Embed Size (px)
Citation preview
HI1011
THE MEDICAL
ADMINISTRATIVE ASSISTANT
Chapter 16
Slide 1
Chapter 16The Basics of Procedure Coding
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 2
Chapter Objectives:
• Understanding the CPT manual
• Classification of sections
• Modifiers
• Evaluation and Management
• Coding the procedure
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 3
Understanding the CPT Manual
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 4
The CPT Manual
• Current Procedural Terminology, fourth edition (CPT4)
• Set of codes, descriptions and guidelines used to describe
services and procedures performed by providers
• Standardized code set used for reimbursement
• Each code has five digits
• CPT is published annually, early fall
• January 1st is effective date for use of updated codes
• Used for professional billing
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 5
CPT Categories
• Category I
– Evaluation and Management
– Anesthesiology
– Surgery
– Radiology
– Pathology
– Medicine
• Category II
– Tracking codes
• Category III
– Temporary codes
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 6
Format of CPT Codes
• Stand alone procedures - a full description of the service
• Indented procedures – listed under the associated stand-
alone code. The indented codes includes the description
of the stand-alone code that precedes the semicolon.
35901 Excision of infected graft; neck
35903 extremity
35905 thorax
35907 abdomen
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 7
Modifying Terms
• Alternative Anatomic Site
– 22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical
– 22222 thoracic
– 22224 lumbar
• Alternative Procedure
– 31505 Laryngoscopy, indirect; diagnostic
– 31510 with biopsy
– 31511 with removal of foreign body
– 31512 with removal of lesion
– 31513 with vocal cord injection
• Description of Extent of the Service
– 11055 Paring or cutting of benign hyperkeratotic lesion; single lesion
– 11056 two or four lesions
– 11057 more than four lesions
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 8
Symbols
Revised Code
New or revised text
New Code
+ Add-on code
x Exemptions to modifier -51
Moderate Sedation
Product pending FDA approval
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 9
Special Reports
• Special reports are used for services performed that are unusual or newly adopted, or use an unlisted code in the CPT book
• The report helps the insurance company determine the reimbursement value
• Requirements:
– Description, extent and for the procedure performed
– Time and effort
– Equipment necessary to provide services
– Additional items: complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems and follow up care
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 10
Unlisted Procedures
• 39599 Unlisted procedure, diaphragm
• 49999 Unlisted procedure, abdomen, peritoneum
and omentum
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 11
Bundled and Unbundled Codes
• Bundled procedure codes are designed to report a group
of services that are paid as one
• Unbundled services are codes that are separated from
the bundled procedure and billed independently
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 12
Separate Procedures
• Codes that are listed as “separate procedure” are commonly carried out with other services
• If notated as “separate procedure” and done with a service considered to be an intregal component of that procedure, the code should not be reported
• If service is done independently or distinct from other services, it can be reported
– Different session
– Different site, organ system or procedure
– Separate incision/excision, lesion or injury
Example:
49400 Injection of air or contrast into peritoneal cavity (separate procedure)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 13
Guidelines
• Guidelines are found at the beginning of each section
• They are specific to the section
• Additional guidelines/notes can be found in subsections
• Written to assist the coder in understanding when and
under what circumstances the code may be used
• Always read and follow the guidelines for proper coding
and maximizing reimbursement
• Inappropriate coding can be considered fraud or abuse
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 14
Notes
• Notes can be found in the category, subcategory or code description
• These notes apply to that particular set of codes
• They can be found throughout the CPT book and should be read and
followed for proper coding and maximizing reimbursement
Example:
Cardiovascular System
Myocardial profusion and cardiac blood pool imaging studies may be
performed at rest and/or during stress. When performed during
exercise and /or pharmacologic stress, the appropriate stress testing
code from the 93015-93018 series should be reported in addition to
78451-78454, 78472-78492.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 15
Appendices
• Appendix A – Modifiers
• Appendix B – Summary of Additions, Deletions & Revisions
• Appendix C – Clinical Examples
• Appendix D – Summary of CPT Add-on Codes
• Appendix E – Summary of CPT Codes Exempt from Modifier -51
• Appendix F – Summary of CPT Codes Exempt from Modifier -63
• Appendix G – Summary of CPT Codes that Include Moderate Sedation
• Appendix H – Alpha Index of Performance Measures
• Appendix I – Genetic Testing Code Modifiers by Clinical Condition
• Appendix J – Electrodiagnostic Medicine Listing of Sensory, Motor, and
Mixed Nerves
• Appendix K – Product Pending FDA Approval
• Appendix L – Vascular Families
• Appendix M – Crosswalk to Deleted CPT Codes
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 16
Classification of Sections
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 17
Procedure Format
• Section – found at the top of the page indicating the
section (surgery, radiology, etc)
• Subsection – also found at the top of the page, indicating
organ system (integumentary, respiratory, etc)
• Subheading – specific anatomical part within organ
system
• Category – type of procedure
• Subcategory – more defined description of procedure
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 18
Example of Procedure Format
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 19
Evaluation and Management
• Code Range 99201-99499
• For physician services evaluating and managing patients
care in the office, hospital, nursing home, emergency
department, and home
• Includes preventative medicine, consultation and critical
care
• Made up of multiple components
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 20
Anesthesia
• Code Range 00100-01999, 99100-99140
• Codes are primarily used for General anesthesia
• Other types of anesthesia include, Epidural, Spinal,
Blood Patch, Regional, Local and PCA (Patient
Controlled Anesthesia)
• Codes are selected on the anatomic location of where
the surgery is performed on the patient
• Some codes are based on age
• Moderate Conscious sedation – decreased level of
consciousness that allows patient to respond to
stimulation and verbal commands of the physician
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 21
Calculating Anesthesia Services
• Basic Value Unit – Issued by the Anesthesiology Society of America
(ASA) referred to as the Relative Value Guide (RVG), is a numeric
value based on the level of complexity of the service.
