CHAPTER 7 CPT Coding.

CHAPTER 7 CPT Coding

Introduction Chapter 7:
Introduces assignment of Current Procedural Terminology CPT: Services and procedure codes reported on insurance claims

Overview of CPT CPT Provides a list of identifying and descriptive codes for reporting procedures and medical services Uniform language that describes medical, surgical procedures and services

Overview of CPT CPT codes are used to report services and procedures
Submitted as claims with linked ICD-9-CM codes Codes justify need for service or procedure

Overview of CPT Changes to CPT CPT supports electronic data
Exchange (EDI), Computer-based patient Record (CPR), or electronic medical Record (EMC) and reference/research database

Overview of CPT Improvements to CPT are underway In 2002
AMA completed the CPT 5 Project, resulting in the establishment of three categories of CPT codes

Overview of CPT Category 1
Procedures/services identified by a five digit CPT code and descriptor nomenclature Codes traditionally associated with CPT organized in six sections

Overview of CPT Category 2
Contain “performance measurements” tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A) Codes located after Medicine section Use is optional

Overview of CPT July 2007 New program from Medicare utilizing these codes to justify documentation “PQRI’s” will begin a project for physicians’ practices Will receive additional percentage of revenue for documentation compliance

Overview of CPT Category 3 codes
Contain “emerging technology” temporary codes assigned for data purposes and assigned in alphanumeric with the letter in the last position

Overview of CPT Field 0001T Codes are located after Medicine section
Archived after five years unless accepted for placement

CPT Sections Category I procedures and services
Evaluation and Management (E/M) Anesthesia ( , ) Surgery ( )

CPT Sections Radiology (70010-79999)
Pathology and laboratory ( ) Medicine ( , )

CPT Sections CPT code number format
Five-digit number and description identifying each procedure and service listed in CPT

CPT Sections CPT Appendices
CPT contains appendices located after the Medicine section and Index Insurance specialist should become familiar with changes that affect the practice

CPT Appendix Description
Appendix A Detailed description of each CPT modifier Appendix B Annual CPT coding changes Added, deleted, revised CPT codes

Appendix C Clinical examples for evaluation and Management (E/M) section codes Appendix D Add-on codes

Appendix E Codes exempt from modifier -51 reporting rules Appendix F CPT codes exempt from modifier -63 reporting rules Appendix G Summary of CPT codes that include moderate (conscious) sedation

Appendix H Alphabetic index of performance measures by clinical condition or topic Serves as a crosswalk to the category II Appendix I Genetic testing code modifiers

Appendix J Electro diagnostic medicine listing of sensory, motor, and mixed nerves

There is also a table that indicates “type of study and maximum of studies” Generally performed for needle electromyogram (EMG) Nerve conduction studies Other EMG studies

Appendix L List of vascular families that is intended to assist in selection of first, second, third, and beyond third-order branch arteries Appendix M Crosswalk of deleted to new CPT codes

CPT Symbols Symbols are located throughout CPT coding book
Bullet located to left of a code number Identifies new procedures and services added to CPT

CPT Symbols Triangle located to left of a code number
Identifies a code description that has been revised

CPT Symbols Horizontal triangles Surround revised guidelines and notes
Not used for revised code descriptions To save space in CPT Code descriptions are not printed in their entirety next to a code number

CPT Symbols Plus sign Identifies add-on codes
For procedures that are commonly, but not always, performed at the same time and by the same surgeon

CPT Symbols Circle with a line through it Bull’s-eye symbol
Identifies codes that are not to be used with modifier Bull’s-eye symbol Indicates a procedure that includes moderate sedation

Guidelines Located at beginning of the CPT section
Should be reviewed each year before attempting to code from this section Guidelines define and explain the assignment of codes, procedures, and services in a particular section

Unlisted Procedures/Services
Unlisted procedure or service Codes are assigned when a procedure or service is performed by a provider for which there is no CPT code

Special Report When an unlisted procedure or service code is reported

Special Report Narrative document must accompany claim to describe nature and extent of the need of service or procedure Some practices place in Box 19 of CMS 1500 claim form the “unlisted code = the closest related code of XXXXX.”

Notes Instructional notes are found throughout

Blocked unindented note: Located below a subsection title and contains instructions that apply to all codes

Indented parenthetical note: Located below a subsection title, code description, or code description that contains an example Highlight and understand each of these notes

CPT Modifiers Clarify services and procedures performed by providers
Have always been reported on claims submitted for provider office services and procedures

CPT Modifiers Coding tip:
List of all CPT modifiers with brief descriptions is located inside front cover of coding manual

CPT Modifiers Documented history, examination, and medical decision making Must “stand on its own” to justify reporting modifier -25 with the Evaluation and Management (E/M) code

CPT Modifiers E/M service:
Must be “above and beyond” what is normally performed during a procedure

Coding Procedures and Services
Step 1: Read introduction in CPT coding manual Step 2: Review guidelines at beginning of each section Step 3: Review procedure

Step 4: Refer to CPT index Locate main term for procedure or service documented Main terms can be located by referring to the following:

a. Procedure or service documented b. Organ or anatomic site c. Condition documented in the record d. Substance being tested

Synonym (term with similar meaning) Eponym (procedures and diagnoses named for an individual) Abbreviation

Step 5: Locate sub terms and follow cross references Step 6: Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements

Step 7: Assign applicable code number and any add-on (+) or additional codes needed to accurately classify statement being coded

Surgery Section Surgery section is organized by body system
Some subsections are further subdivided by procedure categories

Surgery Section Incision Excision Introduction or removal
Repair, revision, or reconstruction Grafts

