CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL

CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 1

Medical Coding • Transforms services/procedures/supplies/drugs into _____ codes CPT/HCPCS • Transforms diagnosis and procedures into diagnosis codes ____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 2

Levels of Service Codes • Level I CPT—(Category 1: 99201 -99607, Category III: 0019 T-0339 T) • Level II HCPCS, National Codes—(A 0021 V 5364) • Level III Local Codes—phased out due to HIPAA Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 3

Diagnosis Codes • ICD-10 -CM/ICD-9 -CM • International Classification of Diseases, 10 th revision, Clinical Modification • International Classification of Diseases, 9 th revision, Clinical Modification Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 4

Why Codes? • Computers understand numbers _______ • Specific descriptions attached to each code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 5

CPT • Developed by the AMA in 1966 ____ • Updated in November ____ for use January 1 • Divided into Category I, II, and III codes Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 6

Examples of Types of CPT Codes • Medical • Surgical • Diagnostic services • Anesthesia, etc. • Category II and Category III codes—alpha numeric performance measuring – Category II = _____ – Category III = emerging _____ technology Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 7

CPT Codes Allow For • Communication that is both effective _______ and ______ efficient • A mechanism to report a service not described by a specific CPT or Level II code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 8

Consider • Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) • OR 50575 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 9

Codes Are • Used to tell third-party payers about _______/procedures provided services payment • Often used as basis of _______ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 10

Incorrect Coding • Results in providers being paid inappropriately ______ – Either over or underpayment – Decreases cash flow – Liability risk Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 11

Codes Are Used By • Clinics • Hospitals • Rehabilitation units • Ambulance services • Long-term care health care services • Wherever _____ are provided Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 12

Outpatient Services for Physicians • Reported electronically in billing systems CMS-1500 = universal paper form • _____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 13

CMS-1500 (Courtesy U. S. Department on Health and Human Services, Centers for Medicare and Medicaid Services. ) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 14

CPT Format • Symbols in CPT information • Used to convey _____ • Bullseye _______, moderate (conscious) sedation included (full list in Appendix G, CPT) – Example 45391, Colonoscopy with endoscopic ultrasound examination bolt pending FDA approval • Lightning ______, (Appendix K, CPT) – Example 90650, Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 15

• Bullet = New ____ Code Figure: 13. 2 • Pound Symbol (#) = resequenced code Figure: 13. 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 16

▲Triangle = Revised _______ Code Figure: 13. 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 17

Triangles = Beginning ►◄ Right and Left ____ and Ending of Text Change Figure: 13. 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 18

+_____ Plus = Add-On Code Figure: 13. 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 19

Add-On Code (…Cont’d) • Can only be used with another specific code • Never used alone _____ • No reduction for multiple services • Full list in Appendix D _ of CPT Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 20

=Circle With Line, -51 Cannot Be Used With these Codes Figure: 13. 8 • CPT Appendix E contains a listing of -51 exempt codes • Services typically exempt from multiple procedure reductions Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 21

Circle = Recycled or Reinstated Code • Circle symbol identifies codes previously published in CPT Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 22

Appendices of CPT • Appendix A: Modifiers _______ • Appendix B: Additions, Deletions ____, Revisions • Appendix C: Clinical Examples, E/M ___ Codes Add-On Codes • Appendix D: _______ • Appendix E: -51 Exempt Codes ___ • Appendix F: -63 Exempt Codes ___ Conscious ) • Appendix G: Include Moderate (_____ Sedation (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 23

Appendices of CPT (…Cont’d) • Appendix H: Performance Measures, II Codes, on website Category __ • Appendix I: Modifiers (Deleted for Genetic Testing ____ 2013) • Appendix J: Electrodiagnostic Medicine Sensory _____, Listing of _______, Motor and Mixed Nerves • Appendix K: FDA Approval Product Pending ____ • Appendix L: • Appendix M: Vascular Families _______ Deleted ______ CPT Codes • Appendix N: Resequenced CPT Codes • Appendix O: Multianalyte Assays with Algorithmic Analyses Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 24

