Word Parts CPT Coding 11 - At-Home Professionsonline.at-homeprofessions.edu/file.php/1/5880/PDF/Course_4_PDFs/… · modification of the ICD. As you may have noticed, some versions

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Word Parts CPT Coding 101

Lesson 31

� Step 1 Learning Objectives for Lesson 31

� When you have completed the instruction in this lesson, you will be trained to do the following:

³ Discuss the history of procedural coding and the CPT.

³ Explain the structure of the CPT.

³ Differentiate among Category I, II and III Codes.

³ Explain the guidelines behind procedural coding.

Step 2 Lesson Preview

� Look how far you’ve come! You have learned about medical insurance and terminology, covered the basics of anatomy and physiology and have a good understanding of the billing process. You know the organization and concepts of ICD-9-CM coding, and have learned the foundation of diagnostic coding. Now that you have a good grasp of diagnostic coding, are you ready to tackle procedural coding? Do you have access to a copy of the current CPT manual? If not, now is the time to get one! You’re going to need it for this and future lessons. In addition, you’ll want to keep your Anatomy and Physiology book handy.

Procedural coding uses many of the same skills that you learned from diagnostic coding. However, procedural coding is slightly different than diagnostic. Over the next several lessons we’ll examine these differences in detail. In this lesson we’re going to study the structure of the CPT—the manual for outpatient procedural coding. You’ll learn about Category I, II and III codes, modifiers, appendices and guidelines for procedural coding.

Are you ready to begin? Great! Remember to work through each of the examples with your CPT manual. Practice makes perfect!

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Step 3 What Is Procedural Coding?

� It’s a bright Tuesday morning. The park is crowded. Kelly has successfully swung across the monkey bars twice, but this time she wants to show off her new skills for her mom. She swings halfway then misses a bar and falls, landing hard on her right wrist. The pain shoots up her arm as she breaks into tears. After a day, Kelly’s mother notices that Kelly isn’t using her right hand and takes her to the doctor.

Upon examination, the physician notices that Kelly’s wrist is very painful, swollen and inflamed. Her range of motion is greatly reduced. He orders an x-ray of her right wrist. After reviewing the x-ray, he determines that the patient’s distal radius is fractured. The fracture is aligned, so the physician performs a distal radius fracture repair using closed treatment. Kelly’s mother may give her children’s ibuprofen at the recommended dosage for the pain. A follow-up appointment is set for the following week. He dictates this information and you transcribe it to create the medical record. You are to assign the diagnosis and procedure code needed to file the claim with the insurance company.

From all your practice in diagnostic coding, you know to open your ICD-9-CM manual to the Index to Diseases to start your search for the diagnosis: distal radius fracture. Locate the main term Fracture, and then the subterms radius, distal to find the tentative code of 813.42. You then turn to the Tabular List to cross reference the tentative code, and you are certain that 813.42 Fracture of radius and ulna, Lower end, closed, Other fractures of distal end of radius (alone) is the correct code. You will write this code on the medical record or a form provided by the office manager.

Now it’s time for the procedure code, which you’ll learn about in this course! We’ll return to this example in the lesson summary. But first, what exactly is a procedure? A procedure is anything the physician does to determine a diagnosis and help a patient get better. This includes diagnostic tools such as x-rays, as well as solutions, like putting a broken bone in a cast. It can also include office visits for services such as consultation or examination.

Procedural coding uses numeric codes to explain what the doctor did in treating the patient. For example, on the claim form you can simply record 12002 rather than “Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.6 cm to 7.5 cm.” Recording 12002 allows you to communicate quickly and in detail with the insurance provider. Procedure codes can be found in the Current Procedural Terminology (CPT) manual.

Kelly wants to show off her new skills for her mom.

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Why Code for Procedures?Procedural coding is important for the same reasons that diagnostic coding is important. You recall that coding is used to:

³ Facilitate payment of medical services

³ Study patients’ use of healthcare facilities

³ Study the cost of health care

³ Research the quality of health care

³ Determine healthcare trends

³ Plan for future healthcare needs

As a healthcare document specialist, you perform the vital task of translating the provider’s dictation into codes, which the entire medical and insurance community can understand! Without codes, the system would get bogged down with information, miscommunication and confusion. Procedure coding is the second half of medical coding and is just as important as diagnostic coding.

