1. Basics of Procedural Coding
Copyright, 1996 © Dale Carnegie & Associates, Inc.

2. Getting to know the CPT-4
Current Procedural Terminology
published by the AMA
used to identify and class provider visits and procedures

3. Format of the CPT
Symbols - top of - serve as instructional notes - always look to the bottom of the page to see what the symbol means
Sections - CPT is broken down in sections based on types of visits and procedures
there are detailed instructions for using each section at the beginning of the section

4. Sections Cont.
Evaluation & Management codes are in the front of the CPT book and cover physician services
Anesthesia codes cover all anesthesia services
Surgery codes are further divided by the type of surgery - must know the definition of the surgical package (surgery plus routine follow-up care for 90 days)
Radiology codes cover x-ray diagnostic procedures

5. Sections Cont.
Pathology and Laboratory codes cover tests an pathologist services - some tests are grouped in to panels
Medicine codes cover many services that aren’t covered elsewhere like immun-izations, psychiatry, physical therapy
Classifications of Sections
Section is the large grouping
Subsection better defines the section
Subheading defines the subsection
Category directs to the specific procedure

6. Sections Cont. Classifications of Sections Example Section: Surgery
Subsection: Integumentary
Subheading: Skin; subcutaneous and accessory structures
Category: Incision and drainage of abscess, CPT code 10060*
The * symbol indicates surgical
procedure only

7. Steps in CPT coding Know the CPT book - changes every year
Review all services and procedures performed at the visit - include all medications administered and trays and equipment used
Find the procedures and/or services in the index - will direct you to a code
Read the description and any related items - these will lead you to the most accurate code

8. Steps in CPT coding Cont.
If the service is an E&M code identify the following:
New or established patient
Consultation or not
Where the service was performed
Modifiers
found in Appendix A
explain circumstances that alter a service - help to clarify what exactly occurred

9. Understanding Evaluation and Management
Factors Considered in E&M Coding
Type of service - well or sick visits, case management, preventive medicine
Place of service - where service occurred
Patient status - new or established

10. Levels of E&M Services
Based on 3 factors - history, medical decision making, and examination
History
Problem focused - concentrates on the chief complaint - symptoms, severity and duration of problem - no ROS or family and social Hx
Expanded problem focused - includes ROS in relation to the CC - no past, family and social Hx

11. History Cont.
History
Detailed - more extensive Hx, ROS and pertinent past, family, and social Hx
Comprehensive - documents all components - usually during initial visit with patients who have significant Hx

12. Medical Decision Making
Based on number of diagnoses/ management options, amount and complexity of data reviewed, and risk of complications and morbidity or mortality
Straightforward - minimal diagnosis/management options and data review, minimal patient risk if untreated
Low-complexity - limited diagnosis/ management options and data review, low patient risk if untreated

13. Medical Decision Making Cont.
Moderate-complexity - multiple diagnosis/ management options, moderate data review, and moderate risk to the patient if untreated
High-complexity - Extensive diagnosis/ management options and data review, high patient risk if untreated

14. Examination
Objective part of the visit includes body areas and organ systems
Body areas - head (face and neck), chest (breasts and axillas), abdomen, GU, back (spine and extremities)
Organ systems - constitutional, eyes, ear/nose/throat and mouth, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, hematological/lymphatic/ immunologic

15. Examination Cont.
Problem-focused - limited to the single body area or system mentioned in the CC
Expanded problem-focused - related body areas or systems also examined
Detailed - extended exam is performed on the related body areas or systems
Comprehensive - complete multisystem exam is performed

16. Putting it all together to determine the code
Determine if patient is new or established
Where is patient being seen?
Patient of practice or consultation?
Sick or preventative services?
History level
Exam level
Medical decision making level
Pick the code