Surgery Section Suture Other procedures

Code Surgeries Properly
Three questions must be asked: What body system was involved? What anatomic site was involved? What type of procedure was performed? Carefully read the procedure outlined in the operative report

Evaluation and Management
Located at the beginning of CPT because these codes describe services most frequently provided by physicians Before assigning E/M codes Make sure you review guidelines and apply any notes

For established patients Two of three key components must be considered

E/M code reported to a payer Must be supported by documentation in the patient’s record

Key Components E/M code selection is based on three key components:
Extent of history Extent of examination Complexity of medical decision making All key components must be considered when assigning codes for new patients

Extent of Examination Physical examination is an assessment of the patient’s organ and body system/s

Extent of Examination Categorized according to four types:
Problem focused examination Expanded problem focused examination Detailed examination Comprehensive examination

Complexity of Medical Decision Making
Complexity of establishing a diagnosis and/or selecting a management option as measured by the: Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality

Patient’s Records Should Include
Laboratory, imaging, and other test results that are significant to the management of the patient care List of known diagnoses as well as those that are suspected Opinions of other physicians who have been consulted

Patient’s Records Should Include
Planned course of action for the patient’s treatment Review of patient records obtained from other facilities

History and Examination
Determined by: Straightforward Low complexity Moderate complexity High complexity

History and Examination
Once the extent of history, extent of examination, and complexity of medical decision making are determined Select the appropriate E/M code

Presenting Problem CPT defines nature of the presenting problem as “a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.”

Presenting Problems Minimal Self-limited or minor Low severity
Moderate severity High severity

Face-to-Face Time Amount of time the doctor spends with the family or the patient

Unit/Floor Time Amount of time the doctor spends at the patient’s bedside and at the management of the patient’s care.

E/M Time Claiming E/M on time you must have:
Total length of time for the encounter Plus the length of time spent coordinating care and/or counseling patient Issues discussed Relevant history, exam, and medical decision making

Observation Services Are furnished in a hospital outpatient setting
Patient is considered an outpatient They are reimbursed only when the doctor orders it

Subcategories Include
Observation care discharge services Initial observation care

Hospital Inpatient Services
E/M services provided to hospital inpatients, including partial hospitalization services.

Initial hospital care Subsequent hospital care Observation care services Hospital discharge services

Consultations Type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem requested by another physician or other appropriate source.

Criteria Consultation is requested by another doctor or provider
Consultant renders an opinion or advice

Criteria Consultant initiates diagnostic or therapeutic services.
Requesting physician documents in the patient’s record, the request, and the need for the consultation.

Criteria Consultant’s opinion, advice, and any services rendered are documented in the patient’s record These are reported to the requesting physician or source

Office or other outpatient consultations Inpatient consultations

Emergency Department Services
Are given in a hospital setting that is open 24 hours to provide services that are not scheduled.

Critical Care Services
When a doctor provides services to someone who is critically ill or injured. The doctor should document the total time spent delivering critical care services Excluding time for allowable services

Neonatal A neonate is a newborn up until 28 days, and an infant is 29 days to a year old.

Subcategories Inpatient pediatric critical care
Inpatient neonatal critical care Continuing intensive care services

Nursing Facility Services
Are provided at nursing facilities: Skilled nursing, intermediate care, and long-term care

Subcategories Initial nursing facility care
Subsequent nursing facility care Nursing facility discharge services Other nursing facility services

Prolonged Services May be reported when a doctor’s services involving patient contact are considered beyond the usual service in either an inpatient or outpatient setting.

Subcategories Prolonged physician service with direct face-to-face
Prolonged physician services without face-to-face Physician standby services

Newborn Care Includes services provided to newborns in a variety of health care settings.

Qualifying Circumstances for Anesthesia
When situations or circumstances make anesthesia administration more difficult and increases the patient’s risk factor.

Physician Status Modifiers
Each “status modifier” Reported with an anesthesia code to indicate the patient’s condition at the time anesthesia was administered.

Modifiers P1 P2 P3 Normal health Mild systemic disease
Severe systemic disease

Modifiers P4 Severe systemic disease that is a constant threat to life P5 Not expected to survive without the operation P6 Declared brain-dead and whose organs are being removed for donor purposes

Anesthesia Time Units Be sure to record the time with the anesthesiologist Anesthesia time unit is one 15-minute increment

Calculating Anesthesia
Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesia Nonmonitored interval time Recovery room time Routine postoperative evaluation by the anesthesiologist or CRNA

Separate Procedure Follows a code explanation identifying procedures that are an important part of an additional procedure or service.

Complete Procedure When the word “complete” is established in the code definition One code is reported to “completely” explain the procedure performed

Pathology and Laboratory
Organized according to the kind of pathology or laboratory procedure performed

Pathology and Laboratory Subsections
Organ or disease oriented panels Drug testing Therapeutic Drug Assays Consultations (Clinical Pathology) Urinalysis, chemistry, hematology and coagulation immunology Microbiology

Pathology and Laboratory Subsections
Anatomic pathology Cytopathology and cytogenetic studies Surgical pathology Transcutaneous procedures Other procedures Reproductive medicine procedures

National Correct Coding Initiative
To encourage national correct coding, methodologies, and manage the improper assignment of codes.

National Correct Coding Initiative
Incorrect coding Results in inappropriate repayment of Medicare Part B claims Centers for Medicare and Medicaid Services implemented the National Correct Coding Initiative

NCCI Coding Policies Analysis of standard medical and surgical practice Coding conventions included in CPT Coding guidelines developed by national medical specialty societies Local and national coverage determinations Review of current coding practices

CHAPTER 7 CPT Coding.

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CHAPTER 7 CPT Coding.

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