SXS11ierPPT-INTC13_P1 • What is the purpose of assigning a code to a procedure or service? It allows health care providers to communicate efficiently and effectively with third-party payers about the services and procedures provided to their patients. The CPT/HCPCS codes are used to identify procedures/services/supplies/drugs delivered as part of patient care. The ICD-9-CM codes provide the diagnostic justification for the delivery of these services
SXS11ierPPT-INTC13_P1 • What are the various levels of physician service codes? Level I: CPT-4 codes used to identify services and procedures delivered by a physician to describe health care services. Level II: National codes used by providers to report services, supplies, and equipment not covered in the CPT-4 code (see Chapter 13). Level III: Codes used for services and materials for which there were no Level I or II codes. These codes were eliminated December 31, 2003. Now only Level I and II codes may be used.
SXS11ierPPT-INTC13_P1 • What do ICD-9-CM codes designate? They constitute the official system for diagnostic coding used in the United States. The ICD-9-CM will be discussed in Chapters 2-6 of this textbook.
SXS11ierPPT-INTC13_P1 On what basis are ICD-9-CM codes categorized? Within the system, disorders are classified into 17 categories on the basis of disease types and/or body systems. Similar to the CPT/HCPCS systems, the ICD-9-CM translates verbal diagnostic descriptions into codes that convey precise information about the condition being treated.
SXS11ierPPT-INTC13_P1 • Why are alphanumeric codes used instead of verbal descriptions of disorders or procedures? Coding allows for greater standardization and simplificatio nof the process of interpreting medical diagnostic and treatment information. Coding makes processing more efficient. Coding permits compilation of statistics related to diseases, disorders, and treatment protocols. No information is lost.
SXS11ierPPT-INTC13_P1 • How many digits are included in a CPT-4 code? (CPT-4 uses 5 digits.)
SXS11ierPPT-INTC13_P1 • What are the six main categories (chapters) used in the CPT manual? Evaluation and Management (E/M) Anesthesia Surgery Radiology Pathology and Laboratory Medicine
SXS11ierPPT-INTC13_P1 • Summarize why CPT codes are important tools for ensuring communication. Numerical codes are the same for all users of CPT, which makes coding more standardized and efficient.
SXS11ierPPT-INTC13_P1 • As this example shows, the code 50575, although it conveys the same level of detail as the verbal description, is a far more efficient way to describe this procedure.
SXS11ierPPT-INTC13_P1 • How are codes used for processing claim payments? Codes inform payers which services and procedures were provided. Codes become the basis for payment of claims submitted. Codes are an unambiguous way to communicate. Codes expedite claim processing for faster reimbursements to providers.
SXS11ierPPT-INTC13_P1 • Correct coding is essential. What are the potential consequences of incorrect coding? Failure to code correctly may result in overpayment, underpayment, or denial of a claim. In addition, incorrect coding may result in fines, imprisonment, or both when it is the result of fraud and/or abuse. The financial consequences to a medical practice for incorrect coding can be substantial. It is the coder’s responsibility to ensure that coding is applied accurately and that error-free claims are submitted to third-party payers.
SXS11ierPPT-INTC13_P1 • What types of institutions use CPT codes? Codes are used wherever health care services are provided, such as in physician’s offices, clinics, hospitals, and rehabilitation units. They form the basis for a universal communication system that ensures accuracy and clarity when the procedures and services delivered within the health care system are described.
SXS11ierPPT-INTC13_P1 • What types of services are reported on CMS-1500? (Those represented by CPT-4 and HCPCS codes)
SXS11ierPPT-INTC13_P1 • CPT-4 codes are entered in section 24D. • Note that complete information must be provided for each claim submitted or it will result in a denial by the insurance carrier. • Effective March 31, 2007 the CMS-1500 claim form changed to reflect the NPI changes. This included the Referring Physician NPI, Rendering Physician NPI, and the Facility NPI. • There is now space for usage of four modifiers.
SXS11ierPPT-INTC13_P1 • Why are symbols used in conjunction with CPT codes in the CPT manual? (To draw special attention to information presented in a particular section.) • For example, the bull’s eye in front of 45391, colonoscopy with ultrasound examination, indicates that conscious sedation is required for this procedure. Appendix G of CPT includes a listing of all procedures that include conscious sedation.
SXS11ierPPT-INTC13_P1 • The bullet in front of a code indicates that this procedure is being included in CPT for the first time. • The circle in front of a code indicates the procedure is being reinstated or recycled back into the CPT manual.