Step 4 A Short History of Procedure Coding

� Did you know that before 1983, there were more than 120 different coding systems being used in the United States alone? (Imagine the size of that course!) Over time, the less useful coding systems were abandoned in place of systems that were easier and more comprehensive.

Today, the International Classification of Diseases, 9 th Edition, Clinical Modification (ICD-9-CM), the Current Procedural Terminology (CPT) and the HCPCS manuals remain as the preferred coding systems. There are others out there still. Mental health clinics use the Diagnostic and Statistical Manual of Mental Disorders, and tumor registries use a different modification of the ICD.

As you may have noticed, some versions of the ICD-9-CM have three volumes. In the last course, you learned how to use Volumes 1 and 2 to look up diagnostic codes. Volume 3 of the ICD-9-CM lists procedural codes. However, these procedural codes are used for inpatient hospital coding. Outpatient procedural coding uses CPT and HCPCS codes. HCPCS stands for Healthcare Common Procedure Coding System, and it provides codes for medical supplies, drugs and special procedures. We’ll discuss the details of this manual later in the course.

Before 1983, there were more than

120 different coding systems!

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The Current Procedural Terminology is based on the California Relative Value System, first published by the California Medical Association in 1956. Ten years later, the American Medical Association (AMA) published the first edition of the CPT manual. It was only 163 pages, used a four-digit numeric coding system, and included both procedural and diagnostic codes. This early manual was helpful because it encouraged standards in descriptions and communication of procedures.

It took the AMA four years to complete the first major revision of the CPT. In 1970, they expanded to five digit codes with corresponding descriptions, included an introduction of coding guidelines and added 70 percent more codes. Internal medicine procedures were among the codes added.

The third edition, which debuted in 1973, saw the addition of two-digit modifiers that allowed the coder to be even more specific. Modifiers are used to show that a typical procedure was altered in some way. For example, a patient may need more anesthesia than normal, or an operation may require two surgeons. You’ll examine modifiers later on in this lesson. The third addition also added an appendix listing all procedures that were deleted from the manual.

In 1977, the fourth edition of the CPT was published. This is the current version used today by healthcare document specialists across the country. The AMA began updating the manual each year to keep up with changing technology and medical practices. Sometimes this version is referred to as CPT-4, as in fourth edition. Sometimes it’s named by year, as in CPT-2013. The AMA publishes the new version each fall. These changes don’t go into effect until January 1st, so healthcare professionals have plenty of time to learn the new codes and providers can update their systems.

You’ll want to be sure that you’re always working from the most current editions of the ICD-9-CM, CPT and HCPCS manuals. Whether you’re working for an employer or running your own business, using out of date codes can delay reimbursement and result in lost revenue. In this program, we’ll refer to Current Procedural Terminology CPT 2013 published by the American Medical Association.

Let’s use this break to review what you’ve learned about procedural coding!

A patient may need more anesthesia than normal, or an operation may require two surgeons.

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� Step 5 Practice Exercise 31-1

� Select the best answer from the choices provided.

1. Procedural codes deal with _____.a. the symptoms the patient feelsb. what’s wrong with the patientc. mental disorders and tumor registering d. what the doctor does in diagnosing and treating the patient

2. CPT stands for _____.a. Correct Physician Treatmentb. Certified Procedural Terminologyc. Current Procedural Terminologyd. Current Practical Terminology

3. ThefirsteditionoftheCPT was published in _____.a. 1940b. 1951c. 1966d. 1979

4. The current CPT manual is the _____ edition.a. firstb. secondc. thirdd. fourth

5. The CPT-4 is updated every _____.a. yearb. two yearsc. three yearsd. four years

³ Step 6 Review Practice Exercise 31-1

� Check your answers with the Answer Key at the back of this book. Correct any mistakes you may have made.

