1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 2-1 Chapter 2 Introduction to Coding and CPT

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives 2.1 Explain the purpose of diagnosis coding. 2.2 Explain the purpose of procedure coding. 2.3 Apply correctly the steps to accurate coding. 2-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives (cont.) 2.4 Abstract documentation thoroughly. 2.5 Use official guidelines provided to apply the best, most accurate code. 2.6 Interpret notations and symbols to code accurately. 2-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Abstracting Diagnosis Durable medical equipment (DME) Inpatient Medical necessity 2-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Outpatient Procedure Query Superbill Supporting documentation 2-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Coding Coding is interpreting healthcare terms into alphanumeric codes that specifically relate to diagnoses and procedures. Coding data used by third-party payers to determine payment is known as the reimbursement process. 2-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Medical Necessity The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) is a directory of every diagnosis. Diagnosis codes report the reason why the physician provided the service or treatment. 2-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Medical Necessity (cont.) Diagnosis codes explain the medical necessity of providing the service or treatment. Every procedure code reported must be accompanied by a justifiable diagnosis code. 2-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Procedures, Services, and Treatments Three code sets: –Current Procedural Terminology (CPT) –Healthcare Common Procedure Coding System (HCPCS) Level II –ICD-10-PCS 2-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Procedures, Services, and Treatments (cont.) CPT codes are HCPCS Level I codes. CPT codes are 5 numbers in a row. 2-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Procedures, Services, and Treatments (cont.) HCPCS Level II codes identify durable medical equipment (DME), dental procedures, and certain other services not listed in the CPT book. Level II codes have one letter followed by four numbers. 2-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Procedures, Services, and Treatments (cont.) Inpatient procedures and services are coded using ICD-10-PCS. ICD-10-PCS codes are seven alphanumeric characters. 2-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Seven Steps to Accurate Coding 1.Read the Superbill and the physician’s notes for this encounter completely. 2.Reread the physician’s notes, and highlight key words. 3.Query physicians regarding unclear or missing information. Never assume. 4.Code the diagnosis or diagnoses. 2-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Seven Steps to Accurate Coding (cont.) 5.Code the procedure or procedures as documented by the physician. –Identify the term that describes WHAT action was taken. –Look the main term up in the CPT alphabetic index. –Look up the suggested code or codes in the numerical listing of CPT (Never code solely from the alphabetic index. Verify the code.) 2-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Seven Steps to Accurate Coding (cont.) 6. Link every procedure code to at least one diagnosis code. 7. Double-check your work by back coding. 2-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Coding from Physician’s Notes Review all of these to accurately code for an encounter: –Physician’s notes –Lab reports –Superbill/encounter form –All documentation for that encounter 2-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. CPT Code Book Lists codes used to report services, procedures, and treatment provided by –A physician in either inpatient facilities or outpatient facilities. –An outpatient facility such as an Ambulatory Surgical Center or an emergency department. 2-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Organization of CPT Sections of the main body –Evaluation and Management –Anesthesia –Surgery –Radiology –Pathology and Laboratory –Medicine 2-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Organization of CPT (cont.) Additional components of CPT: –Category II codes –Category III codes –Appendixes A–M –Alphabetic index 2-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Guidelines, Formats, and Notations Guidelines provide rules and directives when assigning codes. Guidelines are found in two places throughout CPT: –In front of each section. –Within each section at the beginning of applicable sub-sections. 2-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Formats CPT codes –51100 …five numbers in a row Category II codes –2001F …four numbers followed by F Category III codes –0208T …four numbers followed by T 2-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations and Symbols See –Directs you to an alternate listing Plus sign (+) –Add-on code (List Separately in Addition to Code for Primary Procedure) –Add-on code (Use... in Conjunction with...) –Add-on code 2-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations and Symbols (cont.) Bullet () = New code Triangle (∆) = Identifies a revised code Sideways triangles (><) = Revised guidelines Bull’s eye  = Includes reimbursement for moderate sedation  = Code that cannot be used with modifier 51 2-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary Healthcare professionals must ensure supporting documentation is complete. Use all seven steps to code accurately. CPT contains codes used to report services, treatments, and procedures. The book includes guidelines for each section, as well as notations, symbols, and references to assist you in reporting the most accurate code. 2-24