basics of procedural coding

1Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Basics of Procedural CodingBasics of Procedural Coding

Chapter 19


Consider the following while Consider the following while reading this chapter:reading this chapter:

What will the medical assistant find similar to What will the medical assistant find similar to ICD-9-CM as she or he performs procedural ICD-9-CM as she or he performs procedural coding?coding?

What will help in selecting the most specific What will help in selecting the most specific and accurate CPT code? and accurate CPT code?

What are the differences between coding for What are the differences between coding for the CPT and coding for HCPCS? the CPT and coding for HCPCS?

What will be learned about the legal and What will be learned about the legal and compliance implications of improper coding?compliance implications of improper coding?


What is Procedural Coding and What is Procedural Coding and How Is It Used?How Is It Used?

Procedural or CPT coding is defined as the Procedural or CPT coding is defined as the transformation of verbal descriptions of medical transformation of verbal descriptions of medical services and procedures into numeric or services and procedures into numeric or alphanumeric designations. alphanumeric designations.

The medical assistant facilitates accurate medical The medical assistant facilitates accurate medical recordkeeping and the efficient processing of recordkeeping and the efficient processing of insurance claims by using the CPT and HCPCSinsurance claims by using the CPT and HCPCS

CPT and HCPCS are used in the claims CPT and HCPCS are used in the claims submission process to receive reimbursement from submission process to receive reimbursement from payors as well as to track physician productivity payors as well as to track physician productivity and provide statistical data.and provide statistical data.


What is the Purpose of CPT Coding?What is the Purpose of CPT Coding?

Encourage the use of standard terms and Encourage the use of standard terms and descriptors to document procedures in the descriptors to document procedures in the medical recordmedical record

Help communicate accurate information on Help communicate accurate information on procedures and services to agencies procedures and services to agencies concerned with insurance claimsconcerned with insurance claims

Provide the basis for a computer-oriented Provide the basis for a computer-oriented system to evaluate operative proceduressystem to evaluate operative procedures

Contribute basic information for actuarial and Contribute basic information for actuarial and statistical purposesstatistical purposes


The CPT CodeThe CPT Code

The CPT code is a five-digit code also known as a The CPT code is a five-digit code also known as a Category ICategory I code. Category I codes are located in the code. Category I codes are located in the Tabular IndexTabular Index ((Main TextMain Text) of the CPT coding manual and are arranged by Section ) of the CPT coding manual and are arranged by Section

Category IICategory II codes are optional codes used by providers to assist in codes are optional codes used by providers to assist in measuring performance and outcomes. Category II codes include measuring performance and outcomes. Category II codes include the letter F as the fifth digit. the letter F as the fifth digit.

Category IIICategory III codes are temporary codes assigned for emerging and codes are temporary codes assigned for emerging and new technology, services and procedures that have not been new technology, services and procedures that have not been officially added to the Main Text of the CPT manual. The fifth digit officially added to the Main Text of the CPT manual. The fifth digit of the Category III code is the letter T. of the Category III code is the letter T.

ModifiersModifiers provide a way for providers to indicate that a service or provide a way for providers to indicate that a service or procedure performed has been altered by some specific procedure performed has been altered by some specific circumstance but not changed in its definition. circumstance but not changed in its definition.


Format of the CPT Coding Manual Format of the CPT Coding Manual

Each procedure or service is represented by Each procedure or service is represented by a five-digit numeric code a five-digit numeric code – a type of medical a type of medical shorthand that saves enormous amounts of shorthand that saves enormous amounts of time and effort and helps to ensure the time and effort and helps to ensure the accuracy of information accuracy of information


CPT ContentCPT Content

Comprehensive instructions for use of the Comprehensive instructions for use of the manual, including steps for coding manual, including steps for coding

A complete Alphabetic IndexA complete Alphabetic Index Main Text (Tabular Index)Main Text (Tabular Index)

Six sectionsSix sections Guidelines and notesGuidelines and notes ConventionsConventions