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Step 7 How the CPT Is Organized

� In order to master procedural coding, you must understand how the CPT is organized. In this step, you’re going to walk through each part of the CPT. You’ll look at what’s included in each section and note how you’ll use this information. To help you see how it all fits together, let’s start with an overview of the steps to CPT coding.

1. As with diagnostic coding, your first step is to read the documentation and determine the main term. Main terms can be:

³ A procedure or service (such as an arthroscopy)

³ An anatomical site (such as a knee)

³ A condition or disease (such as a dislocation)

³ A synonym (such as Unguis)

³ An eponym (such as Marcellation Operation)

³ An acronym (such as CMRI)

2. Next, look up the main term in the CPT Index located at the back of the manual. Find the main term and subterms which best represent the procedure.

3. You’ll notice that there are several types of code listings. Some terms have one code, such as Epiploectomy…49255. Other terms have two codes separated by a comma. For example, look at Scapula, Bone, Excision, Partial…23172, 23182, 23190. If you were coding for a scapula bone excision, you would have to cross-reference all three of these codes to see which is best. There are also terms with two codes separated by a hyphen. A good example is Nerves, Decompression 64702-64727. In this case, you would have to cross-reference all of the codes between 64702 and 64727. You may also run into some term listings that combine commas and hyphens.

4. Once you have your tentative code, codes or range of codes, turn to the main part of the CPT to find your tentative code. This part is divided into six sections, each listing a different variety of procedures. We’ll examine each section in a little bit. For now, flip through this part and see how the codes are listed numerically. Each section and subcategory begins with helpful guidelines and rules.

5. Read the guidelines for the section you’re using.

6. Read the procedure description to be sure you’ve found the right code.

The first step is to read the documentation and determine the main term.

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7. If there are any symbols next to your code, double-check the legend at the bottom of each page. (We’ll discuss all of the symbols you’ll need to know.)

8. If necessary, apply a modifier(s) for your code. (We’ll review these, too!)

9. Read the dictation to identify all procedure(s), then assign the CPT code(s) and pat yourself on the back for a job well done.

Do these steps remind you of diagnostic coding? Many of the skills are the same. The key is to understand how each manual is organized so you can easily find codes in both. Let’s take a tour of the CPT manual and see what’s inside.

The IntroductionIntroductions are always good places to start. The introduction to the CPT is the most important part of the book and requires a close look. Essentially, this section is a mini-guide to the manual. Included are the code ranges for each section and instructions on how to use the CPT. There is also information on symbols, modifiers and appendices.

Category I CodesCategory I Codes are all of the “regular CPT codes” found in the six main sections of the book. The six sections are:

³ Evaluation and Management 99201-99499

³ Anesthesia 00100-01999 and 99100-99140

³ Surgery 10021-69990

³ Radiology 70010-79999

³ Pathology and Laboratory 80047-89398

³ Medicine 90281-99199, 99500-99607

They are all five digit codes from 00100 to 99607. However, you’ll notice that the six sections are not in numerical order. This is because healthcare document specialists found that they used the Evaluation and Management section more than any of the others, so that section was moved to the front.

You’ll explore these sections in greater detail in the following lessons.

Introductions are always good places to start.

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The sections of the CPT can be broken into smaller parts. The six main sections are divided into subsections, headings and subheadings. Individual code listings can be found in each subheading.

Section

Subsection

Heading

Subheading

Listing

A good way to see this structure is to work up from an individual code listing. Let’s find the code for a resection of a pericardial cyst or tumor.

Start in the Index at the back. What is the main term of the procedure? Resection. What are the subterms? Under resection, you find Cyst with a list by anatomic site. Scrolling down to the “p’s”, you find Pericardial: 33050. This is your tentative code. Back in the main section of the CPT, locate code 33050. The listing reads Resection of pericardial cyst or tumor. It’s the right code!

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33050 Resection of pericardial cyst or tumor is the listing. You can see that this listing is in the “Pericardium” subheading. The “Pericardium” subheading is the first subheading in the “Heart and Pericardium” heading. All of these are in the “Cardiovascular System” subsection, which is part of the “Surgery” section of the CPT.