• Time Unit – Usually 15 minutes equals one unit of time. Starts when
the Anesthesiologist begins preparing the patient to receive
anesthesia and end when the patient no longer requires the
independent care of the anesthesiologist.
• Modifying Unit – reflects circumstances that modify the environment.
Included are Qualifying Circumstance (QC) Codes and Physical
Status (PS) Modifier codes.
Anesthesia Formula:
Basic Value Units + Time Units + Modifying Units = Total Units
(B + T + M = Total)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 22
Qualifying Circumstances
• +99100 Anesthesia for patient of extreme age, under 1
or over 70
• +99116 Anesthesia complicated by utilization of total
body hypothermia
• +99135 Anesthesia complicated by utilization of
controlled hypotension
• +99140 Anesthesia complicated by emergency
conditions (An emergency is defined as existing when
delay in treatment of the patient would lead to a significant
increase in the threat to life or body part)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 23
Physical Status Modifiers
• P1: Normal Health Patient
• P2: Patient with mild systemic disease
• P3: Patient with severe systemic disease
• P4: Patient with severe systemic disease that is a
constant threat to life
• P5: Moribund patient who is not expected to survive
without the operation
• P6: A declared brain-dead patient whose organs are
being removed for donor purposes
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 24
Surgery
• Code Range 10021-69990
• Largest Section of the CPT book
• 10021 – 19499 Integumentary System
• 20000 – 29999 Musculoskeletal System
• 30000 – 32999 Respiratory System
• 33010 – 39599 Cardiovascular System
• 40490 – 49999 Digestive System
• 50010 – 53899 Urinary System
• 54000 – 55980 Male Genital System
• 56405 – 58999 Female Genital System
• 59000 – 59899 Maternity Care and Delivery
• 60000 – 60699 Endocrine System
• 61000 – 64999 Nervous System
• 65091 – 68899 Eye and Ocular Adnexa
• 69000 – 69979 Auditory System
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 25
Surgery Section Procedures
• Incision and drainage
• Excision
• Biopsy
• Introduction and Removal
• Repair, Revision, Reconstruction
• Destruction
• Endoscopy/Arthroscopy/Laproscopy
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 26
Surgical Package
• Pre-Op
– One related E/M service
– Local Anesthesia (General Anesthesia billed separately)
• Procedure
– Operation
• Post-OP
– Follow-up care
– Written orders
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 27
Radiology
• Code Range 70010-79999
• Divided by type of imaging and further divided by anatomical site
• Diagnostic imaging includes:
– X-ray
– MRI – Magnetic Resonance Imaging
– MRA – Magnetic Resonance Angiography
– CT – Computerized Tomography
– US – Ultrasound or Sonography
– Nuclear
– Radiation Oncology
• Guidance procedures used during surgical procedures
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 28
Radiology Cont.
