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 Anesthesiology – – Surgery – Radiology – Pathology and Laboratory – Medicine – – 99602

E&M Codes Initial Visit CodeHistoryExamFace to Face Time 99201Problem FocusedProblem focused10 minutes 99202Expanded problem focused 20 Minutes 99203Detailed30 Minutes 99204Comprehensive45 minutes 99205Comprehensive60 minutes

E&M Follow up CodeHistoryExamFace to Face time 99211Not required5 minutes 99212Problem focused10 minutes 99213Expanded focused15 minutes 99214Detailed25 minutes 99215Comprehensive40 minutes

E&M Treatment codes CodeExplanationMinutesUnits 97800AcupunctureN/A Acupuncture with Electrical stimulation N/A CuppingN/A MoxibustionN/A Hot or cold packs applied to one or more areas N/A Infrared therapyHeat Lamp Manual therapyTui Na (15 minutes) Therapeutic exercise 15 minutes Therapeutic massage 15 minutes1

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

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

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

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 Endocrine System Nervous System –Subheadings by anatomic sites –Subdivided by procedure –Specialized guidelines

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