Surgery

Cardiovascular System

Heart and Pericardium

Pericardium

33050 Resection of pericardial cyst or tumor

Learning how the CPT is organized is half of the battle!

Category II CodesCategory II Codes are a special collection of codes used by providers to track and measure performance internally. (Internally as in within the medical office or practice, not like inside the body!) These codes are not used by insurance companies to determine reimbursement. Physicians use them to see just how much work they’re doing for certain situations.

Category II codes are optional. Check with your employer regarding its use of these codes.

Category III CodesAccording to the American Medical Association, a procedure must be approved by the FDA, performed by a lot of healthcare professionals and be used across the country before it can be included as a Category I Code. What about the procedures that don’t fit this criteria? They are listed as Category III Codes. Category III Codes are “temporary codes for emerging technology, services and procedures.”

While there are unspecified codes in Category I––if a Category III Code matches your procedure, that’s the code you have to use. In other words, use Category III Codes before Category I unlisted codes.

The reason for putting all of the up-and-coming procedure codes in their own section is to facilitate data collection. With healthcare document specialists across the country using Category III Codes when appropriate, it helps everyone in the medical field keep an eye on trends and procedure outcomes.

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AppendicesThe CPT has 15 appendices located between the Category III Codes and the Alphabetic Index:

³ Appendix A—Modifiers

³ Appendix B—Summary of Additions, Deletions, and Revisions

³ Appendix C—Clinical Examples

³ Appendix D—Summary of CPT Add-on Codes

³ Appendix E—Summary of CPT Codes Exempt from Modifier 51

³ Appendix F—Summary of CPT Codes Exempt from Modifier 63

³ Appendix G—Summary of CPT Codes That Include Moderate (Conscious) Sedation

³ Appendix H—Alphabetical Clinical Topics Listing (AKA—Alphabetical Listing)

³ Appendix I—Genetic Testing Code Modifiers

³ Appendix J—Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves

³ Appendix K—Product Pending FDA Approval

³ Appendix L—Vascular Families

³ Appendix M—Deleted CPT Codes

³ Appendix N––Summary of Resequenced CPT Codes

³ Appendix O—Multianalyte Assays with Algorithmic Analyses

We’ll take a closer look at some of these sections later in this lesson.

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IndexWe’ve already used the Index a couple of times. You already know that the Index is organized alphabetically. You also know that all of the main terms and subterms are procedures or services, anatomic sites, conditions or diseases, synonyms, eponyms and acronyms. Let’s examine it now in more detail.

Main terms in the CPT Index cover a wide range. For example, all of the following can be main terms:

Procedure or Service

³ X-ray

³ Laparoscopy

³ Nutrition Therapy

³ Telephone Calls

Anatomic Site

³ Ankle

³ Femur

³ Ovary

³ Tendon Sheath

Condition or Disease

³ Tumor

³ Polio

Synonyms

³ Finger See Phalanx

³ Broken See Fracture

Eponyms

³ Burrow’s Operation See Skin, Adjacent Tissue Transfer

³ Farnsworth-Munsell Color Test See Color Vision Examination

Acronyms

³ BUN See Blood Urea Nitrogen; Urea Nitrogen

³ CABG See Coronary Artery Bypass Graft (CABG)

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In the Index, main terms are listed in boldface. They may or may not be followed by subterms. All subterms are listed in normal type. Some subterms have their own subterms, which are indented two spaces. Take a moment to scan through the Index. Note the main terms and subterms. Do you see the three different listings of code numbers: specific codes, multiple codes (comma) and range of codes (hyphen)?

Remember that the Index is not a substitute for the main part of the CPT manual. It’s merely your starting point. Whether you find a specific code, multiple codes or a range of codes in the Index, you must look them up in the Category I Codes section.

Let’s review what you’ve learned about the organization of the CPT.


� Use your CPT manual to complete the information pertaining to each code.

1. Locate the page for code 21010 and identify the following information.a. Section: ____________________________________________________b. Subsection: _________________________________________________c. Heading: ___________________________________________________d. Subheading: ________________________________________________





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Step 10 CPT Codes: Up Close and Personal

� Now that you know how to find codes in the Index and how the CPT is structured, let’s take an up close and personal look at procedural codes.

