Procedure Coding (CPT) Robert R. Pontecorvo Jr.. Introduction Procedural coding –Translate medical procedures and services into codes –Explains what services

Procedure Coding (CPT)

Robert R. Pontecorvo Jr.

Introduction

• Procedural coding– Translate medical procedures and services

into codes– Explains what services were provided

• Code “linkage” with diagnostic codes

• Maximum reimbursement

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

Organization of the CPT ManualRange of odes

Evaluation and Management 99201 99499

Anesthesiology 00100 – 0199999100 – 99140

Surgery 10021 – 69990

Radiology 70010 – 79999

Pathology and Laboratory 80048 – 89356

Medicine 90281 – 9960299500 – 99602

E&M Codes Initial VisitCode History Exam Face to Face Time

99201 Problem Focused Problem focused 10 minutes

99202 Expanded problem focused

20 Minutes

99203 Detailed 30 Minutes

99204 Comprehensive 45 minutes


E&M Follow upCode History Exam Face to Face time

99211 Not required 5 minutes

99212 Problem focused 10 minutes

99213 Expanded focused 15 minutes

99214 Detailed 25 minutes


E&M Treatment codesCode Explanation Minutes Units

97800 Acupuncture N/A 1

97810 Acupuncture with Electrical stimulation

N/A 1

97812 Cupping N/A 1

97813 Moxibustion N/A 1

97010 Hot or cold packs applied to one or more areas

N/A 1

97026 Infrared therapy Heat Lamp 1

97140 Manual therapy Tui Na (15 minutes) 1

97110 Therapeutic exercise

15 minutes 1

97124 Therapeutic massage

15 minutes 1

Organization of the CPT Manual (cont.)

• Manual Introduction – General instructions

– Information about common• Prefixes• Suffixes• Word roots

• Guidelines for each section


• Sections– Guidelines at

beginning– Categories

headings

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

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

Symbols Used in CPT

Code description has been revised

A new code

# Codes are out of numeric sequence

New or revised text information

Symbols Used in CPT (cont.)

Does not require modifier of 51

FDA approval pending

Moderate (conscious) sedation is included in the procedure


• Modifiers– Up to three per procedure

– Indicate that special circumstance applies

– Appendix A

– Section guidelines

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

Coding Terminology

• Bundled codes– Read description

carefully– Do not unbundle

• Critical care– Provided to unstable

patients– Documentation

• Concurrent care– More than one

physician– If different specialties,

not considered duplication

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

Coding Terminology (cont.)

• Downcoding – Reimbursement on a lower code level than

submitted– Lack of documentation most common cause

• Unbundling

• Upcoding

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

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


• 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 History


• Elements – Constitutional exam

– Body areas (BA)

– Organ systems (OA)

• Coding description– Problem-focused

– Expanded problem-focused

– Detailed

– Comprehensive

Physical Exam


• 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-Making


• Complexity level – Straightforward MDM

– Low-complexity MDM

– Moderate-complexity MDM

– High-complexity MDM


• Contributory factors in assigning codes1. Counseling

• Reason for encounter• 50% or more of time

2. Coordination of care


3. Nature of presenting problem• Minimal complaint

• Self-limited complaint

• Low severity complaint

• Moderate severity complaint

• High severity complaint


• Additional considerations– Time

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

– Location where services occurred

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

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


• 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


• Hemic/Lymphatic Systems and Mediastinum and Diaphragm

• Digestive System– Upper– Lower

• Urinary System– Kidneys and renal

function

– Diagnostic and therapeutic procedures

– Laparoscopy vs. incision


• Male Genital System

• Female Genital System/Maternity and Delivery

• Endocrine System

• Nervous System– Subheadings by

anatomic sites

– Subdivided by procedure

– Specialized guidelines


• 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


• Laboratory Procedures – panels

• Medicine and Immunizations– Two codes

• Procedure • Vaccine or toxoid

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

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

The HCPCS Coding Manual

• Health Care Common Procedure Coding System

• Use for coding services for Medicare patient

• HCPCS Level I codes – CPT codes

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

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

Coding Compliance

• Physician – ultimate responsibilitySubmit correct claims– Help ensure maximum appropriate

reimbursement

• Claims must comply with– Federal and state law– Payer requirements

Code Linkage

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

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?

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

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

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

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

The End

Documents

Procedure Coding (CPT) Robert R. Pontecorvo Jr.. Introduction Procedural coding –Translate medical procedures and services into codes –Explains what services