1. CPT GUIDELINES REVIEW
Marsha S. Diamond, CPC, COC, CCS, CPMA, AAPC Fellow
Greater Orlando AAPC Chapter
July 17, 2018

2. Cpt layout
How To Maximize Your Use of CPT

3. FINDING THE CORRECT CODE
Determine appropriate chapter
Evaluation and Management Visits/Encounters/”Face-to-face”
Anesthesia “Without Feeling”
Surgery Definitive/Restorative/Invasive
Radiology Imaging
Pathology Study of diseases, bodily substances
Medicine Diagnostic/Therapeutic
Determine type/location
EX:
E/M Office/Hospital
Surgery Anatomical System (i.e. Integumentary)
Determine specific type
E/M New/Established
Surgery Anatomical Part (i.e.Skin)
Specific Procedure
E/M Level 1
Surgery Incision/Excision/Repair/Introduction
(See details on CPT Coding Steps for additional information)

4. CORRECT CODING STEPS
Determine procedure(s) performed (from appropriate documentation)
Assign appropriate code(s)
Determine if any procedure(s) bundled and eliminate code(s)
Sequence codes correctly
Assign modifier codes as appropriate

5. BASIC CPT CODING CONCEPTS
Concepts for Coding Correctly in CPT

6. Global procedures
What’s Included??

7. GLOBAL PROCEDURES DEFINITION: Major Surgery: Preoperative period 1 day
Those procedures that follow a predetermined outline that specifically addresses services necessary to complete a surgical package, including preoperative and postoperative care
MEDICARE GUIDELINE (and other applicable carriers)
Major Surgery: Preoperative period 1 day
Postoperative: 90 days or more
Minor Surgery: Preoperative period day of the procedure
Postoperative: 0 or 10 days depending upon procedure
Refer to Medicare Physician Fee Schedule Data Base at:
Other carriers utilize RBRVS (Resource Based Relative Value Study)

8. GLOBAL PROCEDURES Preoperative Care Intra-Operative Services/Surgery
Visits or care provided up to one day before of day of the surgical procedure.
Some carriers allow for “decision for surgery” during this timeframe
Intra-Operative Services/Surgery
Cleaning, shaving, prep
Draping, positioning of patient
Insertion IV access
Sedation or anesthesia administered by physician performing surgery
Surgical approach
Surgical cultures
Wound irrigation
Insertion/Removal of drain
Surgical closures/dressing
Surgical supplies
Documentation and photographs
Normal, uncomplicated postoperative care
Services defined as follow-up visits/services related to recovery from surgery. (Medicare only allows addtl service during postoperative period if requires return to OR)

9. GENERAL CONCEPT FOR GLOBAL
Surgical procedures are considered:
Invasive
Restorative
Definitive
Codes should be assigned for these services only

10. Bundling/ unbundling

11. DEFINITIONS
Bundling: The grouping of all procedures necessary to perform the definitive, restorative procedure Unbundling: The “ungrouping” of all procedures necessary to perform the definitive, restorative procedure EX: Laparoscopic cholecystectomy was attempted, however, unsuccessful Open cholecystectomy was subsequently performed during surgical encounter Only the surgical cholecystectomy codeable as it was the definitive procedure

12. Examples of Services Typically “Bundled” (Not separately reportable)
Administration of fluids/drugs during operative period
Biopsy performed after procedure for evaluation
Exposure/exploration of surgical field
Access through diseased tissue to definitive surgical procedure
Debridement of skin to repair fracture
Elimination of “Incidental” pathology in removal, destruction of elimination of lesion
Excision/Removal includes Incision/Opening
Procedure approach that fails

13. Services that May be Separately Reportable (Modifiers may be necessary)
More invasive vascular access than usually req for admin of drugs/medicines
(Ex: Insertion of central venous access device)
Diagnostic biopsy is utilized to determine whether to proceed with another procedure
Diagnostic endoscopy is utilized to determine whether to proceed with open procedure. Endoscopic procedure is separately reportable IF documentation substantiates necessity for diagnostic endoscopic procedure
Treatment for underlying condition or added course of treatment not related or part of normal recovery from surgical procedure
Treatment for postoperative conditions requiring return to Operating Room

14. How Can I Determine if Services Bundled?
National Correct Coding Initiatives (NCCI)
Instituted by CMS/Medicare
Based on coding conventions outlined in CPT
Provide additional information regarding procedures included/excluded in global procedures
NCCI MANUAL – Column 1/Column 2 Edits 0 = Not Allowed
Column Column = Allowed
Separate Procedure Definition
Indicates never allowed with (45378 is designated as “sep procedure”)
More extensive procedure
Indicates may be allowed with in appropriate instances