• Radiology procedures are divided into professional and technical components
• Interventional Radiology consists of the Radiologist performing both the surgical and radiology (guidance) procedures
• Contrast - used in many sections of radiology procedures for imaging enhancement
• Intravascularly
• Intra-articularly
• Intrathecally
• Oral and/or rectal contrast administration does not qualify
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 29
Pathology
• Code Range 80048-89356
• Procedures are performed using serum (blood), urine, feces, sputum and other to determine health or disease status of specific organ systems
• Codes are chosen by exam and the source utilized
• Section includes:
– Organ and Disease panels
– Drug testing
– Evocative and suppression testing
– Urinalysis
– Chemistry
– Infectious agents
– Microbiology
– Cytopathology
– Cytogenetic studies
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 30
Surgical Pathology
• Evaluation of specimens to determine the disease process
• Codes are chosen based on specimen source and reason for exam
• Pathology codes consist of six classification levels:
• Level I Gross exam only
• Level II Gross and Microscopic
• Level III Gross and Microscopic
• Level IV Gross and Microscopic
• Level V Gross and Microscopic
• Level VI Gross and Microscopic
• The classification level is determined by the complexity of exam
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 31
Medicine
• Code Range 90281-99199, 99500-99602
• Codes are used for diagnostic and therapeutic services
• Large various subsection groups
• Immunizations and vaccinations
• Hydration, Therapeutic, Prophylactic and Diagnostic injections and infusions
• Psychiatry
• Dialysis
• Cardiology
• Sleep Testing
• Nervous system
• Health and Behavioral Assessment
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 32
Medicine Cont.
• Chemotherapy Administration
• Modalities
• Active Wound Care Management
• Acupuncture
• Osteopathic Manipulative treatment
• Chiropractic Manipulative Treatment
• Education and Training for Patient
Self-Management
• Home Health Procedures and Services
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 33
HCPCS
• Healthcare Common Procedure Coding System
• Used for Medicare billing and most private insurances
• HCPCS codes represent:
– Procedures
– Supplies
– Products
– Services
• Codes are five position alpha-numeric
(J0735 Injection, clonidine HCl, 1mg)
• Codes are divided into two levels:
– Level I CPT codes
– Level II HCPCS codes
• Table of Drugs
• Alphabetical Index
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 34
HCPCS Sections
• A0000-A0999 Transport Services
• A4000-A8999 Medical and Surgical Supplies
• A9000-A9999 Administrative, Miscellaneous and
Investigational
• B4000-B9999 Enteral and Parenteral Therapy
• C1000-C9999 For Use Only under the Hospital Outpatient
Prospective Payment System
• D0000-D9999 Dental Procedures (not listed, ® to ADA)
• E0100-E9999 Durable Medical Equipment
• G0000-G9999 Procedures/Professional Services
(temporary)
• H0001-H1005 Alcohol and/or Drug Services
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 35
HCPCS Sections Cont.
• J0100-J8999 Drugs Other Than Chemotherapy
• K0000-K9999 Codes for Durable Medical Equipment (temporary)
• L0100-L4999 Orthotic Procedures
• L5000-L9999 Prosthetic Procedures
• M0000-M0399 Medical Services
• P0000-P2999 Pathology and Laboratory
• Q0000-Q9999 Temporary Codes
• R0000-R5999 Domestic Radiology Services
• S0000-S9999 Temporary National Codes
• T1000-T9999 National T Codes for State Medicaid
• V0000-V2999 Vision Services
• V5000-V5999 Hearing Services
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 36
Modifiers
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 37
Why Use Modifiers?
• A modifier is a two digit code that indicates that the procedure has
been altered in some way, but has not changed the definition of the
code.
• Examples:
– Service was for professional and/or technical component
– Performed by more than one physician
– Service performed more than once
– Service was increased or reduced
– Only one part of service was performed
– Bilateral service was performed
– An adjunctive service
– Unusual circumstances
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 38
Modifiers
21 – Prolonged evaluation and management service
22 – Unusual procedural services
23 – Unusual anesthesia
24 – Unrelated evaluation and management service by the same physician during a postoperative period
25 – Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
26 – Professional component
32 – Mandated services
47 – Anesthesia by surgeon
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 39
Modifiers Cont.
50 – Bilateral procedure
51 – multiple procedures
52 – Reduced services
53 – Discontinued Procedure
54 – Surgical care only
55 – Postoperative management only
56 – Preoperative management only
57 – Decision for surgery
58 – Staged or related procedure or service by the same physician during the postoperative period
59 – Distinct procedural services
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 40
Modifiers Cont.
62 – Two surgeons
63 – Surgical team
76 – Repeat procedure by same physician
77 - Repeat procedure by another physician
78 – Return to the operating room for a related procedure
during the postoperative period
79 – Unrelated procedure or service by the same physician
during the postoperative period
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 41
Modifiers Cont.
