are assigned: Counseling – considered critical for E/M codes when counseling is the reason for the encounter and constitutes 50% or more of the total time of the visit. Coordination of care – time the physician uses to coordinate patient care with other healthcare agencies like home care or nursing home care.

Nature of presenting problem Minimal complaint Self-limited complaint Low severity complaint Moderate severity complaint High severity complaint Learning Outcome: List the types of E/M Codes within the CPT. Three contributory factors (cont.) Nature of the presenting problem – severity of the patient’s chief complaint. A minimal complaint – may not require the presence of a physician. (BP check) A self-limited complaint – a minor problem that will run a “known” course and is transient in nature. Low severity complaints – those with a low risk of morbidity and mortality (death) if there is no treatment. Full recovery is expected. Moderate severity complaints – a moderate risk of morbidity and mortality if there is no treatment. Prognosis is uncertain and there is increased risk of impairment. High severity complaints – those of high to extreme risk. Risk of death is moderate to high and there is a high risk of prolonged functional impairment.

Additional considerations Time Average times Not critical unless code choice is based on time Location where services occurred Learning Outcome: List the types of E/M Codes within the CPT. Time is listed as a component to some codes. Times listed are considered averages and unless the code choice is based on time. Time should not be considered a critical factor when choosing an E/M code. Location of the service is also important. Different E/M codes apply to different locations where a service is provided. Appendix C of the CPT code manual lists clinical examples of each E/M code type

Apply Your Knowledge Good Job!
What are the 3 factors in determining how select E/M codes for different levels of service? ANSWER: Extent of patient history taken Extent of the examination conducted Complexity of medical decision-making Learning Outcome: List the types of E/M Codes within the CPT. Good Job!

Surgical Coding The surgical package
All procedures normally a part of an operation Preoperative exam and testing Surgical procedure Routine follow-up care Global period – time period covered for follow-up care Learning Outcome: List the areas included in the Surgical Coding Section. Many insurance carriers cover the surgical procedures found in CPT as part of a surgical package. The preoperative exam and testing The surgical procedure itself, including local or regional anesthesia if used, Routine follow-up care for a set period of time. If using anesthesia other than local anesthesia, the anesthesiologist billing for his services would use an anesthesia code. The period of time covered for follow-up care is called the global period – any care provided related to the surgical procedure is included in the surgical fee and cannot be billed separately. If a patient is seen for an unrelated problem, the service or procedure may be billed separately using a modifier 24 for E/M services, or modifier 79 for an unrelated surgical procedure taking place in a global period. Remember to update both the ICD and CPT codes on the superbills and in any computer programs when the new codes are available each year (October for ICD codes and January for CPT codes)

Surgical Coding (cont.)
Integumentary System Codes based on size and location Read and follow instructions carefully Musculoskeletal System Subheadings general Head to toe Fracture codes most common Learning Outcome: List the areas included in the Surgical Coding Section. Integumentary System Subheadings are further subdivided by the procedures done within each subheading Codes in this section are based on size and location Read everything carefully and follow the instructions exactly. Musculoskeletal System Codes start from the top of the body and work their way down within each section and subsection. Most common codes from this section include the fracture codes A fracture treatment is closed unless stated otherwise Be careful with cast and strapping codes. Fracture repair assumes cast application and includes it. Any therapeutic procedure includes the diagnostic procedure, so if a diagnostic procedure becomes a therapeutic (surgical) procedure, in the end, only the therapeutic procedure will be coded.

Respiratory System Code to furthest extent of the procedure Approach Scope Incision Incision vs. excision codes Repair procedures Cardiovascular System Complicated coding Read instructions carefully Sequence codes correctly Learning Outcome: List the areas included in the Surgical Coding Section. Respiratory System Code to the furthest extent of the procedure. Read information regarding the approach for the procedure. Many procedures can be done via a scope (scopy) or as an open procedure using an incision (tomy); these procedures are very different, so be cautious when coding similar procedures using different approaches. Be alert also for incision codes (cutting into-suffix tomy) versus excision (removal- suffix ectomy); and for the suffix plasty, signifying a repair procedure. Cardiovascular System Cardiology coding consists of some of the more complicated coding scenarios Read instructions carefully. Use the correct coding sequence. Read everything and make sure to code procedures completely, using as many codes as necessary.