15. General NCCI Coding Concepts
One repair method only reported for single organ/body part
When one repair method fails, only the successful method is reportable
Do not report multiple CPT codes when a single comprehensive code is available
Do not fragment procedure into component parts
Do not unbundle a bilateral procedure into two (2) unilateral procedures
Do not unbundle services that are integral to a more comprehensive procedure
Only code the most extensive services such as:
Simple procedures included in those described as complex
Simple procedures included in those described as complicated
Superficial procedures included in those described as deep
(See NCCI procedures, General Definitions)

16. SEPARATE PROCEDURE

17. Separate Procedure DEFINITION:
Codes designated in CPT as “separate procedures” cannot be reported when the procedure is an integral component of another.
NCCI states:
CPT codes designated as “separate procedure“ may not be reported when performed with another procedure in an “anatomically related region” often through the same incision, orifice or surgical approach.
(NCCI, Narrative, General Correct Coding Policies)
Only time a CPT designated as “separate procedure” may be utilized is when it is the only (i.e. separate) procedure performed

18. WHAT WOULD YOU ASSIGN? EX: Colonoscopy CPT Code 45378
Colonoscopy with Snare Polypectomy CPT Code 45385
Colonoscopy with Biopsy, Separate Lesion CPT Code 45380
(CPT Code designated as “separate procedure” therefore not codeable
CPT Code to separate lesion, therefore, codeable with modifier 59)
TRY THIS ONE:
Diagnostic Knee Arthroscopy CPT Code 29870
Arthroscopic Chondroplasty CPT Code 29877
Arthroscopic Knee Synovectomy CPT Code 29875
Arthroscopic Meniscectomy CPT Code 29880

19. Add on procedures

20. ADD ON PROCEDURES Designated by + sign
Indicates procedures performed on conjunction with a primary procedure
Refer to CPT notations for possible primary CPT codes
Add on codes should NOT be utilized without a primary procedure
No modifier 51 appended to “add on” procedures
EXAMPLE:
Split Thickness Skin Graft, Arm 200 sq cm was performed
Split Thickness Skin Graft, Arms, Legs, First 100 sq cm or less AND
Split Thickness Skin Graft, Arms, Legs, Each Additional 100 sq cm

21. ADD ON PROCEDURES
TRY THIS ONE: Transfer/Repair of 3 anterior tibial extensor tendons CODE ASSIGNMENT:

22. Each, each addtl, per

23. EACH, EACH ADDITIONAL, PER
Assigned in units rather than line item on CMS-1500
EXAMPLE:
Destruction 5 premalignant lesions
Destruction premalignant lesion, first lesion
17003X4 Destruction premalignant lesion, 2-14 lesions each
No modifier 51 needed for X 4
Code would never be utilized without the primary code 17100

24. TRY THIS ONE:
Prolonged Services on patient on outpatient basis for a total of 1 hour 45 minutes CODE ASSIGNMENT(S):

25. UNLISTED

26. UNLISTED CPT CODES
Should only be utilized when no other procedure available
Operative report will probably be necessary for carrier to determine appropriate payment
Carrier will review claim and assign payment based on procedure as procedure that is approximately the same complexity

27. modifiers

28. MODIFIERS
Means by which provider indicates service/procedure altered in some fashion
The two –digit modifier describes what that modification was, and is utilized by third-party carriers to determine any modification(s) in payment
May be utilized in when following conditions met:
Service greater/less than usually provided with CPT code descriptor
Documentation to substantiate must be present
Service would typically not be paid by carrier
Adjustments to charges should NOT be made, that will be determined by carrier
Modifier 59 (distinct procedural services) should only be utilized when a more appropriate modifier is not available
When more modifiers are necessary than can be accommodated on the CMS-1500, assign modifier 99 and then on the next line of the claim indicate the modifiers in the correct sequencing
Sequencing of modifiers should be in order of most significant to reimbursement
EXAMPLE: Modifier 51 would be sequenced before RT
General rule: Numeric modifiers before Anatomical Modifiers for sequencing

29. MODIFIER USAGE Anatomical Modifiers RT Right side LT Left side
50 Bilateral
TA Left Foot, Great Toe T5 Right Foot, Great Toe
T1 Left Foot, second digit T6 Right Foot, second digit
T2 Left Foot, third digit T7 Right Foot, third digit
T3 Left Foot, fourth digit T8 Right Foot, fourth digit
T4 Left Foot, fifth digit T9 Right Foot, fifth digit
FA Left Hand, Thumb F5 Right Hand, Thumb
F1 Left Hand, second digit F6 Right Hand, second digit
F2 Left Hand, third digit F7 Right Hand, third digit
F3 Left Hand, fourth digit F8 Right Hand, fourth digit
F4 Left Hand, fifth digit F9 Right Hand, fifth digit
Assigned only when anatomical descriptor in CPT code pertains only to a site that has those specific entities
Not assigned to skin, as skin is one organ
Not assigned to CPT descriptors that indicate more than fingers/toes such as
descriptors that include hand, fingers, toe, foot, arm, legs

