Procedure Coding CPT Robert R Pontecorvo Jr Introduction

Procedure Coding (CPT) Robert R. Pontecorvo Jr.

Introduction • Procedural coding – Translate medical procedures and services into codes – Explains what services were provided • Code “linkage” with diagnostic codes • Maximum reimbursement

The CPT Manual • Procedure code • • Medical procedures and services Based on encounter form or patient record • Current Procedural Terminology (CPT) – HIPAA-required code set – Published by the AMA – Updated annually – Use the appropriate CPT based on date of service

Organization of the CPT Manual Range of odes Evaluation and Management 99201 99499 Anesthesiology 00100 – 01999 99100 – 99140 Surgery 10021 – 69990 Radiology 70010 – 79999 Pathology and Laboratory 80048 – 89356 Medicine 90281 – 99602 99500 – 99602

E&M Codes Initial Visit Code History Exam Face to Face Time 99201 Problem Focused Problem focused 10 minutes 99202 Expanded problem focused 20 Minutes 99203 Detailed 30 Minutes 99204 Comprehensive 45 minutes 99205 Comprehensive 60 minutes

E&M Follow up Code History Exam Face to Face time 99211 Not required 5 minutes 99212 Problem focused 10 minutes 99213 Expanded focused 15 minutes 99214 Detailed 25 minutes 99215 Comprehensive 40 minutes

E&M Treatment codes Code Explanation Minutes Units 97800 Acupuncture N/A 1 97810 Acupuncture with Electrical stimulation N/A 1 97812 Cupping N/A 1 97813 Moxibustion N/A 1 97010 Hot or cold packs applied to one or more areas N/A 1 97026 Infrared therapy Heat Lamp 1 97140 Manual therapy Tui Na (15 minutes) 1 97110 Therapeutic exercise 15 minutes 1 97124 Therapeutic massage 15 minutes 1

Organization of the CPT Manual (cont. ) • Manual Introduction – General instructions – Information about common • Prefixes • Suffixes • Word roots • Guidelines for each section

Organization of the CPT Manual (cont. ) • Sections – Guidelines at beginning – Categories headings • Page – Section name – Subsection name – Subheading – Category

General CPT Guidelines • Code format – 5 -digit numeric code – Stand-alone unless description contains a semicolon • Add-on codes – Additional procedures – Indicated by plus sign (+) – Indented codes

Symbols Used in CPT � Code description has been revised A new code # Codes are out of numeric sequence � New or revised text information

Symbols Used in CPT (cont. ) Does not require modifier of 51 FDA approval pending Moderate (conscious) sedation is included in the procedure

Organization of the CPT Manual (cont. ) • Modifiers – Up to three per procedure – Indicate that special circumstance applies – Appendix A – Section guidelines

Category II, III, And Unlisted Procedure Codes • Category II – supplemental tracking codes • Category III – temporary codes • Unlisted codes – code not yet assigned – Include a description of service or procedure – Check with payers regarding use

Coding Terminology • Bundled codes – Read description carefully – Do not unbundle • Critical care – Provided to unstable patients – Documentation • Concurrent care – More than one physician – If different specialties, not considered duplication

Coding Terminology (cont. ) • Consultations – Must have request, record of findings and recommendations, and report – Verify if payer is accepting these codes • Counseling – use codes if history or physical is not done

Coding Terminology (cont. ) • Downcoding – Reimbursement on a lower code level than submitted – Lack of documentation most common cause • Unbundling • Upcoding

Evaluation and Management Services • E/M codes – Used by all physicians – New patient vs. established patient • New patients – require more time • Established patient – seen within 3 years

Evaluation and Management Services (cont. ) • Key factors that help determine level of service Extent of patient history taken Extent of examination conducted Complexity of medical decision making

Evaluation and Management Services (cont. ) Patient History • Elements • Coding descriptions – Problem-focused – Chief complaint (CC) – Expanded problemfocused – History of present illness (HPI) – Detailed – Review of systems (ROS) – Past, family and/of social history (PFSH) – Comprehensive

Evaluation and Management Services (cont. ) Physical Exam • Elements • Coding description – Problem-focused – Constitutional exam – Expanded problemfocused – Body areas (BA) – Detailed – Organ systems (OA) – Comprehensive

Evaluation and Management Services (cont. ) Medical Decision. Making • Elements for documentation – Number of diagnoses and management options – Amount or complexity of data to be reviewed – Risk of complication or death if untreated

Evaluation and Management Services (cont. ) • Complexity level – Straightforward MDM – Low-complexity MDM – Moderate-complexity MDM – High-complexity MDM

Evaluation and Management Services (cont. ) • Contributory factors in assigning codes 1. Counseling • Reason for encounter • 50% or more of time 2. Coordination of care

Evaluation and Management Services (cont. ) 3. Nature of presenting problem • Minimal complaint • Self-limited complaint • Low severity complaint • Moderate severity complaint • High severity complaint

Evaluation and Management Services (cont. ) • Additional considerations – Time • Average times • Not critical unless code choice is based on time – Location where services occurred

Surgical Coding • The surgical package – All procedures normally a part of an operation • Preoperative exam and testing • Surgical procedure • Routine follow-up care • Global period – time period covered for follow-up care

Surgical Coding (cont. ) • Integumentary System – Codes based on size and location – Read and follow instructions carefully • Musculoskeletal System – Subheadings • general • Head to toe – Fracture codes most common

Surgical Coding (cont. ) • Respiratory System – Code to furthest extent of the procedure – Approach • Scope • Incision – Incision vs. excision codes – Repair procedures • Cardiovascular System – Complicated coding – Read instructions carefully – Sequence codes correctly

Surgical Coding (cont. ) • Hemic/Lymphatic Systems and Mediastinum and Diaphragm • Digestive System – Upper – Lower • Urinary System – Kidneys and renal function – Diagnostic and therapeutic procedures – Laparoscopy vs. incision

Surgical Coding (cont. ) • Male Genital System • Female Genital System/Maternity and Delivery • Nervous System – Subheadings by anatomic sites – Subdivided by procedure – Specialized guidelines • Endocrine System

Surgical Coding (cont. ) • Eye and Ocular Adnexa – Highly specialized procedures – Read instructions and guidelines carefully • Auditory System • Radiology – Diagnostic and therapeutic procedures – Read all includes and excludes carefully

Surgical Coding (cont. ) • Laboratory Procedures – panels • Medicine and Immunizations – Two codes • Procedure • Vaccine or toxoid

Using the CPT Manual • Become familiar with guidelines and notes for each section • Find the procedures and services provided by the office • Determine appropriate codes – E/M sections – Alphabetic listing – Check all codes listed

Using the CPT Manual • Determine appropriate modifiers – Required if available – Enhance reimbursement • Enter codes and modifiers on CMS-1500 form – Primary procedure first and match with appropriate diagnostic code – All other procedures matched with appropriate diagnostic code

The HCPCS Coding Manual • Health Care Common Procedure Coding System • Use for coding services for Medicare patient • HCPCS Level I codes – CPT codes

The HCPCS Coding Manual (cont. ) • HCPCS Level II codes – National codes for supplies and DME – Cover services and procedures not in CPT – 5 characters ~ numbers, letters, or a combination of both – Modifiers

The HCPCS Coding Manual (cont. ) • Coding procedures – Locate service in the Alphabetic Index – Verify description in the alphanumeric Index – Choose code that matches service, procedure, or item supplied – Enter on CMS-1505 form or into the billing program

Coding Compliance • Physician – ultimate responsibility Submit correct claims – Help ensure maximum appropriate reimbursement • Claims must comply with – Federal and state law – Payer requirements

Code Linkage • Analysis of the connection between diagnostic and procedural information to evaluate medical necessity

Code Linkage (cont. ) • Codes are checked against the medical documentation • Coding audit: – Are codes appropriate and is each coded service billable? – Is code linkage correct? – Have rules ben followed? – Does documentation support services? – Do reported services comply with regulations?

Insurance Fraud • Investigators look for patterns such as – Reporting services that were not performed – Reporting services at a higher level – Performing and billing for procedures not related to the patient’s condition and therefore not medically necessary

Insurance Fraud (cont. ) • Patterns (cont. ) – Unbundling – Reporting the same service twice • Copayments – Waiver may violate payer policies – Ensure policies are consistent with law and requirements of payers

Compliance Plans • Process for finding, correcting, and preventing illegal medical practices • Goals of compliance plan – Prevent fraud and abuse – Ensure compliance with applicable laws – Help defend physicians if investigation occurs

Compliance Plans (cont. ) • Developed by a compliance officer and committee who also: – Audit and monitor compliance with government regulations – Develop consistent written policies and procedures – Provide ongoing staff training and communication – Respond to and correct errors

The End