SXS11ierPPT-INTC13_P1 • The upright triangle preceding this code indicates that the description used with this code has changed in some manner since the last revision was released.
SXS11ierPPT-INTC13_P1 • Text enclosed in pairs of right- and left-facing triangles reflects a change in text from the previous release of the CPT. • Text changes may occur in any section of the CPT, and multiple changes may be noted in any particular section, if appropriate, as this example illustrates.
SXS11ierPPT-INTC13_P1 • In this example, the code is prefaced by both an upright triangle and the plus sign, indicating that it is an add-on code whose description has been altered in some fashion. • The right- and left-facing triangles surrounding the parenthetical note below the code description indicate that this is the portion of the text that has been changed.
SXS11ierPPT-INTC13_P1 • What is the purpose of an add-on code? (Using an additional code to show the furthest extent of the procedure.) • Have students provide an example of an add-on code. • Add-on codes are modifier -51 exempt.
SXS11ierPPT-INTC13_P1 • What is modifier -51? (It is used to indicate that multiple procedures have been performed.) • What is the role of the circle with a line through it? (This sign indicates that a -51 modifier cannot be used with this code.)
SXS11ierPPT-INTC13_P1 • Have students describe each appendix of the CPT manual and provide an example that would apply to each.
SXS11ierPPT-INTC13_P1 • For which class of patients would Appendix F apply? (Infants weighing less than 4 kg) • Appendix I is a list of genetic testing modifiers that are reported with molecular laboratory procedures. The first character of these codes is a number that indicates the disease category; the second character is a letter that denotes the gene type.
SXS11ierPPT-INTC13_P1 • Why is E/M listed first? (Because procedures and services listed in the E/M are frequently used) • Evaluation and Management (Codes 99201-99499) • Anesthesia (Codes 00100-01999, 99100-99140) • Surgery (Codes 10021-69990) • Radiology (Codes 70010-79999) • Pathology and Laboratory (Codes 80047-89398) • Medicine (Codes 90281-99602)
SXS11ierPPT-INTC13_P1 • How are the main sections of the CPT manual subdivided? (Into subsections which are body systems) • How are these further subdivided? (In subheadings, which are body areas, and then further divided by category, which is incision, excision, etc.)
SXS11ierPPT-INTC13_P1 • Categorization within the major sections of the CPT depends on what makes most sense for the section in question. • Subdivisions may be based on anatomy, procedure, condition, description, or surgical approach, as described here.
SXS11ierPPT-INTC13_P1 • The main section is Evaluation and Management (E/M). • One subsection of E/M is Office or Other Outpatient Services. • Within the Office or Other Outpatient Services subsection, the subheading “New Patient” is found.
SXS11ierPPT-INTC13_P1 • Where do Guidelines appear in the CPT manual? (At the start of each section of the CPT) • What is the role of Guidelines? (The information they contain, which is specific to a particular section, allows the coder to appropriately interpret and report on procedures and services included in that section.)
SXS11ierPPT-INTC13_P1 • Where do Notes appear in the CPT manual? (Notes appear throughout CPT and are listed before and after the codes that they pertain to.) • What is the role of notes? (Special instructions that must be followed for coding to be accurate)
SXS11ierPPT-INTC13_P1 • What are the two types of codes used in the CPT manual? Stand-alone codes have complete, full descriptions attached to them. Indented codes are listed under related stand-alone codes. Descriptions for these codes depend on information in the code that precedes them. NOTE TO INSTRUCTOR: If preferred, the order of slides 30 and 31 can be switched.
SXS11ierPPT-INTC13_P1 • What does a semicolon signify when used with CPT codes? It divides the portion of the description that is related to all indented codes that follow it from the portion that pertains specifically and only to the current code. This convention is used throughout the CPT as a major space-saving device. It also increases readability by eliminating unnecessary repetition of text.
SXS11ierPPT-INTC13_P1 • To recap, when indented codes are used, a portion of the code description will be found in the last stand-alone code encountered before the code in question. The portion of the description for the stand-alone code that precedes the semicolon must be added to the description for the indented code.
SXS11ierPPT-INTC13_P1 • What are CPT modifiers? (Two-digit codes that are placed after the CPT code to give additional information to third-party payers.) • Have students provide examples of modifiers. • A complete list of all modifiers is found in Appendix A of the CPT.
SXS11ierPPT-INTC13_P1 • The HCPCS Level II codes also make use of modifiers, in this case, 2-character alphanumeric codes. These tend to relate mnemonically to the modification they describe. For example, -AS is used to indicate that a physician’s assistant delivered the procedure or service; -F1 indicates left hand, second digit.
