Transcript BLUE CROSS/BLUE SHIELD

Chapter 4
PROCEDURAL
CODING
PROCEDURAL CODING

Learning Objectives





Identify the purpose and format of the Current
Procedural Terminology (CPT).
Name three key factors that influence the selection
of Evaluation and Management codes.
Recognize surgical packages and laboratory
panels that are coded as single procedures.
Describe the three levels of codes in the Health
Care Financing Administration’s Common
Procedure Coding System (HCPCS) and discuss
when they should be used.
Find correct procedure codes using CPT.
Chapter 4
2
Key Terms







Add-on code
Attending physician
Category II codes
Category III codes
Centers for Medicare
and Medicaid
Services (CMS)
Code linkage
Consultation







Chapter 4
Current Procedural
Terminology (CPT)
E/M code
Established patient
Global period
Health Care Common
Procedure Coding
System (HCPCS)
Main number
Modifier
3
Key Terms








New patient
Panel
Primary procedure
Procedure code
Referral
Surgical package
Unbundle
Unlisted procedures
Chapter 4
4
Introduction to
Procedural Coding

Procedure code(s)

Detail the treatment and services provided to
the patient by the provider, such as surgery and
diagnostic tests, and medical services, such as
examination to evaluate a patient’s condition.

Use standardized, numeric codes.
Chapter 4
5
Introduction to
Procedural Coding

Code Linkage

The connection between a service and a
patient’s condition or illness

Establishes the medical necessity of the
procedures.
Chapter 4
6
Organization of The CPT

The CPT



Published by the American Medical
Association (AMA).
Currently in 4th edition.
Published Yearly


New codes added/old codes deleted
Available as software, such as Encoder Pro
Chapter 4
7
Organization of The CPT

Category I Codes




5 Digits Numbers
Organized into Six Sections
Arranged in Numerical order, except for
“Evaluation & Management”
Each section open with “Guidelines” that
apply to its procedure.
Chapter 4
8
Organization of The CPT

Codes divided into 6 Sections
Section
Range Of Code
Evaluation and Management
Anesthesia
99201-99499
00100-01999
10021-69990
70010-79999
80047-89356
90281-99607
Surgery
Radiology
Pathology and Laboratory
Medicine
Chapter 4
9
Organization of The CPT

Codes divided into 6 Sections - Cont
Sections are divided into subsections
 They are further divided into headings according to
the type of test, service, or body system.
 Code ranges on a page are found in the upper-right
corner

Sections are arranged in numerical order (exception
E/M, & Anesthesia).
Chapter 4
10
Organization of The CPT

Procedure Codes are located by referring to:

The CPT Index (an alphabetic index of procedures, organs
and conditions)

Main Terms are in Bold



May be followed by descriptions and groups of indented
terms.
Codes are selected by reviewing each description and
indented term under the main term.
PERFORMANCE EXERCISE

Figure 4-1 – Page 63
Chapter 4
11
The CPT Format/Symbols

Special Symbols (highlight changes or special
points)
 new procedure
 change in code’s description
 new or revised information
 add-on codes (procedures carried out in addition
to other procedures)
Chapter 4
12
The CPT Format/Symbols

Special Symbols (highlight changes or special points)
– Cont.
 (Bullet inside a circle) next to a code means that the
conscious sedation is a part of the procedure that the
surgeon performs.

(Lightning Bolt) is used with vaccine codes that have
been submitted to the Federal Drug Administration
(FDA) and are expected to be approved for use soon.


The Code can not be used until approved
When approved the symbol is removed for the next printing of the
CPT.
Chapter 4
13
The CPT Format/Listings

Numbering

28
29
Written as XXXXX-XX

8 -2
2


78
47
8
5 digits plus 2 digit modifiers when necessary
Modifiers


992
13

Always shown with hyphen
33427
Complete listing in Appendix A
Appendix A details proper use
 Modifiers that pertain to each section are also
listed in each section
5
8
8
1
6
Chapter 4
14
The CPT Format/Listings

28
29
992
13
Modifiers

Show that some special circumstance applies to the
service or procedure the physician performed.

