copyright © 2008 delmar learning. all rights reserved. chapter 7 cpt coding

Copyright © 2008 Delmar Learning. All rights reserved.

CHAPTER 7

CPT Coding


2

Introduction

• Chapter 7: – Introduces assignment of Current Procedural

Terminology– CPT:

• Services and procedure codes reported on insurance claims


3

Overview of CPT

• CPT – Provides a list of identifying and descriptive

codes for reporting procedures and medical services

– Uniform language that describes medical, surgical procedures and services


4

Overview of CPT

• CPT codes are used to report services and procedures

• Submitted as claims with linked ICD-9-CM codes – Codes justify need for service or procedure


5

Overview of CPT

• Changes to CPT – CPT supports electronic data – Exchange (EDI), Computer-based patient– Record (CPR), or electronic medical – Record (EMC) and reference/research

database


6

Overview of CPT

• Improvements to CPT are underway

• In 2002– AMA completed the CPT 5 Project, resulting

in the establishment of three categories of CPT codes


7

Overview of CPT

• Category 1 – Procedures/services identified by a five digit

CPT code and descriptor nomenclature– Codes traditionally associated with CPT

organized in six sections


8

Overview of CPT

• Category 2– Contain “performance measurements”

tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A)

– Codes located after Medicine section• Use is optional


9

Overview of CPT

• July 2007– New program from Medicare utilizing these

codes to justify documentation– “PQRI’s” will begin a project for physicians’

practices • Will receive additional percentage of revenue for

documentation compliance


10

Overview of CPT

• Category 3 codes– Contain “emerging technology” temporary

codes assigned for data purposes and assigned in alphanumeric with the letter in the last position


11

Overview of CPT

• Field 0001T– Codes are located after Medicine section– Archived after five years unless accepted for

placement


12

CPT Sections

• Category I procedures and services– Evaluation and Management (E/M) 99201-

99499– Anesthesia (00100-01999, 99100-99140)– Surgery (10021-69990)


13

CPT Sections

• Radiology (70010-79999)

• Pathology and laboratory (80048-89356)

• Medicine (90281-99199, 99500-99602)


14

CPT Sections

• CPT code number format– Five-digit number and description identifying

each procedure and service listed in CPT


15

CPT Sections

• CPT Appendices– CPT contains appendices located after the

Medicine section and Index – Insurance specialist should become familiar

with changes that affect the practice


16

CPT Appendix Description

• Appendix A – Detailed description of each CPT modifier

• Appendix B – Annual CPT coding changes

• Added, deleted, revised CPT codes


17


• Appendix C– Clinical examples for evaluation and

Management (E/M) section codes

• Appendix D – Add-on codes


18


• Appendix E – Codes exempt from modifier -51 reporting

rules

• Appendix F – CPT codes exempt from modifier -63

reporting rules

• Appendix G– Summary of CPT codes that include moderate

(conscious) sedation


19


• Appendix H – Alphabetic index of performance measures by

clinical condition or topic• Serves as a crosswalk to the category II

• Appendix I – Genetic testing code modifiers


20


• Appendix J – Electro diagnostic medicine listing of sensory,

motor, and mixed nerves


21


• There is also a table that indicates “type of study and maximum of studies” – Generally performed for needle

electromyogram (EMG)– Nerve conduction studies– Other EMG studies


22


• Appendix L – List of vascular families that is intended to

assist in selection of first, second, third, and beyond third-order branch arteries

• Appendix M – Crosswalk of deleted to new CPT codes


23

CPT Symbols

• Symbols are located throughout CPT coding book

• Bullet located to left of a code number– Identifies new procedures and services

added to CPT


24

CPT Symbols

• Triangle located to left of a code number– Identifies a code description that has been

revised


25

CPT Symbols

• Horizontal triangles – Surround revised guidelines and notes– Not used for revised code descriptions– To save space in CPT

• Code descriptions are not printed in their entirety next to a code number


26

CPT Symbols

• Plus sign – Identifies add-on codes– For procedures that are commonly, but not

always, performed at the same time and by the same surgeon


27

CPT Symbols

• Circle with a line through it – Identifies codes that are not to be used

with modifier

• Bull’s-eye symbol – Indicates a procedure that includes

moderate sedation


28

Guidelines

• Located at beginning of the CPT section– Should be reviewed each year before

attempting to code from this section

• Guidelines define and explain the assignment of codes, procedures, and services in a particular section


29

Unlisted Procedures/Services

• Unlisted procedure or service– Codes are assigned when a procedure or

service is performed by a provider for which there is no CPT code


30


• Special Report– When an unlisted procedure or service

code is reported


31


• Special Report– Narrative document must accompany claim

to describe nature and extent of the need of service or procedure

• Some practices place in Box 19 of CMS 1500 claim form the “unlisted code = the closest related code of XXXXX.”


