CHAPTER 19 Procedure Coding 19-2 Learning Outcomes (cont.) 19.1List the sections of the CPT manual, giving the code range for each. 19.2Describe briefly

CHAPTER

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19Procedure Coding

19-2


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.

19-3


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

19-4


Introduction

• Procedural coding– Translate medical procedures and services

into codes– Explains what services were provided

• Code “linkage” with diagnostic codes

• Maximum reimbursement

19-5


The CPT Manual

• Procedure code• 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

19-6


Organization of the CPT Manual

Section Range of Codes

Evaluation and Management 99201 – 99499

Anesthesiology 00100 – 0199999100 – 99140

Surgery 10021 – 69990

Radiology 70010 – 79999

Pathology and Laboratory 80048 – 89356

Medicine 90281 – 9960299500 – 99602

19-7


Organization of the CPT Manual (cont.)

• Manual Introduction – General instructions

– Information about common• Prefixes• Suffixes• Word roots

• Guidelines for each section

19-8



• Sections– Guidelines at

beginning– Categories

headings

• Page– Section name– Subsection name– Subheading– Category

19-9


Apply Your Knowledge

Match CPT section to number range ANSWER:

Evaluation and management

Anesthesiology

Surgery

Radiology

Pathology and Laboratory

Medicine (except for Anesthesia)

70010-79999

00100-0199999100-99140

90281-9919999500-99602

80048-89356

99201-99499

10021-69990

19-10


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

25500 Closed treatment of radial shaft fracture; without manipulation

25505 with manipulation

19-11


Symbols Used in CPT

Code description has been revised

A new code

# Codes are out of numeric sequence

New or revised text information

19-12


Symbols Used in CPT (cont.)

Does not require modifier of 51

FDA approval pending

Moderate (conscious) sedation is included in the procedure

19-13



• Modifiers– Up to three per procedure

– Indicate that special circumstance applies

– Appendix A

– Section guidelines

19-14


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

19-15


Coding Terminology

• Concurrent care– More than one physician– If different specialties,

not considered duplication

19-16


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

19-17


Coding Terminology (cont.)

• Downcoding – Reimbursement on a lower code level than

submitted– Lack of documentation most common cause

• Unbundling

• Upcoding

19-18


2. 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:

a. Use the current book to validate accuracy of the codes

b. Use last year’s book to validate accuracy of the codes

c. Use next year’s book to validate accuracy of the codes


ANSWER:

19-19


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

19-20


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

19-21



• 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

Patient HistoryPatient History

19-22



• Elements – Constitutional exam

– Body areas (BA)

– Organ systems (OA)

• Coding description– Problem-focused

– Expanded problem-focused

– Detailed

– Comprehensive

Physical ExamPhysical Exam

19-23



• Elements for documentation– Number of diagnoses and management

options

– Amount or complexity of data to be reviewed

– Risk of complication or death if untreated

Medical Decision-MakingMedical Decision-Making

19-24



• Complexity level – Straightforward MDM

– Low-complexity MDM

– Moderate-complexity MDM

– High-complexity MDM

19-25



• Contributory factors in assigning codes1. Counseling

• Reason for encounter• 50% or more of time

2. Coordination of care

19-26



3. Nature of presenting problem• Minimal complaint

• Self-limited complaint

• Low severity complaint

• Moderate severity complaint

• High severity complaint

19-27



• Additional considerations– Time

• Average times• Not critical unless code choice is based on time

– Location where services occurred

19-28



ANSWER: – Extent of patient history taken– Extent of the examination conducted– Complexity of medical decision-making

What are the 3 factors in determining how select E/M codes for different levels of service?

19-29


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

19-30


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

19-31



• 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

19-32



• Hemic/Lymphatic Systems and Mediastinum and Diaphragm

• Digestive System– Upper– Lower

• Urinary System– Kidneys and renal

function

– Diagnostic and therapeutic procedures

– Laparoscopy vs. incision

19-33



• Male Genital System

• Female Genital System/Maternity and Delivery

• Endocrine System

• Nervous System– Subheadings by

anatomic sites

– Subdivided by procedure

– Specialized guidelines

19-34



• 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

19-35



• Laboratory Procedures – panels

• Medicine and Immunizations– Two codes

• Procedure • Vaccine or toxoid

19-36



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.

Bravo!

19-37


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

19-38


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

19-39



What are the steps for locating a code in the CPT manual?ANSWER:

1. Determine if the patient is new or established

2. Find procedures and services provided (encounter form)

3. Verify information with the medical record

4. Locate the correct code in the CPT manual starting with the alphabetic index and verifying with the numeric index.

5. Check for modifiers

6. Document on CMS-1505 or in the billing program

19-40


The HCPCS Coding Manual

• Health Care Common Procedure Coding System

• Use for coding services for Medicare patient

• HCPCS Level I codes – CPT codes

19-41


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

19-42


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

19-43



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).

19-44


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

19-45


Code Linkage

• Analysis of the connection between diagnostic and procedural information to evaluate medical necessity

DiagnosticCodes

Procedural Codes

19-46


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?

19-47


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

19-48


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

19-49


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

19-50


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

19-51



Why is code linkage important?

ANSWER: Code linkage will ensure clean claims in which each reported service is connected to a supporting diagnosis.

19-52


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 00100-99602.

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.

19-53


In Summary (cont.)

19.3 The E/M code types include: office and other outpatient services as well as other E/M services.

19.4 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.

19-54


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.

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Things gained through unjust fraud are never secure.

~ Sophocles

End of Chapter 19

Screen captures of SpringCharts™ Electronic Health Records software are reprinted with permission from Spring Medical Systems, Inc. All rights reserved.

Documents

CHAPTER 19 Procedure Coding 19-2 Learning Outcomes (cont.) 19.1List the sections of the CPT manual, giving the code range for each. 19.2Describe briefly