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49 Cards in this Set
- Front
- Back
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The CPT Manual
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*Current Procedural Terminology, fourth edition(CPT4)
*Set of codes, descriptions and guidelines used to describe services and procedures performed by providers *Standardized code set used for reimbursement *Each code has five digits *CPT is published annually, early fall *January 1st is effective date for use of updated codes *Used for professional billing |
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CPT Categories
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*Category 1
-Evaluation and Management -Anesthesiology -Surgery -Radiology -Pathology -Medicine *Category 2 -Tracking codes *Category 3 -Temporary codes |
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Format of CPT Codes
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*Stand alone procedures-has a full description of the code
*Indented procedures-listed under the associated stand-alone code. The indented codes includes the description of the stand-alone code that precedes the semicolon. 35901 Excision of infected graft; neck 35903 extremity 35905 thorax 35907 abdomen |
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Modifying Terms
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*Alternative Anatomic Site
-22220 Osteotomy of spine, including discetomy, anterior approach, single vertebral segment; cervical -22222 thoracic -22224 lumbar *Alternative Procedure -31505 Laryngoscopy, indirect; diagnostic -31510 with biopsy -31511 with removal of foreign body -31512 with removal of lesion -31513 with vocal cord injection *Description of Extent of the Service -11055 paring or cutting of benign hyperkeratotic lesion; single lesion -11056 two or four lesions -11057 more than four lesions |
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Symbols
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*triangle-revised code
*triangles pointing toward each other-new or revised text *dot-new code *+-add-on code *circle with a line through it-exemptions to modifier-51 *circle with a dot in the center-moderate sedation *lightning symbol-product pending FDA approval |
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Special Reports
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*used for services that are performed that haven unusaul services in the CPT book
*there either a unusual procedure or a newly docotrine procedure or even experimental *some of the procedures may not be covered under the patients insurance policies *the report helps the insurance company determine the reimbursement value *the requirements for the report has to list the description the expect for the perscription being performed *needs to include the time and effort that the provider spent on the particular procedure *it needs to explain the equipment that was necessary in order to provide these services *additional items that are usually added to the reports are the complexion of the syptoms, why they felt this was the best opition for the patient, what the final diagnosic is, any important physical findings to help support the procedures, diagnostic and therapedic procedures, and concurrent problems/follow-up care *have a full section in the front of the CPT Coding book |
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Unlisted Procedures
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*39599 Unlisted procedure, diaphragm
*49999 Unlisted procedure, abdomen, peritoneum and omentum *situation were a procedure is not pacifically listed in a CPT manual *needs to go in at the time the insurance company is being billed |
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Bundled and Unbundled Codes
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*is a situation were more than one service is being performed
*bundled procedure codes are designed to report a group of services are actually paid as one *unbundled services are codes separated from a bundled procedure and are billed independently *insurance don't like unbundled cause there is a cost issue |
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Separate Procedures
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*Codes that are listed as "separate procedure" are commonly carried out with other services
*If notated as "separate procedure" and done with a service considered to be an intregal component of that procedure, the code should not be reported *If service is done independently or distinct from other services, it can be reported -Different session -Different site, organ system or procedure -Separate incision/excision, lesion or injury Example: -49400 Injection of air or contrast into peritoneal cavity(separate procedure) |
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Guidelines
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*Guidelines are found at the beginning of each section
*They are specific to the section *Additional guidelines/notes can be found in subsections *Written to assist the coder in understanding when and under what circumstances the code may be used *Always read and follow the guidelines for proper coding and maximizing reimbursement *Inappropriate coding can be considered fraud or abuse |
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Notes
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*Notes can be found in the category, subcategory or code description
*These notes apply to that particular set of codes *They can be found throughout the CPT book and should be read and followed for proper coding and maximizing reimbursement Example: Cardiovascular System -Myocardial profusion and cardiac blood pool imaging studies may be performed at rest and/or during stress. When performed during exercise and /or pharmacologic stress, the appropriate stress testing code from the 93015-93018 series should not be reported in addition to 78460-78472-78492 |
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Appendices
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*Appendix A-Modifiers
*Appendix B-Summary of Additions, Deletions & Revisions *Appendix C-Clinical Examples *Appendix D-Summary of CPT Add-on Codes *Appendix E-Summary of CPT Codes Exempt from Modifier -51 *Appendix F-Summary of CPT Codes Exempt from Modifier -63 *Appendix G-Summary of CPT Codes that include Moderate Sedation *Appendix H-Alpha Index of performance Measures *Appendix I-Genetic Testing Code Modifiers by Clinical Condition *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 |