32


• Notes – Instructional notes are found throughout


33


• Blocked unindented note: – Located below a subsection title and contains

instructions that apply to all codes


34


• Indented parenthetical note: – Located below a subsection title, code

description, or code description that contains an example

• Highlight and understand each of these notes


35

CPT Modifiers

• Clarify services and procedures performed by providers

• Have always been reported on claims submitted for provider office services and procedures


36

CPT Modifiers

• Coding tip: – List of all CPT modifiers with brief

descriptions is located inside front cover of coding manual


37

CPT Modifiers

• Documented history, examination, and medical decision making – Must “stand on its own” to justify reporting

modifier -25 with the Evaluation and Management (E/M) code


38

CPT Modifiers

• E/M service: – Must be “above and beyond” what is normally

performed during a procedure


39

Coding Procedures and Services

• Step 1: – Read introduction in CPT coding manual

• Step 2: – Review guidelines at beginning of each

section

• Step 3: – Review procedure


40


• Step 4: – Refer to CPT index – Locate main term for procedure or service

documented• Main terms can be located by referring to the

following:


41


a. Procedure or service documented

b. Organ or anatomic site

c. Condition documented in the record

d. Substance being tested


42


e. Synonym (term with similar meaning)

f. Eponym (procedures and diagnoses named for an individual)

g. Abbreviation


43


• Step 5: – Locate sub terms and follow cross references

• Step 6: – Review descriptions of service/procedure

codes, and compare all qualifiers to descriptive statements


44


• Step 7: – Assign applicable code number and any add-

on (+) or additional codes needed to accurately classify statement being coded


45

Surgery Section

• Surgery section is organized by body system– Some subsections are further subdivided by

procedure categories


46

Surgery Section

• Incision

• Excision

• Introduction or removal

• Repair, revision, or reconstruction

• Grafts


47

Surgery Section

• Suture

• Other procedures


48

Code Surgeries Properly

• Three questions must be asked:– What body system was involved?– What anatomic site was involved?– What type of procedure was performed?

• Carefully read the procedure outlined in the operative report


49

Evaluation and Management

• Evaluation and management– Located at the beginning of CPT because

these codes describe services most frequently provided by physicians

• Before assigning E/M codes– Make sure you review guidelines and apply

any notes


50


• For established patients – Two of three key components must be

considered


51


• E/M code reported to a payer – Must be supported by documentation in the

patient’s record


52

Key Components

• E/M code selection is based on three key components:– Extent of history– Extent of examination– Complexity of medical decision making

• All key components must be considered when assigning codes for new patients


53

Extent of Examination

• Physical examination is an assessment of the patient’s organ and body system/s


54

Extent of Examination

• Categorized according to four types:– Problem focused examination – Expanded problem focused examination – Detailed examination – Comprehensive examination


55

Complexity ofMedical Decision Making

• Complexity of establishing a diagnosis and/or selecting a management option as measured by the: – Number of diagnoses or management options– Amount and/or complexity of data to be

reviewed– Risk of complications and/or morbidity or

mortality


56

Patient’s Records Should Include

• Laboratory, imaging, and other test results that are significant to the management of the patient care

• List of known diagnoses as well as those that are suspected

• Opinions of other physicians who have been consulted


57

Patient’sRecords Should Include

• Planned course of action for the patient’s treatment

• Review of patient records obtained from other facilities


58

History and Examination

• Determined by: – Straightforward– Low complexity – Moderate complexity – High complexity


59

History and Examination

• Once the extent of history, extent of examination, and complexity of medical decision making are determined– Select the appropriate E/M code


60

Presenting Problem

• CPT defines nature of the presenting problem as “a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.”


61

Presenting Problems

• Minimal

• Self-limited or minor

• Low severity

• Moderate severity

• High severity


62

Face-to-Face Time

• Amount of time the doctor spends with the family or the patient


63

Unit/Floor Time

• Amount of time the doctor spends at the patient’s bedside and at the management of the patient’s care.


