Transcript The Complete Procedure Coding Book By Shelley C. Safian

The
Complete Procedure
Coding Book
By
Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA
Chapter 2
Introduction to Coding and CPT
McGraw Hill/Irwin
Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved
2-2
Learning Outcomes
• Explain the purpose of diagnosis
coding.
• Relate diagnosis coding to
procedure coding.
• Apply correctly the steps to
coding.
2-3
Learning Outcomes
• Use official guidelines provided
to apply the best code.
• Follow the organization of CPT
to determine the best code.
• Comply with notations and
symbols to code accurately.
2-4
Introduction
Coding is interpreting health
care terms and definitions into
numbers or number/letter
combinations that specifically
relate to diagnoses and
procedures.
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Medical Necessity
• Diagnosis codes report the reason
why the physician provided the
service or treatment.
• Diagnosis codes explain the
medical necessity of providing
the service or treatment.
2-6
Procedures
• Procedure codes report what the
physician provided for the
patient.
– CPT codes
– HCPCS Level II codes
– ICD-9-CM volume 3
• Services, treatments, counseling,
surgery, testing, etc.
2-7
CPT
CPT stands for
Current Procedural Terminology
Developed and maintained by the
American Medical Association
2-8
Steps to Accurate Coding
1. Read through the notes
completely.
2. Highlight key words.
3. Query the physician regarding
any confusing, conflicting, or
missing information.
2-9
Steps to Accurate Coding
4. Code the diagnoses.
5. Code the procedures.
- Look up key words relating to
WHAT the physician provided.
- Verify the code’s description.
6. Link every procedure code to at
least one diagnosis code.
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Coding From Physician’s Notes
• More accurate than coding from
a superbill.
• More complete than coding from
a superbill.
• Official guidelines state that
coding should be done from
notes and not superbills.
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CPT Coding Book
Report
• Physician services
• All procedures performed in an
outpatient facility
– Physician’s office
– Ambulatory care center
– Clinic
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Organization of CPT
• Sections of the main body of CPT
– Evaluation and Management
– Anesthesia
– Surgery
– Radiology
– Pathology
– Medicine
2 - 13
Organization of CPT
•
Second part of CPT includes
- Category II codes
- Category III codes
- Appendixes A through I
- Alphabetic index
2 - 14
Alphabetic Index
Procedures, services, and
treatments listed by:
•
•
•
•
•
Procedure or service
Anatomical site
Condition
Eponym, synonym, or
abbreviations
2 - 15
Official Guidelines
Guidelines are located:
•
•
•
In front of each of the six
sections.
Within each section, leading into
appropriate subsection.
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Codes Formats
•
•
•
•
•
•
CPT codes:
Category II:
Category III:
Modifiers:
HCPCS Level II:
ICD-9-CM Vol. 3
12345
1000F
0001T
-12 or -A1
A1234
12.34
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CPT Book Formats
•
Indented information attaches to
the description above it….up to the
semi-colon ( ;)
•
35501 Bypass graft, with vein; carotid
•
35506
carotid-subclavian
The complete description is read:
35506 Bypass graft, with vein; carotidsubclavian
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Notations
See
– Directs you to an alternate listing
+ (plus sign)
– Identifies an add-on code
(List separately in addition…)
– Identifies an add-on code
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Symbols
• (bullet)
– Identifies a new code
∆ (triangle)
– Identifies a revised code
>< (sideways triangles)
– Identifies revised guidelines
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Symbols

– Identifies a code that includes
reimbursement for moderate
sedation

– Identifies a code that cannot be
used with modifier 51
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Chapter Summary
CPT contains thousands of codes
used to report services, treatments,
and procedures. The book includes
guidelines for each section, as well
as notations, symbols, and
references to assist you in reporting
the most accurate code.