Procedure Coding

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19

• Procedure Coding

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Learning Outcomes (cont.)

• 19.1 List the sections of the CPT manual, giving
  the code range for each.
• 19.2 Describe briefly each of the CPTs general
  guidelines.
• 19.3 List the types of E/M Codes within the CPT.
• 19.4 List the areas included in the Surgical
  Coding Section.

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Learning Outcomes (cont.)

• 19.5 Locate a CPT code using the CPT manual.
• 19.6 Explain how to locate a HCPCS code using
  the HCPCS coding manual
• 19.7 Explain the importance of code linkage in
  avoiding coding fraud

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Introduction

• Procedural coding
• Translate medical procedures and services into
  codes
• Explains what services were provided
• Code linkage with diagnostic codes
• Maximum reimbursement

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The CPT Manual

• Procedure code
• Medical procedures and services
• Based on encounter form or patient record
• Current Procedural Terminology (CPT)
• HIPAA-required code set
• Published by the AMA
• Updated annually
• Use the appropriate CPT based on date of service

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Organization of the CPT Manual
Section
Range of Codes
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Organization of the CPT Manual (cont.)

• Manual Introduction
• General instructions
• Information about common
• Prefixes
• Suffixes
• Word roots
• Guidelines for each section

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Organization of the CPT Manual (cont.)

• Sections
• Guidelines at beginning
• Categories ? headings

• Page
• Section name
• Subsection name
• Subheading
• Category

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Apply Your Knowledge
Match CPT section to number range
ANSWER
70010-79999
Evaluation and management Anesthesiology Surgery R
adiology Pathology and Laboratory Medicine
(except for Anesthesia)
00100-01999 99100-99140
99201-99499
90281-99199 99500-99602
80048-89356
10021-69990
Excellent!
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General CPT Guidelines

• Code format
• 5-digit numeric code
• Stand-alone unless description contains a
  semicolon

• Add-on codes
• Additional procedures
• Indicated by plus sign ()
• Indented codes

Closed treatment of radial shaft fracture without manipulation 25505 with manipulation
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Symbols Used in CPT

• Code description has been revised
• A new code
• Codes are out of numeric sequence
• New or revised text information

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Symbols Used in CPT (cont.)

• Does not require modifier of 51
• FDA approval pending
• Moderate (conscious) sedation is included in
  the procedure

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Organization of the CPT Manual (cont.)

• Modifiers
• Up to three per procedure
• Indicate that special circumstance applies
• Appendix A
• Section guidelines

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Category II, III, And Unlisted Procedure Codes

• Category II supplemental tracking codes
• Category III temporary codes
• Unlisted codes
• code not yet assigned
• Include a description of service or procedure
• Check with payers regarding use

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Coding Terminology

• Concurrent care
• More than one physician
• If different specialties, not considered
  duplication

• Bundled codes
• Read description carefully
• Do not unbundle
• Critical care
• Provided to unstable patients
• Documentation

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Coding Terminology (cont.)

• Consultations
• Must have request, record of findings and
  recommendations, and report
• Verify if payer is accepting these codes
• Counseling use codes if history or physical is
  not done

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Coding Terminology (cont.)

• Downcoding
• Reimbursement on a lower code level than
  submitted
• Lack of documentation most common cause
• Unbundling
• Upcoding

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Apply Your Knowledge

1. The insurance representative has questioned the
   codes listed on three patient forms that were
   submitted last year. When re-checking these forms
   the office medical assistant should

Excellent!

1. Use the current book to validate accuracy of the
   codes
2. Use last years book to validate accuracy of the
   codes
3. Use next years book to validate accuracy of the
   codes

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Evaluation and Management Services

• E/M codes
• Used by all physicians
• New patient vs. established patient
• New patients require more time
• Established patient seen within 3 years

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Evaluation and Management Services (cont.)

