chapter 06 procedural coding

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1

Chapter 06

Procedural Coding

Insurance Handbook for the Medical Office

13th edition

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved

Basics of Procedural Coding

1. Explain the purpose and importance of coding for professional services.

2. Define terminology used in Current Procedural Terminology (CPT).

3. Demonstrate an understanding of CPT code conventions.

4. Describe various methods of payment by insurance companies and state and federal programs.

5. Describe the process in which the Healthcare Common Procedure Coding System (HCPCS) and relative value studies (RVS) are used to create a fee schedule. 2

Lesson 6.1


Basics of Procedural Coding (cont’d)

6. Interpret the meaning of CPT code book symbols.

7. Identify the complexity of evaluation and management (E/M) services codes.

8. Compare a surgical package and a Medicare global package.

9. Explain various types of code edits.

3

Lesson 6.1


Understanding the Importance of Procedural

Coding Skills Procedure coding: the transformation of

written descriptions of procedures and professional services into numeric designations (code numbers)

Procedure codes are a standardized method used to precisely describe the services provided by physicians and allied health professionals

4


Current Procedural Terminology Five-digit system for coding services

Two-digit add-on modifiers Represents diagnostic and therapeutic

services System of choice from CMS

5


Current Procedural Terminology

Level I: The AMA CPT codes and modifiers (national codes)

Level II: CMS-designated codes and alpha modifiers (national codes)

Level III: Codes specific to regional fiscal intermediary or individual insurance carrier (local codes) and not found in either levels I or II

6


Current Procedural Terminology

Physician or provider service = CPT code

Supplies = HCPCS national code Instructions to use from carrier = local

code Integrative healthcare products =

Alternative Billing Codes (ABCs)

7


Methods of Payment

Fee schedule Multiple schedules can be used Consistent charges and uniform application

Usual, customary, and reasonable Three fees determine reimbursement

Relative value scales or schedules Units (RVUs) based on median charges for

all physicians during a given time period Conversion factors translate units to dollars

8


Usual, Customary, and Reasonable

9


Resource-Based Relative Value Scale

Resource-based Relative Value Scale (RBRVS) To distribute Medicare dollars more

equitably To control escalating costs from UCR

Fee schedule based upon relative values Relative Value Unit (RVU) Geographic adjustment factor (GAF) Monetary conversion factor (CF) RVU x GAF x CF = Medicare $ per service

10


Resource-Based Relative Value Scale

11


Code Book Symbols

12


Evaluation and Management Section

Divided into three sections Office visits

• New patients• Established

Hospital visits• Initial visit• Subsequent visits

Consultations

13



Elements of E/M codes History Examination Medical decision-making Nature of presenting problem Counseling Coordination of care Time

14



Subsections of E/M Hospital inpatient services Consultation Critical care Pediatric and neonatal critical care Emergency care Preventative medicine

15



Selecting an E/M code Determine category Determine subcategory Note key components Note contributory factors Determine appropriate E/M level and code

16



17



CPT Code Digit Analysis

18



Code Selection Criteria for Consultation

19



E/M Levels

20


Surgery Section

Always start with the operative report Assign code for postoperative diagnosis Assign codes for additional diagnoses

Attach documentation to the claim form

Code only documented procedures Confirm all diagnosis and procedure

codes Be sure to use appropriate modifiers

21


Surgical Package for Non-Medicare Cases

Includes: The operation Local infiltration; topical anesthesia or

metacarpal, metatarsal, or digital block Subsequent to the decision for surgery, one

related E/M encounter on the date immediately before or on the date of procedure (including history and physical)

Immediate postoperative care, including dictating operative notes and talking with the family and other physicians

Writing orders Evaluating the patient in the post-anesthesia

recovery area Typical postoperative follow-up care (hospital

visits, discharge, or follow-up office visits) 22


Surgery Section Surgical Package vs. Medicare Global

Package

23


Surgery Section Surgery services

Never event Transfer to another facility Follow-up (postoperative) days Repair of lacerations Multiple lesions Supplies Incident-to services Prolonged services, detention, or standby

24


Unlisted Procedures Codes assigned for unusual

procedures Supporting documentation is required to

justify the procedures Comprehensive list of unlisted codes

is at the beginning of each section

25


Comprehensive and Component Edits

Code combinations that are specified as “separate procedures” by the CPT

Codes that are included as part of a more extensive procedure

Code combinations that are restricted by the guidelines outlined in the CPT

Component codes that are used incorrectly with the comprehensive code

26


Mutually Exclusive Code Edits Code combinations that are restricted

by the guidelines outlined in the CPT Procedures that represent two

methods of performing the same service

Procedures that cannot reasonably be done during the same session

Procedures that represent medically impossible or improbable code combinations

27


Coding Guidelines for Code Edits Bundling: to group codes together

that are related to a procedure Unbundling: coding and billing

numerous CPT codes to identify procedures usually described by a single code

28


Coding Guidelines for Code Edits Downcoding: when a coding system

of an insurance carrier converts a code to reduce the level of codes on an insurance claim

Upcoding: the deliberate manipulation of CPT codes for increased payment

29


Code Monitoring

30


Practice Diagnostic Coding

10. Explain how to choose accurate procedural codes for descriptions of services and procedures documented in a patient’s medical record.

11. Explain correct usage of modifiers in procedure coding.

31

Lesson 6.2


Helpful Hints in Coding

Office visits Be careful with assignment the

appropriate E/M code for standing orders Some insurance policies only allow 2

moderate- or high-complexity office visits per patient per year

32


Helpful Hints in Coding Drugs and injections

Name, amount, dosage, strength, how it was administered

Roster billing for mass immunizations for Medicare patients

33


Helpful Hints in Coding

Adjunct codes Identify special services and reports

Basic life or disability evaluation services Code 99450 – life or disability insurance Codes 99455 and 99456 – work-related or

medical disability examinations

34


Code Modifiers Modifiers can indicate:

A service or procedure has either a professional or technical component

A service or procedure was performed by more than one physician or in more than one location

A service or procedure has been increased or reduced

A service or procedure was provided more than once

Only part of a service was performed An adjunctive service was performed A bilateral procedure was performed Unusual events occurred

35


Code Modifiers

Modifier -22: Increased Procedural Services

Modifier -25: Significant, Separately Identifiable Evaluation and Management Service

Modifier -26: Professional Component Modifier -51: Multiple Procedures Modifier -52: Reduced Services Modifier -57: Decision for Surgery

36


Code Modifiers

Modifier -58: Stages or Related Procedure

Modifiers -62, -66, -80, -81: More Than One Surgeon

Modifier -99: Multiple Modifiers

37


Healthcare Common Procedure Coding System

Level II modifiers may be used by some commercial payers Two alpha digits, two alphanumeric

characters, or single alpha digit

38


Questions?

39

chapter 06 procedural coding

Documents

hcpcs codes

imprint of elsevier

ama cpt codes

importance of coding

diagnosis coding

codes specific

types of codes

cpt codesupplies