Thirteen appendixes Thirteen appendixes


CPT ContentCPT Content

The Tabular Index is divided into six sectionsThe Tabular Index is divided into six sections ,, with codes listed in numeric or alphanumeric with codes listed in numeric or alphanumeric order within each section. order within each section. Evaluation and Management (E&M)Evaluation and Management (E&M) AnesthesiaAnesthesia Surgery (all body systems)Surgery (all body systems) RadiologyRadiology Pathology and LaboratoryPathology and Laboratory Medicine Medicine


Sections of the CPT Main TextSections of the CPT Main Text

A A sectionsection is a broad category in the main text is a broad category in the main text of the CPT manual, and each of the six of the CPT manual, and each of the six sections is divided by the general type of sections is divided by the general type of service service Evaluation and Management (E&M)Evaluation and Management (E&M) AnesthesiaAnesthesia SurgerySurgery RadiologyRadiology Pathology and LaboratoryPathology and Laboratory Medicine Medicine



The The subsectionsubsection of the CPT manual is of the CPT manual is indented two spaces below a section, and indented two spaces below a section, and usually describes:usually describes: Anatomic Site Anatomic Site Organ SystemOrgan System

CategoriesCategories are indented two additional are indented two additional spaces below the subsection, and generally spaces below the subsection, and generally refer to:refer to: a specific procedure or servicea specific procedure or service can also be a more specific anatomical site can also be a more specific anatomical site



The The subcategorysubcategory is indented two spaces is indented two spaces below a category, and provides even more below a category, and provides even more specificity about an anatomical site or the specificity about an anatomical site or the procedure or service performed. procedure or service performed.


AppendixesAppendixes

appendixes found in the CPT are as follows:appendixes found in the CPT are as follows: Appendix A: Modifiers Appendix A: Modifiers Appendix B: Summary of Additions, Deletions, and Appendix B: Summary of Additions, Deletions, and

Revisions Revisions Appendix C: Clinical Examples Appendix C: Clinical Examples Appendix D: Summary of CPT Appendix D: Summary of CPT Add-onAdd-on Codes Codes Appendix E: Summary of CPT Codes Exempt from Appendix E: Summary of CPT Codes Exempt from

Modifier -51 Modifier -51 Appendix F: Summary of CPT Codes Exempt from Appendix F: Summary of CPT Codes Exempt from

Modifier -63 Modifier -63


Appendixes Appendixes

Appendix G: Summary of CPT Codes that Include Appendix G: Summary of CPT Codes that Include Moderate (Conscious) Sedation Moderate (Conscious) Sedation

Appendix H: Alphabetic Index of Performance Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or Topic Measures by Clinical Condition or Topic

Appendix I: Genetic Testing Code Modifiers Appendix I: Genetic Testing Code Modifiers Appendix J: Electrodiagnostic Medicine Listing of Appendix J: Electrodiagnostic Medicine Listing of

Sensory, Motor, and Mixed Nerves Sensory, Motor, and Mixed Nerves Appendix K: Product Pending FDA Approval Appendix K: Product Pending FDA Approval Appendix L: Vascular Families Appendix L: Vascular Families


Beginning the Coding ProcessBeginning the Coding Process

The steps for using the CPT manual actually The steps for using the CPT manual actually begin with the medical documentation:begin with the medical documentation: Encounter form, also known as a superbill, fee Encounter form, also known as a superbill, fee

slip, or charge ticket slip, or charge ticket History and physical report (H&P)History and physical report (H&P) Discharge summaryDischarge summary Operative reportOperative report Pathology reportPathology report


Beginning the Coding ProcessBeginning the Coding Process

The basic steps in medical coding are to: The basic steps in medical coding are to: readread analyzeanalyze abstract the procedure or service documentedabstract the procedure or service documented compare it with the encounter form, operative compare it with the encounter form, operative

report, or other documentationreport, or other documentation


Using the Alphabetic Index to SearchUsing the Alphabetic Index to Search

Begin the search by using one or all of the Begin the search by using one or all of the four primary classifications (or types) of main four primary classifications (or types) of main and modifying term entries:and modifying term entries: Procedure or service Procedure or service Organ or anatomic site Organ or anatomic site Condition, illness, or injury Condition, illness, or injury Eponym, synonym, abbreviation, or Eponym, synonym, abbreviation, or acronymacronym