SemicolonsThe CPT manual uses semicolons to cut down on repetitious entries. For example. Look up the codes 47600 and 47605. You’ll find the following listings:

47600 Cholecystectomy;

47605 with cholangiography

When you find a listing that is indented, then you know that it refers to the unindented code above it. The unindented code will have a semicolon in it. Everything to the left of the semicolon is part of the “common code,” meaning it is part of any indented codes below it. For example, the code description for 47600 is Cholecystectomy, while 47605 is Cholecystectomy with cholangiography.

You’ll also find some codes with semicolons that have description to the right and left of the semicolon. Look at this example:

28430 Closed treatment of talus fracture; without manipulation

28435 with manipulation

If there is description to the right of a semicolon, then it is part of that specific code but not any indented codes below it. In this example, “without manipulation” is not part of the common code. The code description for 28430 is Closed treatment of talus fracture without manipulation, while 28435 is Closed treatment of talus fracture with manipulation.

GuidelinesThe guidelines for each section are located at the beginning of each section. Some subsections, headings and subheadings also have guidelines that will help you find the right code. To accurately code from the section, you need to familiarize yourself with the information in the guidelines. There you’ll find definitions, modifiers, unlisted procedures and special reports.

For example, turn to the Anesthesia Guidelines at the beginning of the anesthesia section. The types of services included in this section are listed. Anesthesia modifiers are defined. Qualifying circumstances are explained and listed. Refer to this information when coding from the Anesthesia section of your CPT.

Take a moment to look at the guidelines for the other sections in your CPT. We’ll be taking a closer look at all of these sections in upcoming lessons.

Let’s take an up close and personal look at procedural codes.

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Add-On CodesTo learn about add-on codes, let’s work through an example. Locate the code for the following procedure: “two skin lesions are biopsied.”

First, ask yourself what is the main term? Biopsy. And what are the subterms? Skin and lesion. In the Index, find Biopsy and scroll down to Skin Lesion. There is a range of codes: 11100-11101.

Look up these codes in the main part of the CPT. What section, subsection, heading and subheading do they fall under?

Section: Surgery

Subsection: Integumentary System

Heading: Skin, Subcutaneous and Accessory Structures

Subheading: Biopsy

You see how this range of codes, which includes two codes, makes up the entire Biopsy section. Read the guidelines for biopsy codes. Because the biopsy was performed independently, you know you have found the right section. Now read the code listings.

11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

+11101 each separate/additional lesions (List separately in addition to code for primary procedure)

(Use 11101 in conjunction with 11100)

The first listing—11100—codes only one lesion and only partially matches the procedure. The second code completes the coding for the procedures because two biopsies were performed. Notice that 11101 is an add-on code. Add-on codes are used for additional procedures done by the same physician. Think of an add-on code as adding to the procedure by doing more of the same. In this case, you’re adding another lesion to the original code. Add-on codes are marked with a “+” symbol and are never used by themselves. When you’re assigning an add-on code, you need to use both the base code and the add-on code. (The “+” symbol is for your benefit and doesn’t need to be recorded.) So, for this example, you will assign both 11100 and 11101 to code “two skin lesions are biopsied.”

Add-on codes are Modifier 51 exempt. What does that mean? Let’s take a closer look at modifiers.

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ModifiersA modifier is a two-digit number added to a CPT code to provide more information. A modifier might be added to show extra time spent with the patient or a decision to stop a procedure halfway. The introduction to the CPT lists all of the reasons a modifier might be used. Modifiers show that:

³ A procedure has both evaluation and technical parts.

³ A procedure was performed by multiple doctors and/or in multiple locations.

³ A procedure was larger/longer or smaller/shorter than usual.

³ Only some of the procedure was completed.

³ An additional procedure was completed.

³ A bilateral procedure was completed.

³ A procedure was provided multiple times.

³ Something unusual happened.

Modifiers are your tools to really communicate to insurance payers exactly what procedures were performed. More than one modifier may be applied to a CPT code. Appendix A offers a listing of all modifiers and their descriptions. Take this opportunity to read through the descriptions of the modifiers in your CPT. We will define and explain some of the key ones below.