Hemic/Lymphatic Systems and Mediastinum and Diaphragm Digestive System Upper Lower Urinary System Kidneys and renal function Diagnostic and therapeutic procedures Laparoscopy vs. incision Learning Outcome: List the areas included in the Surgical Coding Section. Hemic/Lymphatic Systems and Mediastinum and Diaphragm Includes procedures on the spleen, bone marrow, and lymph nodes as well as surgical procedures related to the mediastinum and diaphragm. Coding in these sections is pretty straightforward if you read carefully. Digestive System Common procedures found in the upper digestive system are incisions and excisions followed by repairs. The lower digestive system include these as well as endoscopies (and laparoscopies). You will also find procedures on the liver, pancreas, biliary tract, abdomen, and peritoneum in this chapter Urinary System The most “intense” coding in the urinary system revolves around the kidneys and renal function and treatment, including services for renal transplantation. Includes diagnostic (including urodynamics) and therapeutic procedures for the ureters, bladder, and urethra. Read notes and code descriptions carefully to choose the correct approach.

Male Genital System Female Genital System/Maternity and Delivery Endocrine System Nervous System Subheadings by anatomic sites Subdivided by procedure Specialized guidelines Learning Outcome: List the areas included in the Surgical Coding Section. Male Genital System: because of the many repair codes associated with it, the subheading Penis is the largest within the male genital section. Female Genital System/Maternity and Delivery Used almost exclusively by OB/GYN providers. Chapter is set up from “the outside in,” starting with the introitus (vaginal opening) moving to the ovaries within the pelvis, with a separate subsection devoted to labor and delivery. Many definitions and specialized guidelines – read the entire chapter carefully. Endocrine System: codes include those for procedures on the thyroid, parathyroid, thymus, adrenal glands, pancreas, and carotid body. Nervous System Anatomic sites create the subheadings, which are subdivided by the procedure performed. Multiple specialized guidelines – read carefully. Consider the approach when coding surgery on the brain. Consider the definitive procedure that describes the procedure done to the lesion and the reconstruction or repair necessary at the end of the surgery.

Eye and Ocular Adnexa Highly specialized procedures Read instructions and guidelines carefully Auditory System Radiology Diagnostic and therapeutic procedures Read all includes and excludes carefully Learning Outcome: List the areas included in the Surgical Coding Section. Eye and Ocular Adnexa Includes everyday eye exams and removal of a foreign body from the external eye to enucleation surgery. Procedures are highly specialized and require careful reading of instructions and guidelines. The codes are divided by anterior and posterior segments, ocular adnexa, and conjunctiva (including the lacrimal system). Auditory System Divided by the external ear diagnostics and treatments, middle ear diagnostics and treatments and then the inner ear diagnostics and treatments, followed by temporal bone procedures. Read code descriptions carefully to avoid unbundling. Radiology Includes diagnostic radiology (imaging), diagnostic ultrasound, radiologic guidance, mammography, bone and joint procedures, radiation oncology, and nuclear medicine. Many diagnostic radiology procedures use modifiers 26 (professional component only) and TC (technical component only); however, read descriptions carefully. Read all includes and excludes instructions carefully.

Laboratory Procedures – panels Medicine and Immunizations Two codes Procedure Vaccine or toxoid Learning Outcome: List the areas included in the Surgical Coding Section. Laboratory Procedures Organ or disease-oriented panels listed in the pathology and laboratory section of the CPT include tests frequently ordered together. The code for the panel must be used rather than the separate procedure codes. The physician must order each test listed within the panel and there must be a need for each of them. Any additional tests are coded separately. Medicine and Immunizations Injections and infusions require two codes – one for giving the injection and one for the particular vaccine or toxoid that is given.