64

E/M Time

• Claiming E/M on time you must have:– Total length of time for the encounter– Plus the length of time spent coordinating

care and/or counseling patient– Issues discussed– Relevant history, exam, and medical decision

making


65

Observation Services

• Are furnished in a hospital outpatient setting– Patient is considered an outpatient

• They are reimbursed only when the doctor orders it


66

Subcategories Include

• Observation care discharge services

• Initial observation care


67

Hospital Inpatient Services

• E/M services provided to hospital inpatients, including partial hospitalization services.


68


• Initial hospital care

• Subsequent hospital care

• Observation care services

• Hospital discharge services


69

Consultations

• Type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem requested by another physician or other appropriate source.


70

Criteria

• Consultation is requested by another doctor or provider

• Consultant renders an opinion or advice


71

Criteria

• Consultant initiates diagnostic or therapeutic services.

• Requesting physician documents in the patient’s record, the request, and the need for the consultation.


72

Criteria

• Consultant’s opinion, advice, and any services rendered are documented in the patient’s record – These are reported to the requesting

physician or source


73


• Office or other outpatient consultations

• Inpatient consultations


74

Emergency Department Services

• Are given in a hospital setting that is open 24 hours to provide services that are not scheduled.


75

Critical Care Services

• When a doctor provides services to someone who is critically ill or injured.

• The doctor should document the total time spent delivering critical care services– Excluding time for allowable services


76

Neonatal

• A neonate is a newborn up until 28 days, and an infant is 29 days to a year old.


77

Subcategories

• Inpatient pediatric critical care

• Inpatient neonatal critical care

• Continuing intensive care services


78

Nursing Facility Services

• Are provided at nursing facilities:– Skilled nursing, intermediate care, and long-

term care


79

Subcategories

• Initial nursing facility care

• Subsequent nursing facility care

• Nursing facility discharge services

• Other nursing facility services


80

Prolonged Services

• May be reported when a doctor’s services involving patient contact are considered beyond the usual service in either an inpatient or outpatient setting.


81

Subcategories

• Prolonged physician service with direct face-to-face

• Prolonged physician services without face-to-face

• Physician standby services


82

Newborn Care

• Includes services provided to newborns in a variety of health care settings.


83

Qualifying Circumstances for Anesthesia

• When situations or circumstances make anesthesia administration more difficult and increases the patient’s risk factor.


84

Physician Status Modifiers

• Each “status modifier”– Reported with an anesthesia code to indicate

the patient’s condition at the time anesthesia was administered.


85

Modifiers

• P1 – Normal health

• P2 – Mild systemic disease

• P3 – Severe systemic disease


86

Modifiers

• P4 – Severe systemic disease that is a constant

threat to life

• P5 – Not expected to survive without the operation

• P6 – Declared brain-dead and whose organs are

being removed for donor purposes


87

Anesthesia Time Units

• Be sure to record the time with the anesthesiologist

• Anesthesia time unit is one 15-minute increment


88

Calculating Anesthesia

• Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesia

• Nonmonitored interval time

• Recovery room time

• Routine postoperative evaluation by the anesthesiologist or CRNA


89

Separate Procedure

• Follows a code explanation identifying procedures that are an important part of an additional procedure or service.


90

Complete Procedure

• When the word “complete” is established in the code definition– One code is reported to “completely” explain

the procedure performed


91

Pathology and Laboratory

• Organized according to the kind of pathology or laboratory procedure performed


92

Pathology and Laboratory Subsections

• Organ or disease oriented panels

• Drug testing

• Therapeutic Drug Assays

• Consultations (Clinical Pathology)

• Urinalysis, chemistry, hematology and coagulation immunology

• Microbiology


93

Pathology and Laboratory Subsections

• Anatomic pathology

• Cytopathology and cytogenetic studies

• Surgical pathology

• Transcutaneous procedures

• Other procedures

• Reproductive medicine procedures


94

National Correct Coding Initiative

• To encourage national correct coding, methodologies, and manage the improper assignment of codes.


95

National Correct Coding Initiative

• Incorrect coding – Results in inappropriate repayment of

Medicare Part B claims– Centers for Medicare and Medicaid Services

implemented the National Correct Coding Initiative


96

NCCI Coding Policies

• Analysis of standard medical and surgical practice

• Coding conventions included in CPT

• Coding guidelines developed by national medical specialty societies

• Local and national coverage determinations

• Review of current coding practices

copyright © 2008 delmar learning. all rights reserved. chapter 7 cpt coding

Documents

cpt slide

overview of cpt cpt

delmar learning

cpt coding slide

categories of cpt codes

overview of cpt category

codes codes

overview of cpt field