Modifier 25—Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

SCENARIO: A regular patient visits a doctor due to an ingrown toenail, as well as feelings of depression. The doctor performs a wedge excision of skin for the nail and takes a detailed history and exam for the depression.

In this scenario, the office visit is a significant and separately identifiable Evaluation and Management service. It is provided by the same physician on the same day as the wedge excision. To show this, you would assign two codes: 11765 (for the toe) and 99214-25.

Modifier Tip Modifier 25 can only be used with Evaluation and Management codes. Any level of Evaluation and Management code can carry this modifier.

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Modifier 50—Bilateral Procedure

SCENARIO: A 13-year-old falls while rollerblading and injures both of her wrists. The physician takes three-view x-rays of both wrists to determine if a fracture is present.

Bilateral procedures are procedures performed at the same time on paired organs, such as knees, breasts and eyes. In this scenario, there are x-rays of the girl’s right and left wrists.

Notice that 73110 is the code for “Radiologic examination, wrist; complete, minimum of 3 views.” However, this code does not indicate that the procedure is bilateral, so you will add modifier 50. Unless the code listing already states that the procedure is considered bilateral, add modifier 50 to show both sides were worked on. In this scenario, you will use the code 73110-50.

Modifier Tip Depending upon requirements by different insurance payers, you may be asked to list the procedure code twice and append modifier 50 to the second procedure. Also, be aware that some CPT codes include bilateral in the code description, and in that case you will not add modifier 50. When coding for bilateral procedures in this program, you will list the CPT code only once with the bilateral modifier 50 (as shown above).

Modifier 51—Multiple Procedures

SCENARIO: A physician performs a laminotomy (hemilaminectomy) with decompression of nerve roots and a posterior or posterolateral arthrodesis on the L2 through L3 interspace.

Multiple procedures are services done at the same session by the same provider. When two or more procedures are done, you must code all of them. To show that they were done at the same time by the same physician, you would add modifier 51 to all of the codes except for the primary one.

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In this example, the laminotomy (hemilaminectomy) is the primary procedure. You will assign the code 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar. The code for the arthrodesis with the multiple procedures modifier is 22612-51 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) - Multiple Procedures.

Modifier Tip Modifier 51 is used for multiple procedures that are performed on the same day by the same physician. If the procedures are not regularly done together but are appropriate for the circumstances, use modifier 59—Distinct Procedural Service. Between add-on codes, bilateral procedures and modifier 59, the multiple procedures modifier may not be used as often as you may think.

Modifier 59—Distinct Procedural Service

SCENARIO: A physician performs a skin lesion biopsy on the patient’s face and removes four skin tags from his back on the same day.

Here is another situation where a doctor performed more than one procedure on the same patient on the same day. However, the skin lesion biopsy and skin tag removals are performed on different body areas. Modifier 59 is used to show that these two operations were separate procedures. To report the procedures for this scenario, assign 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion and 11200-59Removalofskintags,multiplefibrocutaneoustags,anyarea;up to and including 15 lesions - Distinct Procedural Service.

Modifier Tip Modifier 59 is also used when the procedures have separate incisions or excisions or separate injury or areas of injury.

The Use of ModifiersSometimes, it’s not clear which code or modifier is the best. There is a lot of gray area between multiple procedures, add-on codes and distinct procedural services. Different providers and insurance companies may have different preferences when it comes to modifier usage.

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In addition to Appendix A, your CPT manual helps you find the right code in several ways. All add-on codes are identified with a “+” symbol. They’re also listed in Appendix D. (And all add-on codes are 51 exempt. This means that you don’t have to add a 51 to an add-on code. It is understood that multiple procedures were performed.) Individual code listings and subheadings often have rules for bilateral procedures. Always read all of the guidelines. Sections, subsections and headings also often have helpful guidelines.

Appendix E is also useful. Not only are all add-on codes modifier 51 exempt, but all of the codes in Appendix E cannot be used with modifier 51 either. These codes are identified in the body of the CPT with a symbol.


