Copyright © 2008 Delmar Learning. All rights reserved. CHAPTER 7 CPT Coding.

Copyright © 2008 Delmar Learning. All rights reserved.

CHAPTER 7

CPT Coding


2

Introduction

• Chapter 7: – Introduces assignment of Current Procedural

Terminology– CPT:

• Services and procedure codes reported on insurance claims


3

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


4

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


5

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


6

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


7

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


8

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


9

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


10

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


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Overview of CPT

• Field 0001T– Codes are located after Medicine section– Archived after five years unless accepted for

placement


12

CPT Sections

• Category I procedures and services– Evaluation and Management (E/M) 99201-

99499– Anesthesia (00100-01999, 99100-99140)– Surgery (10021-69990)


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CPT Sections

• Radiology (70010-79999)

• Pathology and laboratory (80048-89356)

• Medicine (90281-99199, 99500-99602)


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CPT Sections

• CPT code number format– Five-digit number and description identifying

each procedure and service listed in CPT


15

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


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CPT Appendix Description

• Appendix A – Detailed description of each CPT modifier

• Appendix B – Annual CPT coding changes

• Added, deleted, revised CPT codes


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• Appendix C– Clinical examples for evaluation and

Management (E/M) section codes

• Appendix D – Add-on codes


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• 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


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• 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


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• Appendix J – Electro diagnostic medicine listing of sensory,

motor, and mixed nerves


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• 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


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• 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


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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


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CPT Symbols

• Triangle located to left of a code number– Identifies a code description that has been

revised


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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


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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


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CPT Symbols

• Circle with a line through it – Identifies codes that are not to be used

with modifier

• Bull’s-eye symbol – Indicates a procedure that includes

moderate sedation


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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


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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


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• Special Report– When an unlisted procedure or service

code is reported


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• 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.”


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• Notes – Instructional notes are found throughout


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• Blocked unindented note: – Located below a subsection title and contains

instructions that apply to all codes


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• Indented parenthetical note: – Located below a subsection title, code

description, or code description that contains an example

• Highlight and understand each of these notes


35

CPT Modifiers

• Clarify services and procedures performed by providers

• Have always been reported on claims submitted for provider office services and procedures


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CPT Modifiers

• Coding tip: – List of all CPT modifiers with brief

descriptions is located inside front cover of coding manual


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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


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CPT Modifiers

• E/M service: – Must be “above and beyond” what is normally

performed during a procedure


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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


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• Step 4: – Refer to CPT index – Locate main term for procedure or service

documented• Main terms can be located by referring to the

following:


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a. Procedure or service documented

b. Organ or anatomic site

c. Condition documented in the record

d. Substance being tested


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e. Synonym (term with similar meaning)

f. Eponym (procedures and diagnoses named for an individual)

g. Abbreviation


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• Step 5: – Locate sub terms and follow cross references

• Step 6: – Review descriptions of service/procedure

codes, and compare all qualifiers to descriptive statements


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• Step 7: – Assign applicable code number and any add-

on (+) or additional codes needed to accurately classify statement being coded


45

Surgery Section

• Surgery section is organized by body system– Some subsections are further subdivided by

procedure categories


46

Surgery Section

• Incision

• Excision

• Introduction or removal

• Repair, revision, or reconstruction

• Grafts


47

Surgery Section

• Suture

• Other procedures


48

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


49

Evaluation and Management

• 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


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• For established patients – Two of three key components must be

considered


51


• E/M code reported to a payer – Must be supported by documentation in the

patient’s record


52

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


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Extent of Examination

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


54

Extent of Examination

• Categorized according to four types:– Problem focused examination – Expanded problem focused examination – Detailed examination – Comprehensive examination


55

Complexity ofMedical 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


56

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


57

Patient’sRecords Should Include

• Planned course of action for the patient’s treatment

• Review of patient records obtained from other facilities


58

History and Examination

• Determined by: – Straightforward– Low complexity – Moderate complexity – High complexity


59

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


60

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.”


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Presenting Problems

• Minimal

• Self-limited or minor

• Low severity

• Moderate severity

• High severity


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Face-to-Face Time

• Amount of time the doctor spends with the family or the patient


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Unit/Floor Time

• Amount of time the doctor spends at the patient’s bedside and at the management of the patient’s care.


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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


65

Observation Services

• Are furnished in a hospital outpatient setting– Patient is considered an outpatient

• They are reimbursed only when the doctor orders it


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Subcategories Include

• Observation care discharge services

• Initial observation care


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Hospital Inpatient Services

• E/M services provided to hospital inpatients, including partial hospitalization services.


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• Initial hospital care

• Subsequent hospital care

• Observation care services

• Hospital discharge services


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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.


70

Criteria

• Consultation is requested by another doctor or provider

• Consultant renders an opinion or advice


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Criteria

• Consultant initiates diagnostic or therapeutic services.

• Requesting physician documents in the patient’s record, the request, and the need for the consultation.


72

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


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• Office or other outpatient consultations

• Inpatient consultations


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Emergency Department Services

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


75

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


76

Neonatal

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


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Subcategories

• Inpatient pediatric critical care

• Inpatient neonatal critical care

• Continuing intensive care services


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Nursing Facility Services

• Are provided at nursing facilities:– Skilled nursing, intermediate care, and long-

term care


79

Subcategories

• Initial nursing facility care

• Subsequent nursing facility care

• Nursing facility discharge services

• Other nursing facility services


80

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.


81

Subcategories

• Prolonged physician service with direct face-to-face

• Prolonged physician services without face-to-face

• Physician standby services


82

Newborn Care

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


83

Qualifying Circumstances for Anesthesia

• When situations or circumstances make anesthesia administration more difficult and increases the patient’s risk factor.


84

Physician Status Modifiers

• Each “status modifier”– Reported with an anesthesia code to indicate

the patient’s condition at the time anesthesia was administered.


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Modifiers

• P1 – Normal health

• P2 – Mild systemic disease

• P3 – Severe systemic disease


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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


87

Anesthesia Time Units

• Be sure to record the time with the anesthesiologist

• Anesthesia time unit is one 15-minute increment


88

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


89

Separate Procedure

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


90

Complete Procedure

• When the word “complete” is established in the code definition– One code is reported to “completely” explain

the procedure performed


91

Pathology and Laboratory

• Organized according to the kind of pathology or laboratory procedure performed


92

Pathology and Laboratory Subsections

• Organ or disease oriented panels

• Drug testing

• Therapeutic Drug Assays

• Consultations (Clinical Pathology)

• Urinalysis, chemistry, hematology and coagulation immunology

• Microbiology


93

Pathology and Laboratory Subsections

• Anatomic pathology

• Cytopathology and cytogenetic studies

• Surgical pathology

• Transcutaneous procedures

• Other procedures

• Reproductive medicine procedures


94

National Correct Coding Initiative

• To encourage national correct coding, methodologies, and manage the improper assignment of codes.


95

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


96

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

Copyright © 2008 Delmar Learning. All rights reserved. CHAPTER 7 CPT Coding.

Documents

cpt slide

overview of cpt cpt

delmar learning

cpt coding slide

categories of cpt codes

overview of cpt category

codes codes

overview of cpt field