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Procedure
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*Section-found at the top of the page indicating the section(surgery,radiology,etc)
*Subsection-also found at the top of the page, indicating organ system(integumentary, respiratory, etc) *Subheading-specfic anatomical part within organ system *Category-type of procedure *Subcategory-more defined description of procedure |
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Evaluation and Management
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*referenced as EMN codes better known to us as office visits
*services that providers charge for what we recognize is based on there time *code range is 99201-99499(physician services, evaluating managment, managing patients care in the office/hospital/nursing homes/emergency departments and homes *services for preventative medicines, consultations and critical care *made out for multiple communications |
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Anesthesia
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*has a code range of 00100-01999-99100-99140(qualifying circumstance codes)
*primarily used for general anesthesia *epidural, spinal, blood patch, regional, PCA(patient control anesthesia), lowcall *codes are coded in a different fashion for the difeerent forms of anesthesia *codes are selected by the anatomic location of where the surgery is being performed on the patient *surgery isn't specfic to the fact of a general anesthsia *some codes are based on patients age *moderate considation is something that is very commonly used for procedures(where the patient has no idea what is being done; but usually are able to respond verbally *is a section that can be used by more than an anesthesiolgist |
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Calculating Anesthesia Services
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*Basic Value Unit-Issued by the Anesthesiology Society of America(ASA) ferferred to as the Relative Value Guide(RVG), is a numeric value based on the level of complexity of the service
*Time Unit-Usually 15 mins = 1 unit of time. Starts when the Anesthesiologist begins preparing the patient to receive anesthesia and end when the patient no longer requires the independent care of the anesthesiologist. *Modifying Unit-reflects circumstances that modify the environment. Included are Qualifying Circumstance (QC) Codes and Physical Status (PS) Modifier codes. Anesthesia Formula: Basic Value Units + Time Units + Modifying Units = Total Units (B+T+M=Total) |
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Qualifying Circumstances
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*+99100 Anesthesia for patient of extreme age, under 1 or over 70
*+99116 Anesthesia complicated by utilization of total body hypothermia *+99135 Anesthesia complicated by utilization of controlled hypotension *+99140 Anesthesia complicated by emergency conditions |
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Physical Status Modifiers
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*P1:Normal Health Patient
*P2:Patient with mild systemic disease *P3:Patient with severe systemic diease *P4:Patient with severe systemic disease that is a constant threat to life *P5:Moribund patient who is not expected to survive without the operation *P6:A declared brain-dead patient whose organs are being removed for donor purposes |
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Surgery
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*Code Range 10021-69990
*Largest Section of the CPT book *10021-19499 Integumentary System *20000-29999 Musculoskeletal System *30000-32999 Respiratory System *33010-39599 Cardiovascular System *40490-49999 Digestive System *50010-53899 Urinary System *54000-55980 Male Genital System *56405-58999 Female Gential System *59000-59899 Maternity Care and Delivery *60000-60699 Endocrine System *61000-64999 Nervous System *65091-68899 Eye and Ocular Adnexa *69000-69979 Auditory System |
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Surgery Section Procedures
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*Incision and drainage
*Excision *Biopsy *Introduction and Removal *Repair, Revision, Reconstruction *Destruction *Endoscopy/Arthroscopy.Laproscopy |
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Surgical Package
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*Pre-Op
-One related E/M service -Local Anesthesia(General Anesthesia billed separately) *Procedure -Operation *Post-Op -Follow-up care -Written orders |
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Radiology
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*Code Range 70010-79999
*Divided by type of imaging and further divided by anatomical site *Diagnostic imaging includes: -X-ray -MRI-Magnetic Resonance Imaging -MRA-Magnetic Resonance Angiography -CT-Computerized Tomography -US-Ultrasound or Sonography -Nuclear -Radiation Oncology *Guidance procedures used during surgical procedures *Radiology procedures are divided into professional and technical components *Interventional Radiology consists of the Radiologist performing both the surgical and radiology(guidance) procedures *Contrast-used in many sections of radiology procedures for imaging enhancement -Intravasculary -Intra-articularly -Intrathecally *Oral and/or restal contrast administration does not qualify |
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Pathology
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*is a code range from 80048-89356
*covers procedures performed using serium(blood), urine, fecies, spedium, and other things that are used to determine disease status using diease organ systems *these codes that are chosen and sometimes determined by exam and what source is utilized in order to do the test *it includes organ and diease panels within these panels you have to make sure all the procedures are done *drug testing, advocating and surpression testing, testing done by urine, chemistry, infectious agents, microbiology, citial pathology, and citial gentics studies |
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Surigical Pathology
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*Evaluation of specimens to determine the disease process