80 – Assistant surgeon
81 – Minimum assistant surgeon
82 – Assistant surgeon (when qualified resident surgeon
not available)
90 – Reference (outside) laboratory
91 – Repeat clinical diagnostic laboratory test
99 – Multiple modifiers
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 42
HCPCS/National Modifiers
LT – left side
RT – right side
LC – left circumflex, coronary artery
LD – left anterior descending coronary artery
RC – right coronary artery
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 43
HCPCS Hand Modifiers
FA – Left hand, thumb
F1 - Left hand, second digit
F2 - Left hand, third digit
F3 - Left hand, fourth digit
F4 - Left hand, fifth digit
F5 - Right hand, thumb
F6 - Right hand, second digit
F7 - Right hand, third digit
F8 - Right hand, fourth digit
F9 - Right hand, fifth digit
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 44
HCPCS Foot Modifiers
TA – Left foot, great toe
T1 - Left foot, second digit
T2 - Left foot, third digit
T3 - Left foot, fourth digit
T4 - Left foot, fifth digit
T5 - Right foot, great toe
T6 - Right foot, second digit
T7 - Right foot, third digit
T8 - Right foot, fourth digit
T9 - Right foot, fifth digit
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 45
HCPCS Eyelid Modifiers
E1 – Upper left, eyelid
E2 – Lower left, eyelid
E3 – Upper right, eyelid
E4 – Lower right, eyelid
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 46
Evaluation and Management
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 47
Considering Factors
To properly code E/M services you must know:
1. Place of Service
– Office, Hospital, Emergency Dept, Nursing Home
2. Type of Service
– Consultation, admission, preventative
3. Patient Status
– New, Established, Inpatient, Outpatient
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 48
E/M Key Components
There are 3 key components in determining the level of service provided for E/M codes:
1. History
2. Examination
3. Medical Decision Making
Contributing factors:
• Counseling
• Nature of Presenting Problems
• Coordination of Care
• Time
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 49
History
• History consists of multiple subjective factors:
– Chief Complaint (CC)
– History of Present Illness (HPI)
– Review of Systems (ROS)
– Past, Family and Social History (PFSH)
• Levels of History
– Problem Focused History (PF)
– Expanded Problem Focused History (EPF)
– Detailed History
– Comprehensive History
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 50
Examination
• Objective part of the patients services performed by provider
• Constitutional
– vital signs and appearance
• Body Areas
– head, neck, chest, abdomen, genitalia, groin, buttocks,
back, and each extremity
• Organ Systems
– Ophthalmology, Otolaryngology, Cardiovascular,
Respiratory, Gastrointestinal, Genitourinary,
Musculoskeletal, Integumentary, Neurological, Psychiatric,
and Hematological/Lymphatic/Immunologic
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 51
Exam Levels
• Levels of Examination:
– Problem Focused Examination (PF)
– Expanded Problem Focused Examination (EPF)
– Detailed Examination
– Comprehensive Examination
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 52
Medical Decision Making
• Three elements make up the medical decision making:
– Number of diagnoses and management options
– Amount and complexity of data reviewed
– Risk of complications and/or morbidity or mortality
• Levels of Medical Decision Making
– Straightforward (SF)
– Low complexity (LO)
– Moderate complexity (MOD)
– High complexity (HI)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 53
Contributing Factors
These contributing factors must exceed 50% of the encounter to
considered.
• Counseling – discussing patients diagnosis, test results,
prognosis, risks, recommendations with the patient and/or
family.
• Coordination of Care – arranging for personal care beyond the
hospital. (i.e. nursing home)
• Nature of Presenting Problem – Usually is the chief complaint.