Six CPT Sections (like chapters) ___ 1. 2. 3. 4. 5. 6. • • Evaluation & Management (E/M) Anesthesia Surgery Radiology Pathology & Laboratory Medicine Category II Codes Category III Codes Appendices A-M Index Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 25

Categorized By • Sections • Subsections • Subheadings • Categories (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 26

Categorized By (…Cont’d) Anatomy • ____ – Knee or Shoulder • _____ Procedure – Incision or Excision Condition • _____ Description • _____ – Cast or Strap Surgical Approach • ________ – Anterior Cranial Fossa or Middle Cranial Fossa – Fracture or Dislocation (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 27

Categorized By, Example (…Cont’d) Figure: 13. 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 28

Guidelines Figure: 13. 11 • Section-specific information begins each section Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 29

Notes Figure: 13. 12 • Must-reading located throughout the CPT Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 30

Two Types of Codes • Stand-alone: ___ Full description • Indented: Dependent on preceding ____ stand-alone _____ – Verbiage before the semicolon applies to all indented codes that follow Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 31

Types of Codes, Example Figure: 13. 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 32

Semicolon code • Indicates full description in preceding _______ • You must return to the stand-alone for full description Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 33

Modifiers Add Information • CPT Modifier • Two digits – 62 Two surgeons performed a surgical procedure – Each surgeon applies his/her individual skill – Each surgeon bills the procedure with modifier -62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 34

Level II HCPCS Modifiers • “-AS” Physician’s Assistant • “-F 1” Left hand, second digit All modifiers used on CPT or HCPCS • __ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 35

Example of Modifier • 43820 Gastrojejunostomy -62 two surgeons -43820 -62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 36

Modifier on the CMS-1500 Health Insurance Claim Form (Courtesy U. S. Department of Health and Human Services, Centers for Medicare and Medicaid Services) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 37

Unlisted Services • Codes ending in “ 99” ___ = “no specific Category I or III code” no more specific code • Used if _________ report must accompany submission • Special ______ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 38

Category I Codes • Category _I codes (00100– 99607) – Approved by AMA and Food and Drug Administration – Proven clinical effectiveness (efficacy) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 39

Category II Codes— Supplemental Tracking Codes • Used for performance _____ measurements • Codes collect data concerning quality of care and test(s) required Alphanumeric and end in the letter “F” (1006 F) • ______ • Location AMA Website Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 40

Category III Codes— New Technology • Temporary codes—up to 5 _ years • Identify emerging technology, services, and procedures • Located after Medicine _______ section • Alphanumeric (0019 T) – May or may not receive future Category _______ I code status Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 41

Category III Codes III codes have not been approved • Category __ and have no proven clinical effectiveness • Usage order Category III code instead of unlisted code – Use _____ – Use unlisted code if no Category III code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 42

Special or Written Report Indicates: • Nature • Extent • Need • Time • Effort • Equipment _____ Used • Photos and medical journal articles if relevant Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 43

The Index! • Used to locate service/procedure terms and codes • Speeds up code location • Like a dictionary • First entries and last entries Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 44

CPT Index Figure: 13. 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 45

Presentation of Codes in Index • Single code: 38115 • Multiple codes: 26645, 26650 - Note ______ comma • Range of codes: 22305 -22325 hyphen - Note ______ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 46

Location Methods with Examples 1. Service/procedure ________: repair, excision 2. Anatomic ______: site median nerve, elbow or disease : cleft lip, clot 3. Condition _________ 4. Synonym ____: toe and interphalangeal joint 5. Eponym _______: Jones procedure, Heller operation 6. Abbreviation _____: ECG, PEEP (Pressure Breathing, Positive) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 47

Always • Reference index main portion of CPT • Locate code in _____ description and • Read the entire _____ any notes _____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 48