*Codes are chosen based on specimen source and reason for exam *Pathology codes consist of six classification levels: -Level I Gross exam only -Level II Gross and Microscopic -Level III Gross and Microscopic -Level IV Gross and Microscopic -Level V Gross and Microscopic -Level VI Gross and Microscopic *The classification level is determined by the complexity of exam |
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Medicine
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*Code Range 90281-99199, 99500-99602
*Codes are used for diagnostic and therapeutic services *Large various subsection groups *Immunizations and vaccinations *Hydration, Therapeutic, Prophylactic and Diagnostic injections and infusions *Psychiatry *Dialysis *Cardiology *Sleep Testing *Nervous system *Health and Behavioral Assessment *Chemotherapy Administration *Modalities *Active Wound Care Management *Acupuncture *Osteopathic Manipulative treatment *Chiropractic Manipulative Treatment *Education and Training for Patient Self-Management *Home Health Procedures and Services |
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HCPCS
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*Healthcare Common Procedure Coding System
*Used for Medicare billing and most private insurances *HCPCS codes represent: -Procedures -Supplies -Products -Services *Codes are five position alpha-numeric (j0735 Injection, clonidine HCI, 1mg) *Codes are divided into two levels: -Level I CPT codes -Level II HCPCS codes *Table of Drugs *Alphabetical Index |
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HCPCS Sections
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*A0000-A0999 Transport Services
*A4000-A8999 Medical and Surgical Supplies *A9000-A9999 Administrative, Miscellaneous and Investigational *B4000-B9999 Enteral and Parenteral Therapy *C1000-C9999 For Use Only under the Hospital Outpatient Prospective Payment System *D0000-D9999 Dental Procedures (not listed, R to ADA) *E0100-E9999 Durable Medical Equipment *G0000-G9999 Procedures/Professional Services (temporary) *H0001-H1005 Alcohol and/or Drug Services *J0100-J8999 Drugs Other Than Chemotherapy K0000-K9999 Codes for Durable Medical Equipment(temporary) *L0100-L4999 Orthotic Procedures *L5000-L9999 Prosthetic Procedures *M0000-M0399 Medical Services *P0000-P2999 Pathology and Laboratory *Q0000-Q9999 Temporary Codes *R0000-R5999 Domestic Radiology Services *S0000-S9999 Temporary National Codes *T1000-T9999 National T Codes for State Medicare *V0000-V2999 Vision Services *V5000-V5999 Hearing Services |
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Why Use Modifiers?
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*A modifier is a two digit code that indicates that the procedure has been altered in some way, but has not changed the defintion of the code.
*Examples: -Service was for professional and/or technical component -Performed by more than one physician -Service performed more than once -Service was increased or reduced -Only one part of service was performed -Bilateral service was performed -An adjunctive service -Unusual circumstances |
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Modifiers
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*21-Prolonged evaluation and mangement service
*22-Unusual procedural services *23-Unusual anesthesia *24-Unrelated evaluation and management service by the same physician during a postoperative period *25-Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service *26-Professional component *32-Mandated services *47-Anesthesia by surgeon *50-Bilateral procedure *51-multiple procedures *52-Reduced services *53-Discontinued Procedure *54-Surgical care only *55-Postoperative management only *56-Preoperative management only *57-Decision for surgery *58-Staged or related procedure or service by the same physician during the postoperative period *59-Distinct procedural services *62-Two surgeons *63-surgical team *76-Repeat procedure by same physician *77-Repeat procedure by another physician *78-Return to the operating room for a related procedure during the postoperative period *79-Unrealted procedure or service by the same physician during the postoperative period *80-Assistant surgeon *81-Minimum assistant surgeon *82-Assistant surgeon(when qualified resident surgeon not available) *90-Reference(outside) laboratory *91-Repeat clinical diagnostic laboratory test *99-Multiple modifiers |
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HCPCS/National Modifiers
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*LT-left side
*RT-rigth side *LC-left circumflex, coronary artery *LD-left anterior descending coronary artery *RC-rigth coronary artery |
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HCPCS Hand Modifiers
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*FA-Left hand, thumb
*F1-Left hand, second digit *F2-Left hand, third digit *F3-Left hand, fourth digit *F4-Left hand, fifth digit *F5-Right hand, thumb *F6-Right hand, second digit *F7-Right hand, third digit *F8-Right hand, fourth digit *F9-Right hand, fifth digit |
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HCPCS Foot Modifiers
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*TA-Left foot, great toe
*T1-Left foot, second digit *T2-Left foot, third digit *T3-Left foot, fourth digit *T4-Left foot, fifth digit *T5-Right foot, great toe *T6-Right foot, second digit *T7- Right foot, third digit *T8-Right foot, fourth digit *T9-Right foot, fifth digit |
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HCPCS Eyelid Modifiers
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*E1-Upper left, eyelid
*E2-Lower left, eyelid *E3-Upper right, eyelid *E4-Lower right, eyelid |
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Considering Factors
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To properly code E/M services you must know:
1. Place of service -Office, Hospital, Emergency Dept, Nursing Home 2. Type of Service -Consultations, admission, preventative 3. Patient Status -New, Established, Inpatient, Outpatient |
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E/M Key Components
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*There are 3 key components in determining the level of service provided for E/M codes:
1. History 2. Examination 3. Medical Decision Making *Contributing factors: - Counseling - Nature of Presenting Problems - Coordination of Care - Time |