• Key factors that help determine level of service
• Extent of patient history taken
• Extent of examination conducted
• Complexity of medical decision making

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Evaluation and Management Services (cont.)
Patient History

• Elements
• Chief complaint (CC)
• History of present illness (HPI)
• Review of systems (ROS)
• Past, family and/of social history (PFSH)

• Coding descriptions
• Problem-focused
• Expanded problem-focused
• Detailed
• Comprehensive

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Evaluation and Management Services (cont.)
Physical Exam

• Elements
• Constitutional exam
• Body areas (BA)
• Organ systems (OA)

• Coding description
• Problem-focused
• Expanded problem-focused
• Detailed
• Comprehensive

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Evaluation and Management Services (cont.)
Medical Decision-Making

• Elements for documentation
• Number of diagnoses and management options
• Amount or complexity of data to be reviewed
• Risk of complication or death if untreated

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Evaluation and Management Services (cont.)

• Complexity level
• Straightforward MDM
• Low-complexity MDM
• Moderate-complexity MDM
• High-complexity MDM

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Evaluation and Management Services (cont.)

• Contributory factors in assigning codes
• Counseling
• Reason for encounter
• 50 or more of time
• Coordination of care

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Evaluation and Management Services (cont.)

• Nature of presenting problem
• Minimal complaint
• Self-limited complaint
• Low severity complaint
• Moderate severity complaint
• High severity complaint

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Evaluation and Management Services (cont.)

• Additional considerations
• Time
• Average times
• Not critical unless code choice is based on time
• Location where services occurred

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Apply Your Knowledge
What are the 3 factors in determining how select
E/M codes for different levels of service?

• ANSWER
• Extent of patient history taken
• Extent of the examination conducted
• Complexity of medical decision-making

Good Job!
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Surgical Coding

• The surgical package
• All procedures normally a part of an operation
• Preoperative exam and testing
• Surgical procedure
• Routine follow-up care
• Global period time period covered for follow-up
  care

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Surgical Coding (cont.)

• Integumentary System
• Codes based on size and location
• Read and follow instructions carefully

• Musculoskeletal System
• Subheadings
• general
• Head to toe
• Fracture codes most common

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Surgical Coding (cont.)

• Respiratory System
• Code to furthest extent of the procedure
• Approach
• Scope
• Incision
• Incision vs. excision codes
• Repair procedures

• Cardiovascular System
• Complicated coding
• Read instructions carefully
• Sequence codes correctly

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Surgical Coding (cont.)

• Hemic/Lymphatic Systems and Mediastinum and
  Diaphragm
• Digestive System
• Upper
• Lower

• Urinary System
• Kidneys and renal function
• Diagnostic and therapeutic procedures
• Laparoscopy vs. incision

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Surgical Coding (cont.)

• Male Genital System
• Female Genital System/Maternity and Delivery
• Endocrine System

• Nervous System
• Subheadings by anatomic sites
• Subdivided by procedure
• Specialized guidelines

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Surgical Coding (cont.)

• Eye and Ocular Adnexa
• Highly specialized procedures
• Read instructions and guidelines carefully
• Auditory System

• Radiology
• Diagnostic and therapeutic procedures
• Read all includes and excludes carefully

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Surgical Coding (cont.)

• Laboratory Procedures panels
• Medicine and Immunizations
• Two codes
• Procedure
• Vaccine or toxoid

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Apply Your Knowledge
What do the terms surgical package and global
period include?
ANSWER Surgical package includes preoperative
exam and testing, the surgical procedure and
local or regional anesthesia if used, and routine
follow-up care. The global period is the time
covered for follow-up care and included any care
provided related to the surgical procedure.
Bravo!
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Using the CPT Manual

• Become familiar with guidelines and notes for
  each section
• Find the procedures and services provided by the
  office
• Determine appropriate codes
• E/M sections
• Alphabetic listing
• Check all codes listed

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Using the CPT Manual

• Determine appropriate modifiers
• Required if available
• Enhance reimbursement
• Enter codes and modifiers on CMS-1500 form
• Primary procedure first and match with
  appropriate diagnostic code
• All other procedures matched with appropriate
  diagnostic code

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Apply Your Knowledge
What are the steps for locating a code in the CPT
manual?