SXS11ierPPT-INTC13_P1 • In this example, Code 43820 is the CPT procedure code for a gastrojejunostomy, without vagotomy. If two surgeons jointly performed this procedure, each performing a specific part of the procedure, code 43820 would be modified to reflect their joint participation, and the claim would indicate code 43820-62. Each surgeon would bill the third-party payer using this modified code, ensuring proper payment for both.
SXS11ierPPT-INTC13_P1 • Where is a modifier placed on the CMS-1500 Form? (Box 24D) • Note the excerpt from the CMS-1500 shown in slide 37. Section 24 includes a space in column D for the listing of any modifiers that apply to codes (CPT or HCPCS) also listed in column D. This is where the modifier should be entered on this form to ensure that the claim is processed correctly.
SXS11ierPPT-INTC13_P1 • Why are there unlisted services? (Because there may not be a more specific code to use) • What code is used to indicate an unlisted service? (The CPT codes ending in “99”) • On what basis are codes for unlisted services categorized? (They are found at the end of each subsection and therefore categorized by body area.) • Sometimes, Category III codes may exist for procedures that lack a specific code within the CPT. In this case, the Category III code and not the unlisted procedure code must be used.
SXS11ierPPT-INTC13_P1 • A written report is required to explain the use of an unlisted code. • Special reports must accompany claims when an unusual, new, seldom used, Category III, or unlisted procedure is performed. • Whose responsibility is it to develop this report? (The physician who performed the procedure) • What is the purpose of the special written report? (It helps the third-party payer determine if the procedure performed was appropriate and medically necessary.)
SXS11ierPPT-INTC13_P1 • What do Category I codes designate? (These codes are widely used to describe services and procedures that have been approved by the FDA and/or that have proved to have clinical effectiveness.) • What does a Category III code represent? (It describes services and procedures that may or may not be approved by the FDA, be widely offered, or proved to be clinically effective.)
SXS11ierPPT-INTC13_P1 • What is the purpose of a Category II code? (Used for performance measurements) • Is use of a Category II code mandatory? (No, it’s optional and is intended to facilitate data collection.) • Category II codes provide supplemental information and are always used in combination with a Category I or Category III code.
SXS11ierPPT-INTC13_P1 • What is the purpose of Category III codes? (They were added in 2002 to provide for coding of procedures and services based on emerging technologies.) • Category III codes are alphanumeric and can be found at the end of the CPT. • Category III codes may eventually achieve Category I status; however, there is no guarantee that this will be the case.
SXS11ierPPT-INTC13_P1 • As noted previously, Category III codes exist for procedures that lack a specific code within the CPT. These codes must be used instead of the unlisted services codes. When neither a Category I nor III code exists, an unlisted code should be used.
SXS11ierPPT-INTC13_P1 • What is the purpose of using the Index in the back of the CPT manual? (It speeds up location of the term or code.) • Is the CPT Index listed alphabetically or numerically? (Alphabetically) • When should you code only from the CPT Index? (Never)
SXS11ierPPT-INTC13_P1 • This slide includes procedures that fall alphabetically between Repair, Iris and Repair, Toe, as the guide words at the top of the page suggest. • Entries may be single codes, multiple codes, or a range of codes, depending on the entry noted in the Index.
SXS11ierPPT-INTC13_P1 • Listed single codes: They will be the only entries listed for the indexed item. • Listed multiple codes: Relevant individual codes are listed and separated by commas. • Listed range of codes: Beginning and ending codes for the range are listed with a hyphen.
SXS11ierPPT-INTC13_P1 • What are the location methods used when a coder must search the Index for the correct code for a procedure or service? • For the first three circumstances listed in slide 46 (Service or Procedure, Anatomic Site, Condition or Disease), find the main term in the Index, and then find one of the subterms that applies. • For the second set of three circumstances, find the synonym, eponym, or abbreviation, and the Index will direct you to the appropriate main entry.
SXS11ierPPT-INTC13_P1 • Is it necessary to read all of the notes that apply to a code? Why? (Yes; the entire description attached to the code, and any notes that apply to it, must be reviewed to ensure that it is the right code to use in the current situation.)
SXS11ierPPT-INTC13_P1 • How is the term see used in the Index of the CPT manual? (It is a cross-reference term found whenever you search for synonyms, eponyms, and abbreviations in the CPT Index.) • What does it indicate? (The term directs you to another term or terms, and it is there that the correct code will be found.)
