Basic Current Procedural Terminology and HCPCS Coding 2018

Basic Current Procedural Terminology and HCPCS Coding 2018 Edition Chapter 2: Application of the CPT System © 2018 American Health Information Management © 2018 American Health Information. Association Management Association

Conditions for Inclusion of a Procedure within CPT • Commonly performed by physicians across the country • Consistent with contemporary medical practice 2 © 2018 American Health Information Management Association

CPT Category I—Major Sections • • • 3 Evaluation and Management (E/M) Anesthesiology Surgery

Evaluation and Management: An Overview • • • Physician visit codes Consultation codes Emergency department services Critical care Nursing facility care 4 © 2018 American Health Information Management Association

Anesthesiology • Anatomic format • Selection based on surgical procedure performed • Include general, regional, supplementation of local anesthesia • Includes preop and postop visits, monitoring, administration of fluids and/or blood • Some insurance carriers use time for reimbursement 5 © 2018 American Health Information Management Association

Surgery • Largest section and most difficult • Note section divided into: o Section (Surgery) o Subsection/category (Urinary system) o Subcategory (Kidney) o Heading (Incision) o Procedure codes (50010) 6 © 2018 American Health Information Management Association

Radiology • Four subsections o Diagnostic radiology o Diagnostic ultrasound o Radiation oncology o Nuclear medicine • Most hospitals maintain these codes in computerized file (chargemaster) 7 © 2018 American Health Information Management Association

Pathology and Laboratory • Most hospitals maintain codes in an electronic file (chargemaster) • Physicians maintain list of common procedures performed (superbill or computer file) 8 © 2018 American Health Information Management Association

Medicine • Specialized section • Types of codes o Psychiatric services o Physical therapy o Ophthalmological services o Cardiac catheterization 9 © 2018 American Health Information Management Association

Category II Codes • • • 10 Performance measurements For data collection End with letter F Use is optional Example: 4008 F Beta-blocker therapy prescribed or currently being taken © 2018 American Health Information Management Association

Category III Codes • Emerging technology • Alphanumeric codes • Used for data collection • Temporary • Updates available on the AMA website • Payment depends on the payer Example: 0085 T. Breath test for heart transplant rejection 11 © 2018 American Health Information Management Association

Format: Conventions and Characteristics of CPT • Stand alone and semicolon ( ; ) • Bullet • Triangle • Facing triangles • Plus sign + 12 © 2018 American Health Information Management Association • Star • Null symbol • Pending FDA Approval symbol • Resequenced code #

Symbols: Stand Alone and Semicolon ; 37600 Ligation; external carotid artery 37605 internal or common carotid artery • Code 37600 stands alone, meaning it needs no interpretation. • Because code 37605 is indented, it relies on the description before the semicolon in the preceding entry to complete the code description. • Therefore, Code 37605 reads as: Ligation; internal or common carotid artery 13 © 2018 American Health Information Management Association

Symbols: Bullet • Indicates a new code for the current year • Listed in Appendix B Example: 64912 Nerve repair; with nerve allograft, each nerve, first strand (cable) 14 © 2018 American Health Information Management Association

Symbols: Triangle ▲ • Indicates a revised code for the current year • Listed in Appendix B Example: 31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) 15 © 2018 American Health Information Management Association

Symbols: Facing Triangles • Indicates new or revised text • Used throughout CPT Example: appears after code 15731 (For muscle, myocutaneous, or fasciocutaneous flap of the head and neck, use 15733) 16 © 2018 American Health Information Management Association

Symbols: Plus Sign + • • • 17 Designed as an add-on code Must

Symbols: Plus Sign—Example 11200 + 11201 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions each additional ten lesions, or part thereof (List separately in addition to code for primary procedure) Note: 11201 is used in conjunction with 11200. 18 © 2018 American Health Information Management Association

Symbols: Null Symbol Exemption to modifier 51 • Alerts coders to the fact that the code cannot be appended with modifier 51 • Applies to physician coding only • All exempt codes listed in Appendix E 19 © 2018 American Health Information Management Association

Symbols: Modifier 51 Exempt Null Symbol—Example: 17004 Destruction (e. g. laser surgery, electrosurgery, cryosurgery, surgical curettement), premalignant lesions (e. g. Actinic keratoses), 15 or more lesions 20 © 2018 American Health Information Management Association

Symbols: Pending FDA Approval Symbol Identifies codes for vaccines that are pending FDA approval. Example: 90666 Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use 21 © 2018 American Health Information Management Association

Symbols: Resequenced Code # • CPT codes do not appear in numeric sequence • For example: 46940 Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial 46942 subsequent 46945 Code is out of numerical sequence. See 46200 -46288 #46945 Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group 22 © 2018 American Health Information Management Association

Telemedicine 99244 Office consultation Use with new Modifier 95 © 2018 American Health Information

Unlisted Procedure • Allows the coder to assign a code to a procedure not listed in CPT • Assigned as a last resort • Payers want documentation (operative report) Note: The Alphabetic Index lists all unlisted procedures. • Example: 45999 Unlisted procedure, rectum 24 © 2018 American Health Information Management Association

Appendices • Appendix A: List of modifiers • Appendix B: Summary of additions, deletions,

Index • • • 26 First step for locating a code Alphabetic list Main

Selecting Appropriate CPT Code • Must always reference Notes • Notes are the guidelines

Coding Tips- more guidance As an example, note the tip before code 27197: The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open (compound) or closed fractures or joint injuries. © 2018 American Health Information Management Association

Checklist: When procedure is not in index • Research alternative names • Perform web

Health Record Documentation CPT-4 and ICD-10 -CM codes reported on the health insurance claim form or billing statement must be supported by the documentation in the health record. 30 © 2018 American Health Information Management Association

Abstracting Look for key “action” terms • Excision • Biopsy • Removal 31 ©

Coding References • CPT Assistant—authoritative reference • General Correct Coding Policies (NCCI Correct Coding Initiative Policy Manual for Medicare Services)- Chapter 1 • CMS Medicare/Medicaid Transmittals o Contains payer advice o Can be confusing if it contradicts CPT guidelines 32 © 2018 American Health Information Management Association

CPT Quick. Ref App • Quick access to CPT Assistant • Clinical Vignettes ©

Coding Skills and Knowledge Abstracting documentation Working knowledge of A&P and medical terminology Use of software and resources 34 © 2018 American Health Information Management Association Use of CPT Accurate code assignment Knowledge of how surgical procedures are performed Knowledge of payer guidelines and NCCI