Apply Your Knowledge What do the terms surgical package and global period include? ANSWER: Surgical package includes preoperative exam and testing, the surgical procedure and local or regional anesthesia if used, and routine follow-up care. The global period is the time covered for follow-up care and included any care provided related to the surgical procedure. Learning Outcome: List the areas included in the Surgical Coding Section. Bravo!

Using the CPT Manual Become familiar with guidelines and notes for each section Find the procedures and services provided by the office Determine appropriate codes E/M sections Alphabetic listing Check all codes listed Learning Outcome: 19.5 Locate a CPT code using the CPT manual When choosing E/M codes you must know whether the patient is a new or established patient and where the services took place. The next step is to find the procedures and services provided by the office. Check the patient’s chart to verify the documentation for the procedures and services. When coding E/M codes, you may find it easiest to go directly to the E/M section in the front of the CPT manual to choose the correct code. For all other procedures, you will need to use the alphabetic listing of procedures found in the back of the CPT manual. Check all codes listed in the numeric index to choose the correct code. The patient’s medical record may show an abbreviation, an eponym (a person or place for which a procedure is named), or a synonym so a knowledge of anatomy and physiology and terminology is important.

Using the CPT Manual Determine appropriate modifiers
Required if available Enhance reimbursement Enter codes and modifiers on CMS-1500 form Primary procedure first and match with appropriate diagnostic code All other procedures matched with appropriate diagnostic code Learning Outcome: 19.5 Locate a CPT code using the CPT manual Once you decide on the appropriate CPT code(s), the next step is to check for any applicable modifiers. Using modifiers can greatly enhance reimbursement and cut down on claim inquiries from the insurance carrier Modifier use is required if one is available for the situation. Enter the 5-digit code(s) and modifiers in block 24d of the CMS-1505 form Primary procedure is listed first and is matched with the appropriate diagnosis code, to demonstrate medical necessity for the insurance carrier. Enter all other procedures provided during this date of service and match each with its appropriate diagnosis to verify its medical necessity as well. Refer to Procedure 19-1 Locating a CPT Code Refer to CONNECT to see a video about Locating a CPT Code.

Apply Your Knowledge Terrific!
What are the steps for locating a code in the CPT manual? ANSWER: Determine if the patient is new or established Find procedures and services provided (encounter form) Verify information with the medical record Locate the correct code in the CPT manual starting with the alphabetic index and verifying with the numeric index. Check for modifiers Document on CMS-1505 or in the billing program Learning Outcome: 19.5 Locate a CPT code using the CPT manual Terrific!

The HCPCS Coding Manual
Health Care Common Procedure Coding System Use for coding services for Medicare patient HCPCS Level I codes – CPT codes Learning Outcome: Explain how to locate a HCPCS code using the HCPCS coding manual. Developed by the Centers for Medicare and Medicaid Services (CMS) for use in coding services for Medicare patients. Many private insurance programs also accept some HCPCS codes but check with the insurance carrier to see if they accept HCPCS codes and, if so, which ones. HCPCS coding system has two levels.

The HCPCS Coding Manual (cont.)
HCPCS Level II codes National codes for supplies and DME Cover services and procedures not in CPT 5 characters ~ numbers, letters, or a combination of both Modifiers Learning Outcome: Explain how to locate a HCPCS code using the HCPCS coding manual. If CPT and HCPCS have identical descriptions, use the HCPCS Level I (CPT) code. If CPT has a generic description and HCPCS has a more specific description, use the HCPCS Level II code. HCPCS modifiers are different from CPT modifiers, but they can be used with CPT codes as well as with Level II codes. Appendix 2 of the HCPCS manual gives a complete list of all HCPCS modifiers.

