Seminar Ch 12.5 Coding

Front 1

CPT-4 Book

Back 1

1. Lists and codes procedures and services performed by practitioners
2. Each procedure is identified by a five-digit code
3. Simplifies reporting to insurance carriers
4. CPT book is divided into 6 sections

Front 2

Sections of CPT book

Back 2

a. Evaluation and Management
b. Anesthesia
c. Surgery
d. Radiology, Nuclear Medicine, and Diagnostic Ultrasound
e. Pathology an Lab
f. Medicine

Front 3

Evaluation and Management (E&M)

Back 3

Section of CPT-4 book.
99200 to 99499

Front 4

Anesthesia

Back 4

Section of CPT-4 book.
00100 to 01999

Front 5

Surgery

Back 5

Section of CPT-4 book.
10000 to 69999

Front 6

Radiology, Nuclear Medicine, and Diagnostic Ultrasound

Back 6

Section of CPT-4 book.
70000 to 79999

Front 7

Pathology and Lab

Back 7

Section of CPT-4 book.
80000 to 89999

Front 8

Medicine

Back 8

Section of CPT-4 book.
90701 to 99199

Front 9

Format and Conventions for CPT-4 book

Back 9

1. Main statement followed by semicolon; subordinate statement describes procedure or extent of services
2. Terms: Indented below main statement giving additional statements
3. Guidelines: specific directions at the beginning of each section; necessary to code correctly
4. Modifiers; two-digit, terminal code; represents an alteration of the procedure or circumstances
5. major headings are boldface
6. notes: provide coding instructions
7. Descriptive qualifiers: descriptions surrounding a code provide more detailed information; sometimes in parenthesis

Front 10

Coding Steps

Back 10

1. Review the guidelines beginning each section
2. Turn to the index and locate the main term
3. Locate the subterm and follow the cross-references
4. Read the code descriptors of all code numbers
5. Record the proper code

Front 11

E&M

Back 11

Includes basic diagnostic and treatment services

Front 12

Division of E&M Section

Back 12

a. New pt : pt who is new to the practice or who has not received any professional services by the practitioner for 3 or more years
b. Established pt: Patient who has received professional services from the practitioner within the last 3 years
c. Concurrent Care: rendering of similar services to the same patient by more than one practitioner on the same day.
d. Counseling: discussion with the pt and/or family regarding diagnosis, treatment, and pt education.

Front 13

Criteria to Code Correct E&M code

Back 13

1. History
2. Examination
3. Complexity of medical decisions-making

Front 14

History

Back 14

One of the E&M coding criteria
1. Problem-Focused : Chief complaint and brief history of the problem
2. Expanded problem-focused: chief complaint, brief history, and review of systems affected by the problem
3. Detailed: chief complaint, expanded history of the problem, expanded review of system affected and pertinent past, family, and/or social history.

Front 15

Examination

Back 15

One of the E&M coding criteria
1. Problem focused: examination is limited to the affected body area or system
2. Expanded problem-focused: Examination is limited to the affected body area or system and other closely related systems
3. Detailed: Extended examination of the affected body area or system and other closely related systems
4. Comprehensive: Complete single-system specialty examination or a complete multisystem examination

Front 16

Complexity of Medical decision-making (diagnosis and/or management)

What are the levels?

Back 16

1. Straightforward: all 3 criteria are minimal
2. Low Complexity: low degree in each criterion
3. Moderate Complexity: moderate degree in each criterion
4. High Complexity: high degree of complexity in each direction

Front 17

Criteria to be considered at each complexity level:

Back 17

A. Number of diagnoses or management options available
B. Amount and/or complexity of data
C. Risk of complication, morbidity, and/or mortality

Front 18

HCPCS

Back 18

Coding system that expands the CPT system
Provides a temporary list of new codes prior to inclusion in the CPT system

Front 19

HCFA

Back 19

Health Care Financing Administration; government agency that regulates Medicaid and Medicare

Front 20

What are the 3 levels of HCPCS?

Back 20

Level 1: existing CPT codes
Level II: Additional codes that provide greater precision in CPT categories; five-character alphanumeric system (A0000 to V5999): Includes: Non-physician services and codes not found within the existing CPT system
Level III: Codes used by private insurance companies contracted to process government claims (Medicare)

Front 21

ICD-10-CM and ICD-10-PCS
Two separate Systems

What's the difference in the two?

Back 21

Two separate Systems:
A: ICD-10-CM – Diagnostic Coding. Replaced Volumes I and II
B: ICD-10-PCS – Procedural Coding. Replaced Volume III

Front 22

ICD-10-CM and ICD-10-PCS

Back 22

WHO (World Health Organization) published first edition in 1992. This is 10th edition.

a. Expands the content, purpose, and scope of system
b. Includes ambulatory care services
c. Increases clinical details
d. captures risk factors in primary care
e. Includes emergent diseases
f. Groups diagnoses for epidemiologic purposes

Front 23

Benefits of ICD-10-CM

Back 23

a. Greater specificity
b. Added descriptions to ambulatory care and managed care encounters
c. Possibly of expansion
d. Extends beyond classification of diseases and injuries
e. General terminology and disease classification updated to current standards