Basics of Procedural Coding Chapter 19 Copyright 2011

Basics of Procedural Coding Chapter 19 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

Consider the following while reading this chapter: What will the medical assistant find similar to ICD-9 -CM as she or he performs procedural coding? What will help in selecting the most specific and accurate CPT code? What are the differences between coding for the CPT and coding for HCPCS? What will be learned about the legal and compliance implications of improper coding? Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

What is Procedural Coding and How Is It Used? Procedural or CPT coding is defined as the transformation of verbal descriptions of medical services and procedures into numeric or alphanumeric designations. The medical assistant facilitates accurate medical recordkeeping and the efficient processing of insurance claims by using the CPT and HCPCS are used in the claims submission process to receive reimbursement from payors as well as to track physician productivity and provide statistical data. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

What is the Purpose of CPT Coding? Encourage the use of standard terms and descriptors to document procedures in the medical record Help communicate accurate information on procedures and services to agencies concerned with insurance claims Provide the basis for a computer-oriented system to evaluate operative procedures Contribute basic information for actuarial and statistical purposes Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

The CPT Code The CPT code is a five-digit code also known as a Category I codes are located in the Tabular Index (Main Text) of the CPT coding manual and are arranged by Section Category II codes are optional codes used by providers to assist in measuring performance and outcomes. Category II codes include the letter F as the fifth digit. Category III codes are temporary codes assigned for emerging and new technology, services and procedures that have not been officially added to the Main Text of the CPT manual. The fifth digit of the Category III code is the letter T. Modifiers provide a way for providers to indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

Format of the CPT Coding Manual Each procedure or service is represented by a five-digit numeric code – a type of medical shorthand that saves enormous amounts of time and effort and helps to ensure the accuracy of information Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

CPT Content Comprehensive instructions for use of the manual, including steps for coding A complete Alphabetic Index Main Text (Tabular Index) Six sections Ø Guidelines and notes Ø Conventions Ø Thirteen appendixes Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

CPT Content The Tabular Index is divided into six sections, with codes listed in numeric or alphanumeric order within each section. Evaluation and Management (E&M) Ø Anesthesia Ø Surgery (all body systems) Ø Radiology Ø Pathology and Laboratory Ø Medicine Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

Sections of the CPT Main Text A section is a broad category in the main text of the CPT manual, and each of the six sections is divided by the general type of service Evaluation and Management (E&M) Ø Anesthesia Ø Surgery Ø Radiology Ø Pathology and Laboratory Ø Medicine Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

Sections of the CPT Main Text The subsection of the CPT manual is indented two spaces below a section, and usually describes: Anatomic Site Ø Organ System Ø Categories are indented two additional spaces below the subsection, and generally refer to: a specific procedure or service Ø can also be a more specific anatomical site Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

Sections of the CPT Main Text The subcategory is indented two spaces below a category, and provides even more specificity about an anatomical site or the procedure or service performed. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

Appendixes appendixes found in the CPT are as follows: Appendix A: Modifiers Ø Appendix B: Summary of Additions, Deletions, and Revisions Ø Appendix C: Clinical Examples Ø Appendix D: Summary of CPT Add-on Codes Ø Appendix E: Summary of CPT Codes Exempt from Modifier -51 Ø Appendix F: Summary of CPT Codes Exempt from Modifier -63 Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

Appendixes Appendix G: Summary of CPT Codes that Include Moderate (Conscious) Sedation Ø Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or Topic Ø Appendix I: Genetic Testing Code Modifiers Ø Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Ø Appendix K: Product Pending FDA Approval Ø Appendix L: Vascular Families Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

Beginning the Coding Process The steps for using the CPT manual actually begin with the medical documentation: Encounter form, also known as a superbill, fee slip, or charge ticket Ø History and physical report (H&P) Ø Discharge summary Ø Operative report Ø Pathology report Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

Beginning the Coding Process The basic steps in medical coding are to: read Ø analyze Ø abstract the procedure or service documented Ø compare it with the encounter form, operative report, or other documentation Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

Using the Alphabetic Index to Search Begin the search by using one or all of the four primary classifications (or types) of main and modifying term entries: Procedure or service Ø Organ or anatomic site Ø Condition, illness, or injury Ø Eponym, synonym, abbreviation, or acronym Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