� Match the following coding term with its description.

1. _____ Add-on code

2. _____Modifier25

3. _____Modifier50

4. _____Modifier51

5. _____Modifier59



a. The same procedure performed on paired organs.

b. Two or more procedures that are often done together.

c. Two or more procedures that are performed on different body areas.

d. An extra procedure that does more of the same.

e. When a surgical procedure and separate evaluation are done for the same patient.

Always read all of the guidelines.

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Step 13 CPT Codes: Part 2

� Good job! You’ve learned a lot of new material in this lesson. Mastering this lesson will make not only your upcoming lessons, but also your future career easier, and more fun. For this last section, let’s look at the skills that separate the experts from the beginners.

Code ChangesIn 1977, when the AMA began updating the CPT annually, healthcare document specialists had to start learning new and revised codes each year. To make this easier, all of the current year’s altered codes are listed in Appendix B. Take a look at Appendix B in your CPT and read the guidelines at the beginning. Let’s look at some of the code change symbols you’ll find in Appendix B and the main part of the CPT:

• indicates a new code to this revision

indicates the code has been revised

text which has been deleted from the CPT is crossed out

new text for a code is underlined

Other Important CPT SymbolsYou already know about the “+” symbol to designate a code as an add-on code. And you’ve learned about the for modifier 51 exempt codes, too. There are three more symbols that will help you in your procedural coding.

A indicates that conscious sedation would not be reported separately. Conscious sedation is a technique in which the patient is insensitive to pain without losing consciousness. Some procedures automatically include conscious sedation so there’s no need to code for both the procedure and the sedation. These codes are listed in Appendix G.

Any time headings, notes, introductory sections or cross-references are added or revised, they are surrounded by this symbol: .

The “#” symbol identifies a resequenced code, or a code that is out of numerical sequence. In some instances, there was no room numerically to add another code in a specific category. Rather than deleting the code and creating a new number, the AMA will move the code to its more appropriate location and leave a road sign (#) for you.

Let’s look at the skills that separate the experts from

the beginners.

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The resquencing initiative involves placing some codes in the best logical position within the context of the CPT book, even though placing them in such a position will cause them to appear out of numerical order.

Even though the number of affected codes is limited at this time, the number of resequenced codes will grow as this placement technique continues to be used in subsequent years.

Unlisted Procedure or ServiceNot every procedure is listed in the CPT. In such cases, use the unlisted procedure codes. Look at the list under “Unlisted Services and Procedures” in the CPT Index. If you code an unlisted procedure, include a description of the procedure performed. You may also have to send the dictation to the third-party payer before reimbursement is approved.

Surgical PackagesA surgical package is the group of services that are always involved in surgical procedures. In the guidelines to the Surgery section you’ll find a list of these services:

³ Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

³ Subsequent to the decision for surgery, one related Evaluation and Management encounter on the date immediately prior to or on the date of procedure

³ Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or qualified health care professionals

³ Writing orders

³ Evaluating the patient in the postanesthesia recovery area

³ Typical postoperative follow-up care

Insurance companies have various definitions and policies regarding surgery packages. You should have this information when coding. The period of time following the surgical procedures is called the global surgery period. This period is usually 90 days. As always, you need to be familiar with the insurance policies for accurate coding. Check with your employer about this information.

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Separate ProceduresIn some procedures, a service that normally stands on its own as a separate procedure is included in the larger service. Look at this example:

A patient has a breast biopsy to determine the condition of the lump in her breast. The code is 19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure). If the biopsy determines the lump to be benign, no further action is taken by the doctor and you code 19100 for the procedure. However, if the biopsy determines a mastectomy is necessary, the doctor may do it in the same session. If she does, you would only apply code 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy). The biopsy was necessary to determine the need for the mastectomy, therefore it is not coded separately when a mastectomy is performed.

UnbundlingUnbundling is the process of coding individual pieces of a service rather than coding a single code that includes all services. In effect, this is like charging someone for six individual sodas instead of one six pack. Unbundling is a form of fraud that you need to watch out for. Look at this example:

A child receives immunizations for measles, mumps and rubella. There is a code for each immunization:

90704 Mumps virus vaccine, live, for subcutaneous use

90705 Measles virus vaccine, live, for subcutaneous use

90706 Rubella virus vaccine, live, for subcutaneous use

However, code 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use describes all of the components to this service. This service should be reported rather than the three separate codes.