“See” in Index • Cross-reference terms – “Look here for code” • Index: Stem, Brain: See Brainstem Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 49

HCPCS • Healthcare Common Procedure Coding System • Developed by Centers for Medicare and CMS Medicaid Services (____) HCFA – Formerly _____ • HCPCS developed in 1983 ____ • CPT did not contain all codes necessary for Medicare services reporting Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 50

Levels of Codes • Level I: CPT ___ • Level II: HCPCS, also known as national codes phased out ) due to • Level III: Local codes (_____ HIPAA Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 51

Level III, Local Codes • Developed by Medicare carriers for use at local level • Varied by locale • Discontinued December 31, 2003 – Some codes incorporated into HCPCS Level I and II Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 52

National Codes Level II: _______ • Codes for wide variety of providers – Physicians – Dentists – Orthodontists – Temporary codes for Medicare (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 53

Level II: National Codes (…Cont’d) • Codes for wide variety of services – Specific drugs Durable medical equipment (DME) – ___________ – Ambulance services Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 54

HCPCS Gains Popularity • Many payers require • Each year increased number of HCPCS codes – J 0585—Botox, per unit Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 55

Format letter followed by four digits • Begins with ____, ____ – Example: E 0618, apnea monitor • Each letter represents group of codes – Example: “_” J codes used to report drugs and dosage Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 56

Temporary Codes • Certain letters (_, _, S, H, T) indicate G K, Q temporary codes – Example: K 0006 heavy duty wheelchair • Code books published every January ______ – But codes added, deleted, and revised throughout the year – Notified through carrier bulletins Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 57

Coverage • Just because item/service has HCPCS code does NOT mean service covered – Example: – V 5130, _______ binaural hearing aid _____ – Not covered under Medicare From Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, editors: Cummings Otolaryngology-Head & Neck Surgery, ed 4, Philadelphia, 2005, Mosby. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 58

Where HCPCS Are Used • Outpatient _____ settings – Including outpatient departments in hospital • Level I and II used to report outpatient services to certain payers Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 59

HCPCS Index • Directs to specific codes • Do not code directly from index • Reference main portion text before assigning code • See Figure 13. 22 in textbook (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 60

HCPCS Index (…Cont’d) Figure: 13. 22 • Alphabetical order (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders. Slide 61

HCPCS Index (…Cont’d) • Main text display Figure: 13. 27 Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 62

HCPCS Modifiers Figure: 13. 25 Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders. HCPCS modifiers used with both • CPT ___ and ______ HCPCS and CPT codes Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 63

Anatomical Modifiers • F 1 Left hand, second digit • F 2 __ Left hand, third digit • F 3 Left hand, fourth digit • F 4 Left hand, fifth digit • FA Left hand, thumb • F 5 __ Right hand, thumb • F 6 Right hand, second digit • F 7 Right hand, third digit • F 8 __ Right hand, fourth digit • F 9 Right hand, fifth digit Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 64

Often Used HCPCS Modifiers • LT __ Left • RT __ Right • Example: • Right kidney biopsy, 50200 -RT • Left kidney biopsy, 50200 -LT Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 65

Ambulance Modifiers • Origin and destination used in combination: Origin – First letter: _____ Destination – Second letter: _____ – Example: • R = Residence • H = Hospital • RH: origin (first letter) residence and destination (second letter) hospital Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 66

Table of Drugs Figure: 13. 26 Modified from Buck CJ: 2014 HCPCS Level II Professional Edition, St. Louis, 2014, Saunders. • Listed by generic name Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 67

Durable Medical Equipment • DME • Used with chronic disabling condition • Medicare and Medicaid pay for some DME items • Physician must attest to need using Certificate of Medical Necessity _________ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 68

Home Oxygen Therapy • Medicare may also pay for oxygen with certain medical conditions • Physician must complete form (CMS-___) 484 attesting to medical necessity Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 69

Conclusion CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 70