CHAPTER 8 INTRODUCTION TO CPT Copyright 2016 by

Medical Coding • Transforms services/procedures/supplies/drugs into _____ CPT/HCPCS codes • Transforms diagnosis and procedures

Levels of Service Codes • Level I CPT—(Category I: 99201 -99607, Category III: 0042

Diagnosis Codes • ICD-10 -CM • International Classification of Diseases, 10 th revision, Clinical

Why Codes? • Computers understand numbers _______ • Specific descriptions attached to each code

CPT • Developed by the AMA in 1966 ____ • Updated in November ____

Examples of Types of CPT Codes • Medical • Surgical • Diagnostic services • Anesthesia, etc. • Category II and Category III codes— alphanumeric performance measuring – Category II = ______ – Category III = emerging _____ technology Copyright © 2017 by Elsevier Inc. Slide 7

CPT Codes Allow For effective and • Communication that is both _______ efficient • A mechanism to report a service not described by a specific CPT or Level II code Copyright © 2017 by 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 © 2017 by Elsevier Inc. Slide 9

Codes Are • Used to tell third-party payers about _______/procedures provided services payment •

Incorrect Coding • Results in providers being paid inappropriately ______ – Either over or

Codes Are Used by • Clinics • Hospitals • Rehabilitation units • Ambulance services

Outpatient Services for Physicians • Reported electronically in billing systems CMS-1500 = universal paper

CMS-1500 (Courtesy U. S. Department of Health and Human Services, Centers for Medicare and

CPT Format • Symbols in CPT information • Used to convey _____ • Triangle _______, changes or modifications to code description since previous edition – Example: 50592, Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency bolt, pending FDA approval • Lightning ______ (Appendix K, CPT) – Example 90630, Influenza virus vaccine, quadrivalent (contains 4 virus strains) Copyright © 2017 by Elsevier Inc. Slide 15

• Bullet = New ____ Code Figure 8. 2 • Pound Symbol (#)

▲Triangle = Revised _______ Code Figure 8. 3 Copyright © 2017 by Elsevier Inc.

Right and Left Triangles ____= Beginning and Ending of Text Change Figure 8. 4

+_____ Plus = Add-On Code Figure 8. 7 (Cont’d…) Copyright © 2017 by Elsevier

Add-On Code (…Cont’d) • Can only be used with another specific code alone • Never used _____ • No reduction for multiple services • Full list in Appendix D _ of CPT Copyright © 2017 by Elsevier Inc. Slide 20

=Circle With Line, -51 Cannot Be Used With These Codes Figure: 8. 8 • CPT Appendix E contains a listing of -51 exempt codes • Services typically exempt from multiple procedure reductions Copyright © 2017 by Elsevier Inc. Slide 21

Circle = Recycled or Reinstated Code • Circle symbol identifies codes previously published

Appendices of CPT • Appendix A: Modifiers _______ • Appendix B: Deletions, Revisions Additions, ____ • Appendix C: Clinical Examples, E/M ___ Codes Add-On Codes • Appendix D: _______ • Appendix E: -51 Exempt Codes ___ • Appendix F: -63 Exempt Codes ___ • Appendix G: Used to include Moderate Conscious Sedation (Deleted for (____) 2017) (Cont’d…) Copyright © 2017 by Elsevier Inc. Slide 23

Appendices of CPT (…Cont’d) • Appendix H: Performance Measures, Category II_ Codes, on website • Appendix I: Modifiers Used to list genetic Testing ____ (Deleted for 2013) • Appendix J: Electrodiagnostic Medicine Sensory _____, Motor and Listing of _______, Mixed Nerves FDA Approval Product Pending ____ • Appendix K: • Appendix M: Vascular Families _______ Deleted CPT Codes _______ • Appendix N: Resequenced CPT Codes • Appendix O: Multianalyte Assays with Algorithmic Analyses • Appendix L: Copyright © 2017 by 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 © 2017 by Elsevier Inc. Slide 25

Categorized By • Sections • Subsections • Subheadings • Categories (Cont’d…) Copyright © 2017

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 © 2017 by Elsevier Inc. Slide 27

Categorized By, Example (…Cont’d) Figure: 8. 6 Copyright © 2017 by Elsevier Inc. Slide

Guidelines Figure: 8. 11 • Section-specific information begins each section Copyright © 2017 by

Notes Figure: 8. 12 • Must-reading located throughout the CPT Copyright © 2017 by

Two Types of Codes • Stand-alone: ___ Full description preceding • Indented: Dependent on __________ stand-alone – Verbiage before the semicolon applies to all indented codes that follow Copyright © 2017 by Elsevier Inc. Slide 31

Types of Codes, Example Figure 8. 14 Copyright © 2017 by Elsevier Inc. Slide

Semicolon • Indicates full description in _______ preceding code • You must return to

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 © 2017 by Elsevier Inc. Slide 34

Level II HCPCS Modifiers • “-AS” Physician’s Assistant • “-F 1” Left hand, second

Example of Modifier • 43820 Gastrojejunostomy -62 two surgeons -43820 -62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payer Example: Medicare requires documentation of medical necessity Copyright © 2017 by Elsevier Inc. Slide 36

Modifier on the CMS-1500 Health Insurance Claim Form (Courtesy U. S. Department of Health

Unlisted Services “ 99” = “no specific Category I or • Codes ending in ____ III code” no more specific code • Used if _________ Special report must accompany submission • ______ Copyright © 2017 by Elsevier Inc. Slide 38

Category I Codes • Category _I codes (00100– 99607) – Approved by AMA and

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 © 2017 by 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 (0042 T) – May or may not receive future Category _______ I code status Copyright © 2017 by Elsevier Inc. Slide 41

Category III Codes III codes have not been approved • Category __ and have no proven clinical effectiveness • Usage order III code instead of unlisted code – Use Category _____ – Use unlisted code if no Category III code Copyright © 2017 by Elsevier Inc. Slide 42

Special or Written Report Indicates: • Nature • Extent • Need • Time •

The Index! • Used to locate service/procedure terms and codes • Speeds up code

CPT Index Figure 8. 18 Copyright © 2017 by Elsevier Inc. Slide 45

Presentation of Codes in Index • Single code: 38115 • Multiple codes: 26645, 26650

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 © 2017 by Elsevier Inc. Slide 47