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History
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*can consist of multiple subjective factors
*subjective is what the patient is actually telling the physician in their own words *Chief Complaint-basic reason the patient is there *history of present illness which is the HPI-talks about their illness form the time it started until the time they are present with the physician *Review of Systems-what they did to be looked at *Passed Family and Social History-patients passed medical history, family's history, social history-may or may not be discussed *4 Different Levels of History -Problem Focused-PF -Expanded Problem Focused History -Detailed History -Comprehensive History |
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Examination
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*Objective part of the patients service performed by provider
*Constitutional - vital signs and appearance *Body Areas - head, neck, chest, abdomen, genitalia, groin, buttocks, back, and each extremity *Organ Systems -Ophthalmology, Otolaryngology, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, and Hematological/Lymphatic/Immunologic |
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Exam Levels
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*deal with problem focused exam, expanded problem focused exam, detailed exam, and comprehensive exam
*mirror images to the history levels |
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Medical Decision Making
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*Three elements make up the medical decision making:
-Number of diagnoses and management options -Amount and complexity of data reviewed -Risk of complications and/or morbidity or mortality *Levels of Medical Decision Making -Straightforward(SF) -Low complexity(LO) -Moderate complexity(MOD) -High complexity(HI) |
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Contributing Factors
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These contributing factors must exceed 50% of the encounter to considered.
*Counseling-discussing patients diagmosis, test results, prognosis, risks, recommendations with the patient and/or family *Coordination of Care-arranging for personal care beyond the hospital. (i.e. nursing home) *Nature of Prsenting Problem-Usually is the chief complaint *Time-Are expressed to assist in determining level of care |
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Selecting an E&M Service
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1. Identify the place
2. Identify the Type of service 3. Identify the Patient Status 4. Determine the extent of history obtained 5. Determine the extent of the exam performed 6. Determine complexity of medical decision making 7. Determine how many key components are required 8. Consdieration of contributing factors(if applicable) 9. Make your code selection |
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Example E/M Codes
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*99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
-A detailed History -A detailed Exam -Medical Decision Making of low complexity *99213 Office or other outpatient visit for the evaluation and management of a established patient, which requires at least two of these key components: -A expanded problem focused History -A expanded problem focused Exam -Medical Decision Making of low complexity |
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Rules to Follow
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*be as specific as possible when coding
*you never want to be in a position to be adding or taking anything away *you never only use the index *You want to read all guidelines and notes that surround that code *You want to make sure to use reference materials or other coding sources-online services, documentations, news letters, correct coding initiative |
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Alphabetical Index Format
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*Classification of main and modifying terms:
-Organ or Anatomic Site -Procedure or Service -Condition, illness or injury -Eponym, synonym, or acronym *Listing of Codes -Hypen-used to indicate a range of codes -Comma-used to indicate multiple codes -Single code-one code |
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Using the Alpha Index
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*Select the main term to begin search
*Add modifying terms to narrow search *Select code Example: Open flexor Tenotomy of the finger *Tenotomy -Achilles Tendon 27605-27606 -Ankle 27605-27606 -Arm, Lower 25290 -Arm, Upper 24310 -Finger 26060, 26455-26460 -Foot 28230,28234 |
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Referencing the Code
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Example: Open flexor Tenotomy of the finger
*26060- Tenotomy, percutaneous, single, each digit *26455 Tenotomy, flexor, finger, open, each tendon *26460 Tenotomy, extensor, hand or finger, open, each tendon *Compare code descriptions with medical documentation *Read and follow all notes and guidelines *Make your selection *Determine if there is a need for modifiers |
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Downcoding
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*charging for a lesser service that has not been performed
*Try not to do downcoding *make sure to get the highest level for reimbursement *disadvantages of downcoding is lower reimbursement *incorrectly recording doctors procedures of those performance *it could be a fraud in a third party pay |
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Upcoding
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*deliberily charging for higher level of services than what has actually been performed
*it is fraud *it is civil and criminal penalities which can include fines and prison time |
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Errors & Omissions Insurance
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*Protects against the loss of money caused by an error or unintentional omission on the part of the individual or billing service creating, submitting and processing claims
*E&O Insurance will pay for judgements against you including court costs *Mistakes can happen, the coverage could save you from embarrassment, loss of work or a bad reputation |
