1. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

2. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Medical Coding Transforms services/procedures/ supplies/drugs into CPT/HCPCS codes Transforms diagnosis and procedures into diagnosis codes

3. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Levels of Service Codes Level I CPT—(Category 1: 99201-99607, Category III: 0017T-0259T) Level II HCPCS, National Codes—(A0021- V5364) Level III Local Codes—phased out due to HIPAA

4. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Diagnosis Codes ICD-10-CM/ICD-9-CM International Classification of Diseases, 10th revision, Clinical Modification International Classification of Diseases, 9th revision, Clinical Modification

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Why Codes? Computers understand numbers Specific descriptions attached to each code

6. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 CPT Developed by the AMA in 1966 Updated in November for use January 1 Divided into Category I, II, and III codes

7. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Examples of Types of CPT Codes Medical Surgical Diagnostic services Anesthesia, etc. Category II and Category III codes—alpha numeric –Category II = performance measuring –Category III = emerging technology

8. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 CPT Codes Allow For Communication that is both effective and efficient A mechanism to report a service not described by a specific CPT or Level II code

9. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Consider Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) OR 50575

10. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Codes Are Used to tell third-party payers about services/procedures provided Often used as basis of payment

11. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Incorrect Coding Results in providers being paid inappropriately –Either over or underpayment –Decreases cash flow –Liability risk

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Codes Are Used By Clinics Hospitals Rehabilitation units Ambulance services Long-term care Wherever health care services are provided

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Outpatient Services for Physicians Reported on insurance form CMS-1500 = universal form

14. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 CMS-1500 Figure: 13.1 (Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.)

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 CPT Format Symbols in CPT Used to convey information Bullseye, moderate (conscious) sedation included (full list in Appendix G, CPT) –Example 45391, Colonoscopy with endoscopic ultrasound examination Lightning bolt, pending FDA approval (Appendix K, CPT) –Example 90650, Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Pound Symbol (#) = resequenced code Bullet = New Code Figure: 13.2 Figure: 13.9

17. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 ▲Triangle = Revised Code Figure: 13.3

18. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 ►◄ Right and Left Triangles = Beginning and Ending of Text Change Figure: 13.4

19. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 + Plus = Add-On Code Figure: 13.7

20. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Add-On Code (…Cont’d) Can only be used with another specific code Never used alone No reduction for multiple services Full list in Appendix D of CPT

21. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 =Circle With Line,-51 Cannot Be Used With these Codes CPT Appendix E contains a listing of -51 exempt codes Services typically exempt from multiple procedure reductions Figure: 13.8

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22  Circle = Recycled or Reinstated Code Circle symbol identifies codes previously published in CPT

23. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Appendices of CPT Appendix A: Modifiers Appendix B: Additions, Deletions, Revisions Appendix C: Clinical Examples, E/M Codes Appendix D: Add-On Codes Appendix E: -51 Exempt Codes Appendix F: -63 Exempt Codes Appendix G: Include Moderate (Conscious) Sedation (Cont’d…)

24. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 (…Cont’d) Appendix H: Performance Measures, Category II Codes, on website Appendix I: Genetic Testing Modifiers Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix K: Product Pending FDA Approval Appendix L: Vascular Families Appendix M: Crosswalk to Deleted CPT Codes Appendix N:Summary of Resequenced CPT Codes Appendices of CPT

25. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Six CPT Sections (like chapters) 1.Evaluation & Management (E/M) 2.Anesthesia 3.Surgery 4.Radiology 5.Pathology & Laboratory 6.Medicine Category II Codes Category III Codes Appendices A-M Index

26. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Categorized By Sections Subsections Subheadings Categories (Cont’d…)

27. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Categorized By (…Cont’d) Anatomy –Knee or Shoulder Procedure –Incision or Excision Condition –Fracture or Dislocation Description –Cast or Strap Surgical Approach –Anterior Cranial Fossa or Middle Cranial Fossa (Cont’d…)

28. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Categorized By, Example Figure: 13.6 (…Cont’d)

29. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Guidelines Section-specific information begins each section Figure: 13.10

30. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Notes Must-reading located throughout the CPT Figure: 13.12

31. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Two Types of Codes Stand-alone: Full description Indented: Dependent on preceding stand-alone –Verbiage before the semicolon applies to all indented codes that follow

32. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Types of Codes, Example Figure: 13.14

33. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Semicolon Indicates full description in preceding code You must return to the stand-alone for full description

34. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 Modifiers Add Information CPT Modifier Two digits –62 Two surgeons performed a surgical procedure –Each surgeon applies his/her individual skill –Each surgeon bills the procedure with modifier -62

35. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 Level II HCPCS Modifiers “-AS” Physician’s Assistant “-F1” Left hand, second digit All modifiers used on CPT or HCPCS

36. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Example of Modifier 43820 Gastrojejunostomy -62 two surgeons -43820-62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity

37. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 Modifiers are placed in 24D on CMS-1500 or 837 Modifier on the CMS-1500

38. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Unlisted Services Codes ending in “99” = “no specific Category I or III code” Used if no more specific code Special report must accompany submission

39. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 Special or Written Report Indicates: Nature Extent Need Time Effort Equipment Used Photos and medical journal articles if relevant

40. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Category I Codes Category I codes (00100–99607) –Approved by AMA and Food and Drug Administration –Proven clinical effectiveness (efficacy)

41. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Category II Codes— Supplemental Tracking Codes Used for performance measurements Codes collect data concerning quality of care and test(s) required Alphanumeric and end in the letter “F” (1006F) Location AMA Website

42. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42 Category III Codes— New Technology Temporary codes—up to _ years Identify emerging technology, services, and procedures Located after Medicine section Alphanumeric (0016T) –May or may not receive future Category I code status 5

43. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Category III Codes Category III codes have not been approved and have no proven clinical effectiveness Usage order –Use Category III code instead of unlisted code –Use unlisted code if no Category III code

44. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44 The Index! Used to locate service/procedure terms and codes Speeds up code location Like a dictionary First entries and last entries

45. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 45 CPT Index Figure: 13.18

46. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 46 Presentation of Codes in Index Single code: 38115 Multiple codes: 26645, 26650 - Note comma Range of codes: 22305-22325 - Note hyphen

47. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 47 1.Service/procedure: repair, excision 2.Anatomic site: median nerve, elbow 3.Condition or disease: cleft lip, clot 4.Synonym: toe and interphalangeal joint 5.Eponym: Jones procedure, Heller operation 6.Abbreviation: ECG, PEEP (Pressure Breathing, Positive) Location Methods with Examples

48. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 48 Always Reference index Locate code in main portion of CPT Read the entire description and any notes

49. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 49 “See” in Index Cross-reference terms –“Look here for code” Index: Stem, Brain: See Brainstem

50. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 50 HCPCS Healthcare Common Procedure Coding System Developed by Centers for Medicare and Medicaid Services (CMS) –Formerly HCFA HCPCS developed in 1983 CPT did not contain all codes necessary for Medicare services reporting

51. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 51 Levels of Codes Level I: CPT Level II:HCPCS, also known as national codes Level III: Local codes (phased out) due to HIPAA

52. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 52 Level III, Local Codes Developed by Medicare carriers for use at local level Varied by locale Discontinued December 31, 2003 –Some codes incorporated into HCPCS Level I and II

53. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 53 Level II: National Codes Codes for wide variety of providers –Physicians –Dentists –Orthodontists –Temporary codes for Medicare (Cont’d…)

54. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 54 Level II: National Codes (…Cont’d) Codes for wide variety of services –Specific drugs –Durable medical equipment (DME) –Ambulance services

55. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 55 HCPCS Gains Popularity Many payers require Each year increased number of HCPCS codes –J0585—Botox, per unit

56. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 56 Format Begins with letter, followed by four digits –Example: E0618, apnea monitor Each letter represents group of codes –Example: “J” codes used to report drugs and dosage

57. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 57 Temporary Codes Certain letters (G, K, Q, S, H, T) indicate temporary codes –Example: K0006 heavy duty wheelchair Code books published every January –But codes added, deleted, and revised throughout the year –Notified through carrier bulletins

58. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 58 Coverage Just because item/service has HCPCS code does NOT mean service covered –Example: –V5130, binaural hearing aid –Not covered under Medicare From Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, editors: Cummings Otolaryngology-Head & Neck Surgery, ed 4, Philadelphia, 2005, Mosby.

59. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 59 Where HCPCS Are Used Outpatient settings –Including outpatient departments in hospital Level I and II used to report outpatient services to certain payers

60. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 60 HCPCS Index Directs to specific codes Do not code directly from index Reference main portion text before assigning code See Figure 13–22 in textbook (Cont’d…)

61. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 61 HCPCS Index Alphabetical order (Cont’d…) (…Cont’d) Figure: 13.22 Modified from Buck CJ: 2012 HCPCS Level II Professional Edition, St. Louis, 2012, Saunders.

62. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 62 HCPCS Index Main text display (…Cont’d) Figure: 13.27 Modified from Buck CJ: 2012 HCPCS Level II Professional Edition, St. Louis, 2012, Saunders.

63. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 63 HCPCS Modifiers CPT and HCPCS modifiers used with both HCPCS and CPT codes Figure: 13.25 Modified from Buck CJ: 2012 HCPCS Level II Professional Edition, St. Louis, 2012, Saunders.

64. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 64 Anatomical Modifiers F1Left hand, second digit F2Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit FA Left hand, thumb F5Right hand, thumb F6Right hand, second digit F7Right hand, third digit F8Right hand, fourth digit F9Right hand, fifth digit

65. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 65 Often Used HCPCS Modifiers LT Left RT Right Example: Right kidney biopsy, 50200-RT Left kidney biopsy, 50200-LT

66. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 66 Ambulance Modifiers Origin and destination used in combination: –First letter: Origin –Second letter: Destination –Example: R = Residence H = Hospital RH: origin (first letter) residence and destination (second letter) hospital

67. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 67 Table of Drugs Listed by generic name Modified from Buck CJ: 2012 HCPCS Level II Professional Edition, St. Louis, 2012, Saunders. Figure: 13.26

68. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 68 Durable Medical Equipment DME Used with chronic disabling condition Medicare and Medicaid pay for some DME items Physician must attest to need using Certificate of Medical Necessity

69. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 69 Home Oxygen Therapy Medicare may also pay for oxygen with certain medical conditions Physician must complete form (CMS-484) attesting to medical necessity

70. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 70 Conclusion CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)