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Step 14 Steps to CPT Coding

� Now that you’re familiar with the organization and format of the CPT manual, let’s take another look at the steps to CPT coding. This time you’ll be able to see how each section, symbol and rule fits into the big picture!

1. Read the documentation and determine the main term. Main terms can be procedures or services, anatomical sites, conditions or diseases, synonyms, eponyms or acronyms.

2. Next, look up the main term in the CPT Index. Find the main term and subterms that best represent your procedure.

3. Locate the tentative code or codes in the CPT Index.4. Turn to the main part of the CPT to locate the tentative code or codes.5. Read the guidelines for the section you’re using.6. Read the procedure description to be sure you’ve found the right code.7. If there are any symbols next to your code, double-check the legend at

the bottom of each page.8. If necessary, apply a modifier(s) for your code.9. Read the dictation to identify all procedures, then assign the CPT code(s)

and modifier(s), if applicable.

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� Match the step numbers with the descriptions to provide the steps to CPT coding.

1. _____

2. _____

3. _____

4. _____

5. _____

6. _____

7. _____

8. _____

9. _____



Step 17 Lesson Summary

� Now let’s look at the example from the beginning of this lesson. Let’s review the scenario first: Upon examination, the physician notices that Kelly’s wrist is very painful, swollen and inflamed. Her range of motion is greatly reduced. He orders an x-ray of her right wrist. After reviewing the x-ray, he determines that the patient’s distal radius is fractured. The fractured is aligned, so the physician performs a distal radius fracture repair using closed treatment. Kelly’s mother may give her children’s ibuprofen at the recommended dosage for the pain. A follow-up appointment is set for the following week. He dictates this information and you transcribe it to create the medical record.

a. Next, look up the main term in the CPT Index. Find the main term and subterms that best represent your procedure.

b. If necessary, apply a modifier(s) for your code.c. Turn to the main part of the CPT to locate the tentative

code or codes.d. Read the documentation and determine the main term.

Main terms can be procedures or services, anatomical sites, conditions or diseases, synonyms, eponym or acronyms.

e. Read the procedure description to be sure you’ve found the right code.

f. If there are any symbols next to your code, double-check the legend at the bottom of each page.

g. Locate the tentative code or codes in the CPT Index.h. Read the dictation to identify all procedures, then assign the

CPT code(s) and modifier(s), if applicable.i. Read the guidelines for the section you’re using.

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To locate the procedure code, determine what the physician did for the patient. The physician was working with the fracture, so locate Fracture as the main term in the Index. The subterm is determined by the part of the body that was fractured, or the distal radius. Locate the subterms Radius, Distal for the tentative code range of 25600-25609. Now turn to the main body of the CPT to review the guidelines and read the code description. Percutaneous skeletal fixation is not noted so 25606 is not correct. The fracture did not require manipulation, so 25605 is not correct. Closed treatment is identified, so 25607, 25608 and 25609 do not apply. You would assign 25600 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation for this scenario.

What do you think of procedural coding? All of your medical terminology, anatomy and diagnostic knowledge is going to be useful in the upcoming lessons as you explore the different sections of the CPT. Don’t worry if you aren’t fully comfortable with procedural coding yet. It takes time and practice to master CPT coding. Keep studying hard and in no time you’ll be coding like a professional!

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Great start to Course Four!Learning the organization of the CPT is the first step

toward accurate procedural coding.

Let’s learn how to apply surgical procedure codes!The next lesson reviews the first part of the

Surgery section of the CPT. You’ll want to get out your Anatomy and Physiology book to use as a reference!

Continue to Lesson 32.

Documents

Word Parts CPT Coding 11 - At-Home Professionsonline.at-homeprofessions.edu/file.php/1/5880/PDF/Course_4_PDFs/… · modification of the ICD. As you may have noticed, some versions