The HCPCS Coding Manual (cont.)
Coding procedures Locate service in the Alphabetic Index Verify description in the alphanumeric Index Choose code that matches service, procedure, or item supplied Enter on CMS-1505 form or into the billing program Learning Outcome: Explain how to locate a HCPCS code using the HCPCS coding manual. Coding with the HCPCS manual coding mimic coding using the CPT. As with all coding procedures, the first step is to locate the description of the service, procedure, or item in the Alphabetic Index. Verify in the alphanumeric index. Choose the code description that exactly matches the service, procedure, or item supplied as documented in the medical record. Medications supplied to the patient – locate in the Table of Drugs found in Appendix 1 of HCPCS Once all CPT and HCPCS codes are located and verified, enter them in block 24d of the CMS-1505 form or in the appropriate area of the office medical billing software Refer to Procedure 19-2 Locating a HCPCS Code and Procedure 19-3 Entering CPT/HCPCS and ICD Codes into an EHR Program

Apply Your Knowledge Stellar!
What are HCPCS Level II codes and who issues them? ANSWER: HCPCS Level II codes are national codes used for supplies, DME, and services not included in the CPT. They are issued by Centers for Medicare and Medicaid Services (CMS). Learning Outcome: Explain how to locate a HCPCS code using the HCPCS coding manual. Stellar!

Coding Compliance Physician – ultimate responsibility
Medical assistants Submit correct claims Help ensure maximum appropriate reimbursement Claims must comply with Federal and state law Payer requirements Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. Physicians have the ultimate responsibility for proper documentation and correct coding as well as for compliance with regulations. These claims, and the process used to create them, must comply with the rules imposed by federal and state law and with payer requirements.

Code Linkage Analysis of the connection between diagnostic and procedural information to evaluate medical necessity Diagnostic Codes Procedural Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. Clean claims are those where each reported service is connected to a diagnosis that supports the procedure as necessary to investigate or treat the patient’s condition. Insurance company representatives perform analysis. Possible consequences of inaccurate coding and incorrect billing Denied claims Delays in processing claims and receiving payment Reduced payments Fines and other sanctions Loss of hospital privileges Exclusion from payers’ programs Prison sentences Loss of physician’s license to practice medicine

Code Linkage (cont.) Codes are checked against the medical documentation Coding audit: Are codes appropriate and is each coded service billable? Is code linkage correct? Have rules ben followed? Does documentation support services? Do reported services comply with regulations? Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. To avoid errors, the codes on healthcare claims are checked against the medical documentation. A code review, also known as a coding audit, checks these key points: Are the codes appropriate to the patient’s profile, and is each coded service billable? Is there a clear and correct link between each diagnosis and procedure? Have the payer’s rules about the diagnosis and the procedure been followed? Does the documentation in the patient’s medical record support the reported services? Do the reported services comply with all regulations?

Insurance Fraud Investigators look for patterns such as
Reporting services that were not performed Reporting services at a higher level Performing and billing for procedures not related to the patient’s condition and therefore not medically necessary Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. Fraud – an act of deception used to take advantage of another person or entity. Claims fraud – representing services or charges to payers.

Insurance Fraud (cont.)
Patterns (cont.) Unbundling Reporting the same service twice Copayments Waiver may violate payer policies Ensure policies are consistent with law and requirements of payers Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. Billing separately for services bundled in a single procedure code (unbundling). The forgiveness or waiver of copayments may violate the policies of some payers. Routine forgiveness or waiver of copayments or deductibles constitutes fraud when billing federal programs. The physician practice should ensure that its policies on copayments are consistent with applicable law and with the requirements of their agreements with payers.

