The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 2 Introduction to Coding and CPT Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes Explain the purpose of diagnosis coding. Relate diagnosis coding to procedure coding. Apply correctly the steps to coding

Learning Outcomes Use official guidelines provided to apply the best code. Follow the organization of CPT to determine the best code. Comply with notations and symbols to code accurately

Introduction Coding is interpreting health care terms and definitions into numbers or number/letter combinations that specifically relate to diagnoses and procedures

Medical Necessity Diagnosis codes report the reason why the physician provided the service or treatment. Diagnosis codes explain the medical necessity of providing the service or treatment

Procedures Procedure codes report what the physician provided for the patient. –CPT codes –HCPCS Level II codes –ICD-9-CM volume 3 Services, treatments, counseling, surgery, testing, etc

CPT CPT stands for Current Procedural Terminology Developed and maintained by the American Medical Association 2 - 7

Steps to Accurate Coding 1.Read through the notes completely. 2.Highlight key words. 3.Query the physician regarding any confusing, conflicting, or missing information

Steps to Accurate Coding 4.Code the diagnoses. 5.Code the procedures. - Look up key words relating to WHAT the physician provided. - Verify the code’s description. 6.Link every procedure code to at least one diagnosis code

Coding From Physician’s Notes More accurate than coding from a superbill. More complete than coding from a superbill. Official guidelines state that coding should be done from notes and not superbills

CPT Coding Book Report Physician services All procedures performed in an outpatient facility –Physician’s office –Ambulatory care center –Clinic

Organization of CPT Sections of the main body of CPT –Evaluation and Management –Anesthesia –Surgery –Radiology –Pathology –Medicine

Organization of CPT Second part of CPT includes - Category II codes - Category III codes - Appendixes A through I - Alphabetic index

Alphabetic Index Procedures, services, and treatments listed by: Procedure or service Anatomical site Condition Eponym, synonym, or abbreviations

Official Guidelines Guidelines are located: In front of each of the six sections. Within each section, leading into appropriate subsection

Codes Formats CPT codes: Category II: 1000F Category III: 0001T Modifiers:-12 or -A1 HCPCS Level II:A1234 ICD-9-CM Vol

CPT Book Formats Indented information attaches to the description above it….up to the semi-colon ( ;) Bypass graft, with vein; carotid carotid-subclavian The complete description is read: Bypass graft, with vein; carotid- subclavian

Notations See –Directs you to an alternate listing + (plus sign) –Identifies an add-on code (List separately in addition…) –Identifies an add-on code

Symbols (bullet) –Identifies a new code ∆ (triangle) –Identifies a revised code >< (sideways triangles) –Identifies revised guidelines

Symbols  –Identifies a code that includes reimbursement for moderate sedation  –Identifies a code that cannot be used with modifier

Chapter Summary CPT contains thousands of codes used to report services, treatments, and procedures. The book includes guidelines for each section, as well as notations, symbols, and references to assist you in reporting the most accurate code