Example:
8 -2
2



78
47
8


33427
-62 indicates two surgeons worked together, each
performing part of a surgical procedure, during an
operation.
Each physician will be paid part of the amount normally
reimbursed for that procedure code.
-80 indicates that the service of a surgical assistant were
used, and
5
188
6

Each the assistant’s fee are a part of the claim.
Chapter 4
15
Using the CPT
(cont’d)

The CPT Index

Main Terms


Modifying Terms



Listed by procedure or service;
organ or anatomic site; condition;
or synonyms, eponyms, and
abbreviations.
In parentheses ( )
Don’t affect the code selection
Code ranges


Commas separate codes (Non-Sequential)
Hyphens show ranges of 3 or more
codes (Sequential)
Chapter 4
INDEX
Performance Test . . . . . . . . . . . 96100
See Physical Medicine/Therapy
Occupational Therapy
Physical Therapy . . . . . . . . . . . . . 97750
Perfusion
Myocardial . .78460-78465, 8478,78480
Imaging . . . . . . . . . . . . 78466-78469
Positron Emission Tomography (PET)
Myocardial Imaging . . . 78491-78492
Perfusion, Intracranial Arterial
Thrombolysis . . . . . . . . . . . . . . . . 61624
Perfusion Pump
See Infusion Pump
Pericardectomies
See Excision, Pericardium
Pericardial Cyst
See Cyst, Pericardial
Pericardial Sac
Drainage . . . . . . . . . . . . . . . . . . . 32659
Pericardial Window
for Drainage . . . . . . . . . . . . . . . . .33205
16
Using the CPT

(cont’d)
CPT format



Cardiovascular System
78460 Myocardial imaging, positron emission
tomography (PET), metabolic evaluation
Common Entry
(For myocardial perfusion study, see 7849178491)
Indented Material
78461
Notes appear in ( )
multiple studies, (planar) arrest and/or
stress (exercise and/or pharmacologic),
and redistribution and/or rest injection,
with or without quantification
(78462, 78463 have been deleted. To report,
see 78460, 78461)
78464
Chapter 4
tomographic (SPECT), single study at
rest or stress (exercise and/or
pharmacologic), with or without
quantification
17
Using the CPT
(cont’d)

Unlisted Procedures




A service not listed in CPT
Codes are located in guideline at beginning of each
section of the CPT, except Anesthesiology.
Unlisted codes for Anesthesiology can be found
under the “Other Procedures” Subsection.
Use as a last resort, then:

A Detailed report must be attached to claim
Chapter 4
18
Using the CPT(cont’d)

Category II Codes




Listed at the end of Category 1 (CPT Codes)
Used to track performance measures for a
medical goal such as reducing tobacco use.
Reporting these codes are optional, because they
are not paid.
Alphabetic charter for the 5th digit (such as,
0002F for tobacco use, smoking, assessed)
Chapter 4
19
Using the CPT(cont’d)

Category III Codes




Listed after the Category II codes.
Are temporary codes for emerging
technology, service, and procedures.
If a Category III code exists for a service, it
must be used, rather than an unlisted code.
Alphabetic 5th digit (such as 0041T for
urinalysis infectious agent detected)
Chapter 4
20
Coding Evaluation and
Management (E/M)
Three Key Factors to determine the
Level of Service:




Extent of patient History
Extent of Exam
Complexity of Medical Decision Making
Chapter 4
21
Coding Evaluation and
Management (E/M)
In addition to the level of service:


Health Plans want to know if the Physician
treated a New or Established Patient
New or Established Patient



NP - not seen before (or for 3 years)
EP - seen within 3 years
Chapter 4
22
Coding Evaluation and
Management (E/M)

Location of Service (POS)
 Location is important, because different procedural codes
apply depending on where the procedures were performed.
 EXAMPLE:


Procedures Code for services done in a physician office differ
from those done in a hospital)
Hospital Coding describe time as “Unit” or “Floor” time.