• ANSWER
• Determine if the patient is new or established
• Find procedures and services provided (encounter
  form)
• Verify information with the medical record
• Locate the correct code in the CPT manual
  starting with the alphabetic index and verifying
  with the numeric index.
• Check for modifiers
• Document on CMS-1505 or in the billing program

Terrific!
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The HCPCS Coding Manual

• Health Care Common Procedure Coding System
• Use for coding services for Medicare patient
• HCPCS Level I codes CPT codes

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The HCPCS Coding Manual (cont.)

• HCPCS Level II codes
• National codes for supplies and DME
• Cover services and procedures not in CPT
• 5 characters numbers, letters, or a combination
  of both
• Modifiers

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The HCPCS Coding Manual (cont.)

• Coding procedures
• Locate service in the Alphabetic Index
• Verify description in the alphanumeric Index
• Choose code that matches service, procedure, or
  item supplied
• Enter on CMS-1505 form or into the billing program

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Apply Your Knowledge
What are HCPCS Level II codes and who issues them?
ANSWER HCPCS Level II codes are national codes
used for supplies, DME, and services not included
in the CPT. They are issued by Centers for
Medicare and Medicaid Services (CMS).
Stellar!
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Coding Compliance

• Physician ultimate responsibility
• Medical assistants
• Submit correct claims
• Help ensure maximum appropriate reimbursement
• Claims must comply with
• Federal and state law
• Payer requirements

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Code Linkage

• Analysis of the connection between diagnostic and
  procedural information to evaluate medical
  necessity

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Code Linkage (cont.)

• Codes are checked against the medical
  documentation
• Coding audit
• Are codes appropriate and is each coded service
  billable?
• Is code linkage correct?
• Have rules ben followed?
• Does documentation support services?
• Do reported services comply with regulations?

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Insurance Fraud

• Investigators look for patterns such as
• Reporting services that were not performed
• Reporting services at a higher level
• Performing and billing for procedures not related
  to the patients condition and therefore not
  medically necessary

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Insurance Fraud (cont.)

• Patterns (cont.)
• Unbundling
• Reporting the same service twice
• Copayments
• Waiver may violate payer policies
• Ensure policies are consistent with law and
  requirements of payers

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Compliance Plans

• Process for finding, correcting, and preventing
  illegal medical practices
• Goals of compliance plan
• Prevent fraud and abuse
• Ensure compliance with applicable laws
• Help defend physicians if investigation occurs

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Compliance Plans (cont.)

• Developed by a compliance officer and committee
  who also
• Audit and monitor compliance with government
  regulations
• Develop consistent written policies and
  procedures
• Provide ongoing staff training and communication
• Respond to and correct errors

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Apply Your Knowledge
Why is code linkage important?
ANSWER Code linkage will ensure clean claims in
which each reported service is connected to a
supporting diagnosis.
Correct!
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In Summary

• 19.1 The sections for the CPT manual are
  Evaluation and Management, Anesthesiology,
  Surgery, Radiology, Pathology and Laboratory, and
  Medicine with code ranges from 00100-99602.
• 19.2 A CPT code is a 5-digit code representing
  the service provided to the patient. The CPT
  manual general guidelines include symbols which
  represents important information about the code
  being described
• Always begin coding by looking up the
  description in the Alphabetic Index and verifying
  in the Tabular (numeric) List. Carefully read all
  guidelines and information surrounding the codes.

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In Summary (cont.)

• 19.3 The E/M code types include office and
  other outpatient services as well as other E/M
  services.
• 19.4 Surgical Coding sections include major
  body systems, radiology, pathology and lab, and
  medicine.
• 19.5 Students should be able to select an
  accurate code using the CPT manual for simple,
  straightforward coding scenarios.

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In Summary (cont.)

• 19.6 Students should be able to select an
  accurate code using the HCPCS manual for simple,
  straightforward coding scenarios.
• 19.7 Code linkage demonstrates the medical
  necessity of services provided to the patient by
  accurately linking each procedure code to its
  appropriate diagnosis.
• All procedures, services, and diagnoses must be
  documented in the patients medical record to be
  used on any health insurance claim form.

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End of Chapter 19
Things gained through unjust fraud are never
secure. Sophocles
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