Steps for Using the Alphabetic Index Ø Ø Ø Ø Abstract the procedures and/or services performed from the medical documentation. Determine the main and modifying terms from the abstracted information. Select the most appropriate main term to begin the search in the Alphabetic Index. Select modifying term(s), if needed, once the main term is located to narrow down the search. If no main or modifying term produces an appropriate code or code range, repeat steps 2, 3, and 4, using a different main term. Find code or code ranges that include all or most of the medical record procedure or service description. Disregard any code or code range containing additional descriptions or modifying terms not found in the abstracted information or the medical documentation. Write down the code or code ranges that best match the medical documentation. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

Steps for Using the Main Text Ø Ø Ø Ø Turn to the Main Text and find the first code or code range found while searching the Alphabetic Index. Compare the description of the code with the medical documentation. Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation. Read the guidelines and notes for the section, subsection, and code to ensure there are no contraindications to the use of the code. Evaluate the conventions, especially add-on codes (+) and exemption from modifier -51. Determine if there are special circumstances that require the use of a modifier. Determine if a Special Report is required. Record the CPT code selected in the medical record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

Surgery coding There are some guidelines and notes related to surgery coding that must be considered when researching and selecting a procedure or service code: Surgical Package Definition Ø Follow Up Care for Diagnostic Procedures Ø Materials Supplied by the Physician Ø Surgical Destruction Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

Surgery Coding Endoscopy Ø X-ray Imaging/Fluoroscopy Ø Excision of Lesions – Benign or Malignant Ø Repair (Closure) Ø Musculoskeletal System Ø Respiratory System Ø Maternity Care and Delivery Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

Understanding Evaluation and Management The first two steps in choosing an E&M code are: Identifying the place of service (POS) Ø Identifying the patient status Ø Determining the level of service provided There are three components for determining the level of service for E&M: history examination medical decision making four contributing factors: counseling nature of the presenting problem coordination of care time Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

Anesthesia Coding STEPS FOR ANESTHESIA CODING Ø Ø Ø Ø Read the medical documentation to determine what procedure or service was provided. Determine the anatomic site or organ system involved. In the Alphabetic Index, go to the heading “Anesthesia” and find the code or code range that includes all or most of the medical record procedure or service. Write down the code or code range found in the Alphabetic Index, under the Anesthesia heading, that best matches the medical documentation. Turn to the Main Text, Anesthesia Section, and find the code or code range found while searching the Alphabetic Index. Read the guidelines and notes for the section, subsection, category, or subcategory. Evaluate the conventions, especially add-on codes (+) and modifier -51 exemptions. Document the code selected. Determine the Basic Unit Value from the Relative Value Guide. Determine the patient’s physical status and document the appropriate modifier. Determine if any qualifying circumstance modifier should be used. If yes, document the modifier. Determine the total anesthesia time, divide by 15 (minutes), and document the time. Select the appropriate geographic conversion factor. Calculate the charge for the anesthesia service using the anesthesia formula. Document the anesthesia charge and the code in the medical record and on the encounter form or charge ticket. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

Healthcare Common Procedure Coding System (HCPCS) Steps for Using HCPCS Codes Ø Ø Ø Ø Read the medical documentation to determine what procedures or services were provided. Determine the main and modifying terms from the abstracted information. Select modifying term(s) if needed once the main term is located. Select the most appropriate main term to begin the search in the Alphabetic Index. If no modifying term produces an appropriate code or code range, repeat steps 2 and 3 using a different main term classification. Find code or code ranges that include all or most of the medical record procedure or service description. Disregard any code or code range containing additional descriptions or modifying terms not found in the medical record. Write down the code or code ranges that best match the medical documentation. Turn to the Main Text and find the first code or code range found while searching the Alphabetic Index. Compare the description of the code with the medical documentation. Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation. Read the guidelines for the section, subsection, and code to ensure there are no contraindications to the use of the code. Evaluate the HCPCS manual conventions. Determine if there are special circumstances that require the use of a modifier. Record the HCPCS code selected in the medical record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

Compliance and Legal Issues Medical assistants should also ensure that proper precautions are taken to avoid incorrect coding, data entry errors, and false claims submissions. Downcoding, in which lower level codes are used even when the diagnostic statement indicates a higher level procedure or service, usually affects reimbursement only by lowering the amount received, but may have civil and criminal penalty implications if it is done to disregard insurance policy restrictions or preexisting condition clauses. Ø Upcoding, on the other hand, in which a procedure or service code is used that is of a higher level than is supported by the medical documentation, can result in civil and criminal penalties, including fines, loss of privileges as a participating provider, and even prison time. Ø Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24