The definition includes the physician’s time spent in the hospital unit
or review medical records or talk with hospital staff about the
patient’s care and time spent directly with the patient.
Chapter 4
23
Referral & Consultation

Referral


Patient is sent to another physician for
examination and treatment
Consultation

The service performed by one physician for the
purpose of advising an attending physician
about a patient’s condition and care.
Chapter 4
24
Types of Consultations

Initial Consultation


Is when the physician ask for consultation with
another physician.
Confirmatory Consultation

Is when patient ask for consultation with another
physician.
Chapter 4
25
Coding Surgical Procedures

Codes in the Surgery Section represent groups
of procedures that include all routine elements,
called a “Surgical Package”

Surgical Package includes:



Combination of Services included in a single procedure
code for some surgical procedures in CPT
Groups of services that should not be listed individually
Payer assign a fee to these codes that reimburse all the
services provided under them.
Chapter 4
26
Coding Surgical Procedures

Surgical package includes (Cont. ):


Example of Global Period:



The period of time that is covered for following-up care is
referred to as the Global Period.
A Global Period for repairing a “Tendon” may be set at 15 days.
A Global Period for major surgery such as an appendectomy may be
set at 100 days.
After the Global Period ends, additional services that are
provided can be reported separately for additional payment.
Chapter 4
27
Coding Surgical Procedures

Two type of services not included in a Surgical
Package
1. Complications or recurrences that arise after
therapeutic surgical procedures.
2. Care for the condition for which a diagnostic surgical
procedure is preformed.

Routine follow-up care included in the code refers only to
care related to recovery from the diagnostic procedure
itself, not the condition
Chapter 4
28
Coding Surgical Procedures

When Health Plans pay for more than one surgical
procedure performed on the same day for the same
patient, they pay the full amount for the first
listed surgical procedure.

The Health Plan pay less than the full amount for the
other procedures.

For maximum payment for reimbursement with
multiple procedures, the coder should list the
procedure with the highest level code first.

The other procedures are listed with the modifier -51 or
modifier -59.
Chapter 4
29
Coding Surgical Procedures

Modifiers 51


Modifiers 59


Used for multiple procedures at the same body site or
system.
Indicates distinct procedures, each fully reimbursed,
rather than multiply procedures.
EXAMPLE:

Modifier 59- is usually used when the surgeon performs
procedures on two different body sites or organ systems,
such as the excision of a lesion on the chest as well as the
incision on drainage (I&D)
of an abscess on the leg.
Chapter 4
30
Coding Laboratory
Procedures

Organ/Disease-Oriented Panels listed in
the Pathology & Laboratory section
include:



Tests frequently ordered together
When tests are performed together, the code for
the panel must be used, rather than listing them
separately
Do not unbundle the Panel
Chapter 4
31
Coding Immunizations
Coding Immunizations


Two codes are required
 A Code for Injection
 A Code for Vaccine
EXAMPLE:


Influenza shot (the administration code 90471) is used
for the injection.
Along with one of the codes for the specific Vaccine,
such as 90655, 90657, 90658, or 90660.
Chapter 4
32
Transcutaneous and/or Neuromuscular
Electrical Nerve Stimulators
E0720 TENS, two lead, localized stimulation
HCPCS Codes

E0730 TENS, four lead, larger area/multiple nerve stimulation
E0731 Form fitting conductive garment for delivery of TENS or
NMES (with conductive fibers separated from the patient’s
skins by layers of fabric)
The Health Care Financing Administration’s Common
Procedure Coding System (HCPCS), was developed by the
Health Care Financing Administration (HCFA) for use in
coding services for Medicare Patients.

Level 1 – Duplicates the CPT

Level II - issued by CMS in Medicare Carrier Manual


Supplies, drugs, durable medical equipment
5 characters plus modifiers; alphanumeric
Chapter 4
33
Five Steps to Procedural Coding
Step 1
Step 2
Step 3
Step 4
Step 5
Become familiar with CPT codes
Find the services listed on patient
encounter form
Look up codes in index, then look up
actual code
Determine appropriate modifiers
Record the procedure code on the
insurance claim; PROOFREAD
numbers
Chapter 4
34
Five Steps to Procedural Coding
Step 1 Become familiar with CPT codes