Compliance Plans Process for finding, correcting, and preventing illegal medical practices Goals of compliance plan Prevent fraud and abuse Ensure compliance with applicable laws Help defend physicians if investigation occurs Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. Medical offices have a compliance plan to uncover compliance problems and correct them. Its goals are to: Prevent fraud and abuse through a formal process to identify, investigate, fix, and prevent repeat violations relating to reimbursement for healthcare services provided. Ensure compliance with applicable federal, state, and local laws, including employment laws and environmental laws as well as antifraud laws. Help defend physicians if they are investigated or prosecuted for fraud by showing the desire to behave compliantly and thus reduce any fines or criminal prosecution.

Compliance Plans (cont.)
Developed by a compliance officer and committee who also: Audit and monitor compliance with government regulations Develop consistent written policies and procedures Provide ongoing staff training and communication Respond to and correct errors Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. A compliance plan demonstrates to payers that honest, ongoing attempts have been made to find and fix weak areas of compliance with government regulations. Compliance plan covers all areas of government regulation of medical practices Coding and billing compliance Equal employment opportunity regulations OSHA regulations

Correct! Apply Your Knowledge Why is code linkage important?
ANSWER: Code linkage will ensure clean claims in which each reported service is connected to a supporting diagnosis. Learning Outcome: Explain the importance of code linkage in avoiding coding fraud. Correct!

In Summary 19.1 The sections for the CPT manual are Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology and Laboratory, and Medicine with code ranges from 19.2 A CPT code is a 5-digit code representing the service provided to the patient. The CPT manual general guidelines include symbols which represents important information about the code being described Always begin coding by looking up the description in the Alphabetic Index and verifying in the Tabular (numeric) List. Carefully read all guidelines and information surrounding the codes. 19.2 A CPT code is a 5-digit code representing the service provided to the patient. The CPT manual general guidelines include the following symbols, each of which represents important information about the code being described: blue triangle, red dot, # sign, triangles facing each other, circle with a diagonal through it, lightning bolt, bull’s-eye, as well as add-on codes and modifiers. Always begin coding by looking up the description in the Alphabetic Index and verifying in the Tabular (numeric) List. Carefully read all guidelines and information surrounding the codes.

In Summary (cont.) 19.3 The E/M code types include: office and other outpatient services as well as other E/M services. Surgical Coding sections include major body systems, radiology, pathology and lab, and medicine. 19.5 Students should be able to select an accurate code using the CPT manual for simple, straightforward coding scenarios. 19.3 The E/M code types include: office and other outpatient services; hospital observation; hospital inpatient; consultations; ED services; critical care, nursing facility, domiciliary, and rest home services; domiciliary and assisted-living services; home care plan oversight; home services; prolonged services; case management; care plan oversight; preventative medicine; non-face-to-face physician services; special E/M; newborn care, neonatal ICU and critical care services; and other E/M services. 19.4 Surgical Coding sections include: integumentary, musculoskeletal, respiratory, cardiovascular, digestive, urinary, male and female genital systems, endocrine, nervous, eye and ear, radiology, pathology and lab, and medicine. 19.5 Student answers will vary depending upon the information (encounter forms or mock medical records) they are given to practice coding with the CPT manual. They should be able to select an accurate code for simple, straightforward coding scenarios.

In Summary (cont.) 19.6 Students should be able to select an accurate code using the HCPCS manual for simple, straightforward coding scenarios. 19.7 Code linkage demonstrates the medical necessity of services provided to the patient by accurately linking each procedure code to its appropriate diagnosis. All procedures, services, and diagnoses must be documented in the patient’s medical record to be used on any health insurance claim form. 19.6 Student answers will vary depending upon the information (encounter forms or mock medical records) they are given to practice coding with the HCPCS manual. They should be able to select an accurate code for simple, straightforward coding scenarios.

End of Chapter 19 Things gained through unjust fraud are never secure.
~ Sophocles Screen captures of SpringCharts™ Electronic Health Records software are reprinted with permission from Spring Medical Systems, Inc. All rights reserved.

19 Procedure Coding.

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19 Procedure Coding.

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