SXS11ierPPT-INTC13_P1 • CPT coding is only one portion of a two-part coding system called HCPCS (pronounced “hick-picks”), which stands for Healthcare Common Procedure Coding System. • What is included in HCPCS? (A collection of codes that represent procedures, supplies, products, and services that may be provided to Medicare and Medicaid beneficiaries and to individuals enrolled in private health insurance programs) SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • Level I codes are the CPT codes in the CPT manual, the primary coding system used in the outpatient setting to code professional services provided to patients. • Level II codes are five-position alphanumeric codes that represent physician and nonphysician services not represented in the Level I codes. • Level III codes are no longer used; some of these have been integrated into the national codes (HCPCS). SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • Local codes are no longer available since the implementation of HIPAA. • What does HIPAA stand for? (Health Insurance Portability and Accountability Act) SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • Allied health care professionals such as dentists and orthodontists and various technical support services such as ambulance services are not covered by the CPT. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • No codes in the CPT coding system pertain to the supplies used in patient care. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 Why is HCPCS becoming more popular? (More and more payers are requiring use of HCPCS codes) SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • The first digit in the national code is a letter—A, B, C, D, E, G, H, J, K, L, M, P, Q, R, S, T, or V. • These letters each have a meaning and are followed by a 4-digit numeric code. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • Codes beginning with G, K, Q, and S are used for temporary assignment until a definitive decision can be made about appropriate code assignment. • What are K codes used for? (Durable medical equipment) • What are G codes used for? (Procedures and professional services) • What are Q codes used for? (Drugs, biologicals, and medical equipment) • What are S codes used for? (Blue Cross/Blue Shield codes that are not valid for Medicare or Medicaid patients) SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • Some codes are not covered by insurance. • Calling your local carrier will assist in letting the patient know if something will be covered by their insurance. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • National codes are not used by health care facilities to code for services provided to inpatients. • Inpatient health care facilities use the diagnosis from the ICD-9-CM (not the service rendered) as the basis of payment for their services. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • Why must coders be able to locate items in the index? (So they can identify the correct code) • Remember to never code from the index, whether you are using the ICD-9 book, CPT book, or HCPCS book. You must reference the main portion, tabular portion, in order to assign the correct codes. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • What is included in the main index terms? (Tests, services, supplies, orthoses, prostheses, medical equipment, drugs, therapies, and some medical and surgical procedures) SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • The subterms of the index are listed under the main term to which they apply, along with the code. • The coder then locates the code in the main part of the manual and reads any notes that are listed under the code. • The entries in the index may be listed under more than one main term. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • More than 50 alphabetical modifiers are available for assignment, to add further specificity to the five-digit national code. • What are some examples of how modifiers can be used? (Modifiers can be used to specify the service provider, the anatomic site, etc.) • Modifiers can be found in the indexes of the coding manuals. There is a difference between CPT and HCPCS modifiers. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • HCPCS modifiers are 2-digit alpha or alpha-numeric codes. • Some HCPCS modifiers are used often in a clinic setting. Body site location modifiers are used often. • What is the correct modifier to show that the procedure was performed on the Right thumb? (F5) • These codes are highly used by podiatrists, but any physician can use these modifiers. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • HCPCS modifiers better define the location of the procedure. • RT and LT modifiers are probably the most common HCPCS modifiers used in a clinic setting. These are to be used anytime you have a body area that has a mirror image. • Would you use an -RT or -LT modifier if a patient had a procedure done on his right arm? (Yes, an -RT) • Would you use a -RT or -LT modifier if the patient had a procedure done on her left hand, fourth digit? (No, because there is a specific modifier for this -F3) SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • HCPCS modifiers also define the origin of who saw the patient and location of where the service occurred. • First letter indicates the origin, who saw the patient. • The second letter shows the destination, where the service occurred. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • J codes are used to identify the drugs administered and the dosages given. • How can you find the generic name of a drug when only the brand name is referenced in the medical documentation? (Use the drug reference book.) • The Route of Administration column lists the most common methods used to deliver the referenced generic drug. • Make sure when billing drugs you have the proper dosage for that J code so your units will be correct. Improper units will mean lost revenue for your facility. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • What is durable medical equipment (DME)? (Equipment used by a patient with a chronic disabling condition) • The term also includes some equipment that is used only temporarily. • Claims for DME can be paid only if the items meet the Medicare definition of covered DME and are deemed medically necessary. • A sample of the DME form is provided in Fig. 13–28 on p. 243 of the text. SXS08ierPPTC13_P2
SXS11ierPPT-INTC13_P1 • A sample of this form is provided in Fig. 13–29 on p. 244 of the text. SXS08ierPPTC13_P2
CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)
Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent)