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CPT Current Procedural Terminology

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contains the standardized classification system for reporting medical procedures and services

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Mandated Code Set

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CPT is the mandated code set for physician procedures and services under HIPAA Electronic Health Care Transactions and Code Sets

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Mandated use of current Codes

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Codes must be current as of the date of service

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Category I codes

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procedure codes found in the main body of CPT - most numerous - have 5 digits with no decimals

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descriptor

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narrative part of a CPT code - brief explanation of the procedure

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Category II codes

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optional CPT codes that track performance measures

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Category III codes

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temporary codes for emerging technology, services, and procedures

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Types of CPT Codes

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three categories of CPT codes: Category I codes Category II codes Category III codes

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CPT is a proprietary code set

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NOT available for free to the public; must be purchased in either electronic or print form

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Updating Vaccine Codes and Category III Codes

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Vaccine product codes and Category III codes updates twice a year and have a six-month period for implementation.

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CPT make-up

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Main Text (6 sections of codes) Appendixes Index

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Main Text section

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Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

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Main Term for CPT index

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printed in bold type in index... may be followed by subterm 5 types 1. name of procedure/service 2. name of organ or anatomical site 3. name of condition.. i.e. abscess, wound, postpartum care 4. synonym or aponym for the term 5. abbreviation for the term CAT scan

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Code Ranges

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range is shown when more than one code applies to an entry. 2 codes are separated by a comma 2+ by hyphen

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Cross-reference

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i.e. See (in italics), mandatory instruction to refer to the term following the code

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Typographic Conventions

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To save space, some words are left out and assumed by reader.

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CPT

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contains the main text, which has six sections of Category I codes: 1. Evaluation and Management 2. Surgery 3. Anesthesia 4. Radiology 5. Patholgoy and Laboratory 6. Medicine

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Category II and Category III codes

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have 14 appendixes and an index

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Section Guidelines

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Usage notes at the beninnings of CPT sections

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Correct Coding Procedure

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never select a code based on only the index entry because the main text may have additional entries and important guidelines that alter the selection.

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Unlisted procedure

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service not listed in CPT (those services not completely described by any code in the section) These codes are used for new services or procedures that have not yet been assigned either Category I or III codes in CPT.

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Special Report

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note explaining the reasons for a new, variable, or unlisted procedure or service; for a rare or new procedure. They permit payers to assess the medical appropriateness of the procedures.

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The Appendixes

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14 appendixes in the American medical Association publication of CPT contain informaion helpful to the coding process

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Unlisted Procedure Codes

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require special reports that delay claims because they must be processed manually.

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Seven symbols used in CPT

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1. Bullet - indicates a nuew procedure code 2. Triangle - indicates the code's descriptor has changed 3. >< facing triangles - enclose new or revised text other than the code's descriptor 4. + plus sign - before a code indicates an add-on code that's used only along with other codes for primary procedures 5. bullet in a circle next to a code = conscious sedeation is a part of the procedure the surgeon performs 6. A lightning bot, used for codes for vaccions that are pending FDA approval 7. # - indicates a resequenced code

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Format used in CPT

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- Semi-colon and indentions - when a common part of a main entry applies to entries that follow - Indented see or use entries in parentheses follow code to refer the coder to other codes - Descriptors often contain clarifying examples in parentheses... e.g.

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Resequenced code

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CPT procedure codes that have been reassigned to another sequence

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Symbols for CHANGED CODES

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Bullet = new procedure code Triangle = code's descriptor has changed >< Facing Triangle = enclose new or revised text other than code's descriptor

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Symbol for Add-On Codes

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+ Plus sign next to a code in the main text indicates a secondary procedure performed in addition to a primary procedure

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Add-on code

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procedure performed and reported in addition to a primary procedure (secondary procedure)

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Secondary procedure

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addtional procdure performed

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primary procdure

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most resource-intensive CPT procedure during an encounter

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Symbol for Conscious Sedation

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Bullet within a circle next to a code = conscious sedation is a part of the procedure surgeon performs.

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conscious sedation

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mederate drug-induced depression of consciousness

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Symbol for FDA Approval pending

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Lightening bolt next to code - used with vaccine codes that are pending FDA approval

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Resequenced

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CPT procecdure codes that have been reassigned to another sequence

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Symbol for Resequenced Codes

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# sign indicates CPT procedure codes that have been reassigned to another sequence

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modifier

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two-digit number attached to most five-digit procedure codes. indicate special circumstances involved with procedures

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A procedure has two parts

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1. Technical compnent (TC) 2. Professional Compnent (PC)

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Technical component (TC)

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reflects the technician's work and the equipment and supplies used in performing it

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Professional component (PC)

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represents a physician's skill, time, and expertise used in performing it

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Professional Component Modifier -26

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tells the payer that the physician did not perform all work, just the professional part, so only part of the fee is due. the other part of the fee, associated with the modifier is paid to the technician.

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When to use Modifiers

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- a service or procedure has been performed more than once by more than one physician & in 1+ locations - service/procedure been increased or reduced - only part of a procdure has been done - bilateral or multiple procedure has been performed - unusual difficulties occured during procedure

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Multiple Modifiers -99

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two or more modifiers used with one code to give the most accurate description possible.

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Coding Steps (6)

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1. Review complete medical documentation 2. Abstract the medical procedure from the visit documentation 3. Identify the main term for each procedure 4. Locate the main terms in the CPT index 5. Verify the code in the CPT main text 6. Determine the need for modifiers

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E/M codes (evaluation & management codes)

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cover physicians' services performed to determine the optimum course for patient care. Listed first in CPT because they are used so often.

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E/M codes

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often call the cognitive codes... cover the complex process physician useds to gather & analyze info about a patient's illness & make decisions about treatment

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Key component

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factor documented for vaious levels of evaluation and management services

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Consultation

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service in which a physician advises a requestion physician about a patient's condition and care

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Consults: the 3 R's

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Request opinion, Render service, Report back

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Medicare does not pay consult codes

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due to fraudulent use by some physicians......

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8 steps to select correct E/M code

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1. Determine category & subcategory of service 2. Determine extent of history documented 3. Determine extent of examination documented 4. Determine complexity of decision making documented 5. Analyze requirements to report the service level 6. Verify service level 7. Verify Documentation is complete 8. Assign the code

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Key components for selecting E/M codes:

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- The extent of the history documented - The extent of the examination documented - The complexity of the medical decision making

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HPI

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History of Present Illness

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ROS

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Review of Systems - an inventory of body systems

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PMH

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Past Medical History

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FH

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Family History

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SH

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Social History - facts gathered which depend on patient's age, maritus status, employment etc...

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PFSH

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Past, Family, Social History

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99203 code for NEW patient Office or outpatient visit

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Requires 3 key components: - detailed history - detailed exam - medical decision making of low complexity

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99213 code for ESTABLISHED patient Office or outpatient visit

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requires 2 of 3 key components below: - expanded problem-focused history - expanded problem-focused exam - medical decision making of low complexity

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Nature of Presenting Problem

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how severe the patient's condition is

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Consultation

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service in which a physician advises a requesting physician about a patient's condition and care

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Outpatient

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patient who receives health care in a hospital setting without admission

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Documentation Guidelines for E/M

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2 sets of guidlines for documenting E/M have been published by CMS and AMA

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Modifier -25

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indicates an additional illness requiring examination is discovered during a routine exam.

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Anesthesia Section codes

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used to report anesthesia services performed or supervised by a physician

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2 Types of Anesthesia Modifiers

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1. Physical status modifier 2. Standard modifiers

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Physical status modifier

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modifier code used with procedure codes to indicate a patient's health status (P1-P6) modifiers

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Standard Modifiers commonly used with anesthesia codes:

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-22, -23, -32, -51, -53, -59

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Physical Status Modifiers

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-P1: Normal, healthy patient -P2: Patient w/ mild systemic disease -P3: Patient w/ severe systemic disease -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: Declared brain-dead patient whose organs are being removed for donation purposes.

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Surgery Codes - largest procedure code sect.

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used for many hundres of surgical procedures performed by physicians

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Surgical Package (or global surgery rule)

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combination of services included in a single procedure code;

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Complete surgical procedure

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includes Operation Use of local anesthetic postoperative care All covered under a single code

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Global Surgery Rule

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combination of services included in a single procedure code

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Global period

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days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package.

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Separate procedure

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descriptor used for a procedure that is usually part of a surgical package but may also be performed separately

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Surgical Reporting Structure

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1.organized by body system 2. body site 3. procedures grouped under headings 4. special procedures

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Reporting Surgical Codes (correct way)

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Bundling

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Bundling of Surgical Codes

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using a single payment for two or more related procedure codes

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Unbundling

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incorrect billing pratice of breaking a panel or package of services/procedures into component parts

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Fragmented billing

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incorrect billing practice in which procedures are unbundled and separately reported

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Sesion Exicion

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choice of correct code depends on pathology report. coders should wait for a pathology report before coding lesion excisions, from benign or malignant code ranges.

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Radiology Section of CPT

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Contains codes reported for radiology procedures either performed by or supervised by a physician.

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Radiology code procedures (2 parts)

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- Technical component - use of equipment to take xrays - Professional component - actual reading of xrays & written physician report

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Radiology Structure and Modifiers

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- Type: (diagnostic Ultrasound) - Body site: (chest) - Procedure: (echography)

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Pathology and Laboratory Codes

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Procedure Includes: - Ordering test - Taking / handling sample - Performing actual test - Analyzing results

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Panel

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single code grouping laboratory tests frequently done together / group of related lab tests; They are bundled codes... to be reported, all indicated tests must have been done and any additional test is coded separately.

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Medicine Codes

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Codes for the many types of evaluative, theraputic and diagnostic procedures that physicians perform

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Ancilliary Services

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services used to support a diagnosis

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Reporting Immunization Codes from Medicine section

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require two codes from Medicine section, one for administering immunization another for particular vaccine or toxoid given

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Category II & III codes

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contain supplemental tracking codes to help collect data regarding services

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Category II & III Codes

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have five (5) characters each four numbers and a letter Released twice a year Jan. 1 and July 1

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Category II Codes

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used for tracking performance measures to improve patients' health (patient Management, History, Phys. Exam, Therapeutic, Preventative, Screening results etc..)

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Category III Codes

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contains temporary codes for emerging technology, services and procedures.

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