30. Anatomical Modifiers Specific to Specialized Areas:
E1 Upper left eyelid E2 Lower left eyelid E3 Upper right eyelid E4 Lower right eyelid LC Left circumflex coronary artery LD Left anterior descending LM Left main coronary artery RC Right coronary artery See HCPCS modifier listing for complete listing

31. Numerical CPT Modifiers
Unusual Procedural Services
Unusual Anesthesia Services
Unrelated E/M during Global/Postoperative Period by Same Provider
Significantly, Separately Identifiable E/M on Same Day as Procedure
Professional Component only
Mandated Services
Preventive Services
Anesthesia Services Performed by Surgeon
Bilateral Services
Multiple Procedures
Reduced Services
Discontinued Procedure
Surgical Care Only
Postop Care Only
Preop Care Only

32. Numerical CPT Modifiers
Decision for Surgery
Related/Staged Procedure
Distinct Procedure Service
Two Surgeons
Surgery <4 gm infant
Surgical Team
Repeat Procedure Same Physician
Repeat Procedure Different Physician
Return to OR for related Procedure
Unrelated Procedure/Service
Assistant Surgeon
Minimum Assistant Surgeon
Asst Surgeon Qualified Resident Not Available
Outside/Reference Lab
Repeat Pathology Service
Alternative Lab Platform Testing
Multiple Modifiers
(See attached listing for appropriate chapters of CPT codes may be applied)

33. MODIFIER REVIEW Professional vs Technical Component
When procedures have a professional and technical component (such as Radiology) and complete procedure is not performed
Professional component only
TC Technical component only
Not necessary when descriptor indicates professional or technical only
Greater Than/Less Than Usual Services
Unusual Procedural Services
Unusual Anesthesia Services
Reduced Services (less than descriptor in CPT)
Discontinued (physician makes decision to discontinue due to patient’s condition)

34. Modifier Review (continued)
Multiple Surgeons
Two Surgeons (utilize same CPT, 125% of allowance)
Surgical Team
Assistant Surgeon
Minimum Assistant Surgeon
Asst Surgeon due to No Qualified Resident Available
Surgical Package
Surgical Care Only
Post Op Care Only
Preop Care Only
Repeat Services
Repeat Procedure Same Provider
Repeat Procedure Different Provider
Repeat Pathology Services
Must be exact same CPT code/services to utilize

35. Modifier Review (continued)
Anesthesia Services
Unusual Anesthesia Services (greater than usual)
Anesthesia performed by surgeon
E & M
24 Unrelated E/M same physician during global period
Significantly, separately identifiable on same day as procedure
Decision for Surgery
Procedure w/E&M-25 only reportable for new problems evaluated, not condition already dx and patient presenting for definitive procedure (CPT Assistant, 2012)
Multiple Procedures Same Session
Multiple
Distinct, separate
51 (same provider, session, anatomical area, often same incision)
Reimbursement: 100% allowance 1st procedure, 50% 2nd, 25% thereafter
59 (distinct/separate, usually could be performed independently from each other)
Reimbursement: 100% allowance for all procedures

36. Modifier Review (continued)
Global Period Services
Related/Staged Procedure During Global Period
Need for Return to OR Related Procedure During Global Period
Need for Unrelated Procedure During Global Period
Services will be denied if performed in global period and no modifier assigned
Concept of “blocked” procedures during global period

37. Concepts application

38. LAPAROSCOPIC CHOLECYSTECTOMY WITH UMBILICAL HERNIA REPAIR
Laparoscopic Cholecystectomy was performed on a 45 year old male. An umbilical hernia was encountered when placing ports and entering the site, and was repaired at the time of closure. CODE ASSIGNMENT(S):

39. DEBRIDEMENT AND REPAIR OF DISTAL RADIAL FRACTURE
45 year old male that presents for closed repair/reduction of distal radial fracture. Debridement was performed to the fracture area and then the fracture site was opened, repair performed and a short arm splint was applied. CODE ASSIGNMENT(S):

40. Marsha S. Diamond, CPC, COC, CCS, CPMA, AAPC Fellow
QUESTIONS/COMMENTS?
Marsha S. Diamond, CPC, COC, CCS, CPMA, AAPC Fellow
Thank You!