Steps for Using the Alphabetic IndexSteps for Using the Alphabetic Index Abstract the procedures and/or services performed from the medical Abstract the procedures and/or services performed from the medical

documentation. documentation. Determine the main and modifying terms from the abstracted information.Determine the main and modifying terms from the abstracted information. Select the most appropriate main term to begin the search in the Select the most appropriate main term to begin the search in the

Alphabetic Index.Alphabetic Index. Select modifying term(s), if needed, once the main term is located to Select modifying term(s), if needed, once the main term is located to

narrow down the search.narrow down the search. If no main or modifying term produces an appropriate code or code If no main or modifying term produces an appropriate code or code

range, repeat steps 2, 3, and 4, using a different main term.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 Find code or code ranges that include all or most of the medical record

procedure or service description.procedure or service description. Disregard any code or code range containing additional descriptions or Disregard any code or code range containing additional descriptions or

modifying terms not found in the abstracted information or the medical modifying terms not found in the abstracted information or the medical documentation.documentation.

Write down the code or code ranges that best match the medical Write down the code or code ranges that best match the medical documentation. documentation.


Steps for Using the Main Text Steps for Using the Main Text Turn to the Main Text and find the first code or code range found while Turn to the Main Text and find the first code or code range found while

searching the Alphabetic Index.searching the Alphabetic Index. Compare the description of the code with the medical documentation. Compare the description of the code with the medical documentation.

Verify that all or most of the medical record documentation matches the Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in code description and that there is no additional element or information in the code description that is not found in the documentation.the code description that is not found in the documentation.

Read the guidelines and notes for the section, subsection, and code to Read the guidelines and notes for the section, subsection, and code to ensure there are no contraindications to the use of the code.ensure there are no contraindications to the use of the code.

Evaluate the conventions, especially add-on codes (+) and exemption Evaluate the conventions, especially add-on codes (+) and exemption from modifier -51.from modifier -51.

Determine if there are special circumstances that require the use of a Determine if there are special circumstances that require the use of a modifier.modifier.

Determine if a Special Report is required. Determine if a Special Report is required. Record the CPT code selected in the medical record documentation next Record the CPT code selected in the medical record documentation next

to the procedure or service performed and in the appropriate block of the to the procedure or service performed and in the appropriate block of the insurance claim form.insurance claim form.


Surgery codingSurgery coding

There are some guidelines and notes related There are some guidelines and notes related to surgery coding that must be considered to surgery coding that must be considered when researching and selecting a procedure when researching and selecting a procedure or service code:or service code: Surgical Package Definition Surgical Package Definition Follow Up Care for Diagnostic Procedures Follow Up Care for Diagnostic Procedures Materials Supplied by the Physician Materials Supplied by the Physician Surgical Destruction Surgical Destruction


Surgery Coding Surgery Coding

Endoscopy Endoscopy X-ray Imaging/Fluoroscopy X-ray Imaging/Fluoroscopy Excision of Lesions – Benign or Malignant Excision of Lesions – Benign or Malignant Repair (Closure) Repair (Closure) Musculoskeletal SystemMusculoskeletal System Respiratory SystemRespiratory System Maternity Care and DeliveryMaternity Care and Delivery


Understanding Evaluation Understanding Evaluation and Managementand Management

The first two steps in choosing an E&M code are: The first two steps in choosing an E&M code are: Identifying the place of service (POS)Identifying the place of service (POS) Identifying the patient statusIdentifying the patient status Determining the level of service provided Determining the level of service provided There are three components for determining the level of service for There are three components for determining the level of service for

E&M: E&M: historyhistoryexaminationexaminationmedical decision makingmedical decision making

four contributing factors: four contributing factors: counselingcounselingnature of the presenting problemnature of the presenting problemcoordination of carecoordination of caretime time


Anesthesia CodingAnesthesia Coding STEPS FOR ANESTHESIA CODINGSTEPS FOR ANESTHESIA CODING