Read the information and main section
guidelines and notes.
Pay attention to modifiers for each section,
because they specify the exact nature of a
procedure being reported
Chapter 4
35
Five Steps to Procedural Coding
Step 2 Find the services listed on patient
encounter form



Check the patient’s encounter form to see what
services were performed.
For E/M procedures look for clues as to the type
of that were involved. history, examination,
and decision making
The encounter may also indicate the amount of
time the physician spent with the patient.
Chapter 4
36
Five Steps to Procedural Coding
Step 3 Look up the procedure code


Select a specific procedure or service, organ, or
condition.
Find the procedure code in the CPT’s Index.




ie., to find the code for “dressing change”:
First look in the alphabetic index for the procedures
Then turn to the procedure code in the body of the CPT to
be sure the code accurately reflect the service performed
The procedure code 15852 explains the dressing change for
“other than burns” and “under anesthesia (other than
local)”.
Chapter 4
37
Five Steps to Procedural Coding
Step 4 Determine appropriate modifiers.



In the section’s guidelines and notes, find the
Modifiers that elaborate on details of the
procedure being coded
If multiple modifiers are required, use the fivedigit main number and the modifier.
Then list additional modifiers
Chapter 4
38
Five Steps to Procedural Coding
Step 5 Record The procedure code on the


insurance claim form.
If the patient has more than one diagnosis
on a single claim form the Primary
diagnosis or the Principal procedure is
listed first.
If secondary procedures are performed, match
up each procedure with its correspondence
diagnosis.
Chapter 4
39
Quiz

Current Procedural
Terminology
CPT means _________
________
________.
modifier
A ___________
is a 2-digit code that
describes special circumstances.
 The Level of Service helps determine the
E/M code
___________.
HCPCS
 Supplies and drugs are coded using ________.

1.
Procedure codes are written as 3 digits, a
decimal, and 2 digits. (T/F)
False, dx codes are written that way.
Chapter 4
40
PERFORMANCE EXERCISE

Excision of tendon, finger, flexor, single
(separate procedure), each
26180

How to Code Effectively
 Identify Main Term(s) in the Procedure Description of
the Medical Record
 Locate Main Term(s) in the Index & Document Code
Range
 Turn to the Correct Section of the CPT & Read all
Description listed in the Code Range
 Select the Correct Code
Chapter 6
41
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Breast reconstruction with free flap
19364

Preoperative placement of needle localization
wire, breast:
19290
Chapter 6
42
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Closed treatment of mandibular fracture;
without manipulation
21450

Closed treatment of metacarpal fracture, with
manipulation, with external fixation, each bone.
26607
Chapter 6
43
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Nasal endoscopy, diagnostic, unilateral or
bilateral (separate procedure)
31231

Bronchoscopy, rigid or flexible, with or without
fluoroscopic guidance; diagnostic, with or without
cell washing (separate procedure)
31622
Chapter 6
44
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Repair of left ventricular outflow tract
obstruction by patch enlargement of the outflow
tract
33414

Thrombolysis, coronary; by intracoronary
infusion, including selective coronary
angiography
92975
Chapter 6
45
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Repair of palate; up to 2 cm
42180

Laparoscopy, surgical, appendectomy
44970
Chapter 6
46
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Biopsy, prostate; needle or punch, single or
multiple, any approach
55700

Biopsy of ovary, unilateral or bilateral (separate
procedure)
58900

Aspiration of bladder by needle
51000
Chapter 6
47
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Twist drill hole for subdural or ventricular puncture; for
implanting ventricular catheter or pressure recording
device
61107

Biopsy of Cornea
65410
Chapter 6
48
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Radiologic examination; forearm, two views
73090

Ultrasound, transvaginal
76830
Chapter 6
49
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Acute hepatitis panel
80074

Insulin antibodies
86337
Chapter 6
50
PERFORMANCE EXERCISE





Identify Main Term(s) in the Procedure Description of the Medical Record
Locate Main Term(s) in the Index & Document Code Range
Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
Select the Correct Code
Lyme disease vaccine, adult dosage, for intramuscular
use
90665

Measles and rubella virus vaccine, live for
subcutaneous use
90708
Chapter 6
51