• Time – Are expressed to assist in determining level of care.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 54
Selecting an E&M Service
1. Identify the Place
2. Identify the Type of service
3. Identify the Patient Status
4. Determine the extent of history obtained
5. Determine the extent of the exam performed
6. Determine complexity of medical decision making
7. Determine how many key components are required
8. Consideration of contributing factors (if applicable)
9. Make your code selection
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 55
Example E/M Codes
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
A detailed History
A detailed Exam
Medical Decision Making of low complexity
99213 Office or other outpatient visit for the evaluation and management of a established patient, which requires at least two of these three key components:
A expanded problem focused History
A expanded problem focused Exam
Medical Decision Making of low complexity
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 56
Coding the Procedure
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 57
Rules to Follow
• Be as specific as possible when coding
• Never add any words, modifying terms, or descriptions to
the procedure or service that is not documented
• Never use Index only
• Read all guidelines and notes surrounding the code
• Use reference materials and/or other coding sources
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 58
Alphabetical Index Format
Classification of main and modifying terms:
• Organ or Anatomic Site
• Procedure or Service
• Condition, Illness or Injury
• Eponym, synonym, or acronym
Listing of codes
• Hyphen – used to indicate a range of codes
• Comma – used to indicate multiple codes
• Single code – one code
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 59
Using the Alpha Index
• Select the main term to begin search
• Add modifying terms to narrow search
• Select code
Example: Open flexor Tenotomy of the finger
Tenotomy
Achilles Tendon 27605-27606
Ankle 27605-27606
Arm, Lower 25290
Arm, Upper 24310
Finger 26060, 26455-26460
Foot 28230, 28234
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 60
Referencing the Code
Example: Open flexor Tenotomy of the finger
26060 Tenotomy, percutaneous, single, each digit
26455 Tenotomy, flexor, finger, open, each tendon
26460 Tenotomy, extensor, hand or finger, open, each tendon
• Compare code descriptions with medical documentation
• Read and follow all notes and guidelines
• Make your selection
• Determine if there is a need for modifiers
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 61
Downcoding
• Charging for a lesser service than performed
• There is no serious consequences for under coding
• May also be done by insurance company if they feel documentation does not support the service
Disadvantages:
• Lower reimbursement
• Set red flags for audit, when billed correctly
• Incorrectly records doctors performance of procedures
• In some cases could be considered fraudulent or abusive with a third party payer (policy restrictions, pre-existing)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 62
Upcoding
• Deliberately charging for a higher level of service than
performed
• This is considered fraudulent
• Can result in civil and criminal penalties (fines, penalties,
prison time)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Slide 63
Errors & Omissions Insurance
• Protects against the loss of money caused by an error or
unintentional omission on the part of the individual or
billing service creating, submitting and processing claims
• E&O Insurance will pay for judgments against you
including court costs
• Mistakes can happen, the coverage could save you from
embarrassment, loss of work or a bad reputation
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Review Questions:
1. Which statement is correct about stand alone codes?
A. They have a full description
B. They have a partial description
C. They are the only codes used
D. They are unspecified codes
2. CPT stands for
A. Common Procedure Terminology
B. Current Procedural Terminology
C. Category Procedural Terminology
D. Current Practice Terminology
3. CPT is published every
A. January
B. July
C. October
D. December
4. CPT codes have a dollar value associated with them.
A. True
B. False
5. Coders only use Category I codes for billing.
A. True
B. False
6. Which one is not a modifying term for a procedure?
A. alternative anatomic site
B. alternative procedure
C. extent of service
D. alternative physician
7. Unbundling codes is a method that can be used to show the insurance company the
extent of the procedures performed by the physician.
A. True
B. False
8. Unlisted procedures should never be used for billing.
A. True
B. False
9. The appendices are where you will find the notes for the section.
A. True
B. False
10. What type of procedure would you find in the surgery section?
A. stereotactic guidance
B. office visit
C. arthroscopy
D. blood smear
11. HCPCS are used for supplies.
A. True
B. False
12. Which one indicates a use of a modifier?
A. service was changed
B. service was reduced
C. date was changed
D. physician assistant performed the service
13. Modifiers are numeric or alphanumeric.
A. True
B. False
14. There are three key components to determine an E/M level.
A. True
B. False
15. Which one is not an E/M factor?
A. place
B. type
C. status
D. date
Answer Key:
1. A
Feedback: Stand alone codes have a full description of the procedure done.
2. B
Feedback: CPT stands for Current Procedural Terminology.
3. C
Feedback: The CPT book is published every year in the fall (October).
4. A
Feedback: CPT codes have a dollar value associated with them and diagnosis codes give
medical reason for those services to be paid.
5. B
Feedback: Coders can also use Category III and HCPCS codes as needed for proper billing
of services.
6. D
Feedback: An alternative physician is not a modifying term to identify a procedure.
7. B
Feedback: Unbundling codes is considered fraudulent by the insurance companies. You
never want to unbundle procedures for billing purposes.
8. B
Feedback: Unlisted procedure codes can be used if necessary. A report will need to go
with the claim.
9. B
Feedback: Notes are found in the Guidelines in front of each section of the CPT book.
10. C
Feedback: An arthroscopy is a surgical procedure and can be found in the surgery
section of the CPT book. A-Radiology, B-Evaluation & Management , D-Pathology
11. A
Feedback: HCPCS are used for supplies, durable medical equipment and medicines.
12. B
Feedback: A modifier can be used if the service performed was reduced from the
original description.
13. A
Feedback: CPT modifiers are numeric and HCPCS modifiers are alphanumeric.
14. A
Feedback: The three key components used in determining the level of service of an
Evaluation and Management procedure is History, Exam and Medical Decision Making.
15. D
Feedback: The Evaluation and Management factors to take into consideration when
selecting a code are the place, type of service and patient status. Not the date.