Read the medical documentation to determine what procedure or service was provided.Read the medical documentation to determine what procedure or service was provided. Determine the anatomic site or organ system involved.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 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.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 Write down the code or code range found in the Alphabetic Index, under the Anesthesia

heading, that best matches the medical documentation.heading, that best matches the medical documentation. Turn to the Main Text, Turn to the Main Text, Anesthesia SectionAnesthesia Section, and find the code or code range found while , and find the code or code range found while

searching the Alphabetic Index.searching the Alphabetic Index. Read the guidelines and notes for the section, subsection, category, or subcategory.Read the guidelines and notes for the section, subsection, category, or subcategory. Evaluate the conventions, especially add-on codes (+) and modifier -51 exemptions.Evaluate the conventions, especially add-on codes (+) and modifier -51 exemptions. Document the code selected.Document the code selected. Determine the Basic Unit Value from the Relative Value Guide.Determine the Basic Unit Value from the Relative Value Guide. Determine the patient’s physical status and document the appropriate modifier.Determine the patient’s physical status and document the appropriate modifier. Determine if any qualifying circumstance modifier should be used. If yes, document the Determine if any qualifying circumstance modifier should be used. If yes, document the

modifier.modifier. Determine the total anesthesia time, divide by 15 (minutes), and document the time.Determine the total anesthesia time, divide by 15 (minutes), and document the time. Select the appropriate geographic conversion factor.Select the appropriate geographic conversion factor. Calculate the charge for the anesthesia service using the anesthesia formula.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 Document the anesthesia charge and the code in the medical record and on the encounter

form or charge ticket.form or charge ticket.


Healthcare Common Procedure Healthcare Common Procedure Coding System (HCPCS)Coding System (HCPCS)

Steps for Using HCPCS CodesSteps for Using HCPCS Codes Read the medical documentation to determine what procedures or services were provided.Read the medical documentation to determine what procedures or services were provided. Determine the main and modifying terms from the abstracted information.Determine the main and modifying terms from the abstracted information. Select modifying term(s) if needed once the main term is located.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.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 If no modifying term produces an appropriate code or code range, repeat steps 2 and 3 using a

different main term classification.different main term classification. Find code or code ranges that include all or most of the medical record procedure or service Find code or code ranges that include all or most of the medical record procedure or service

description.description. Disregard any code or code range containing additional descriptions or modifying terms not found in Disregard any code or code range containing additional descriptions or modifying terms not found in

the medical record.the medical record. Write down the code or code ranges that best match the medical documentation.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 Turn to the Main Text and find the first code or code range found while searching the Alphabetic

Index.Index. Compare the description of the code with the medical documentation. Verify that all or most of the 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 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.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 Read the guidelines for the section, subsection, and code to ensure there are no contraindications to the use of the code.to the use of the code.

Evaluate the HCPCS manual conventions.Evaluate the HCPCS manual conventions. Determine if there are special circumstances that require the use of a modifier.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 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.service performed and in the appropriate block of the insurance claim form.


Compliance and Legal IssuesCompliance and Legal Issues

Medical assistants should also ensure that proper Medical assistants should also ensure that proper precautions are taken to avoid incorrect coding, data precautions are taken to avoid incorrect coding, data entry errors, and false claims submissions. entry errors, and false claims submissions. DowncodingDowncoding, in which lower level codes are used even , in which lower level codes are used even

when the diagnostic statement indicates a higher level when the diagnostic statement indicates a higher level procedure or service, usually affects reimbursement only procedure or service, usually affects reimbursement only by lowering the amount received, but may have civil and by lowering the amount received, but may have civil and criminal penalty implications if it is done to disregard criminal penalty implications if it is done to disregard insurance policy restrictions or preexisting condition insurance policy restrictions or preexisting condition clauses. clauses.

UpcodingUpcoding, on the other hand, in which a procedure or , on the other hand, in which a procedure or service code is used that is of a higher level than is service code is used that is of a higher level than is supported by the medical documentation, can result in civil supported by the medical documentation, can result in civil and criminal penalties, including fines, loss of privileges as and criminal penalties, including fines, loss of privileges as a participating provider, and even prison time.a participating provider, and even prison time.

basics of procedural coding

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