5 Procedural Coding: Introduction to CPT
Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>5.1  Discuss the purpose of...
Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>5.7  Describe t...
Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>5.11  Explain w...
Key Terms <ul><li>add-on code </li></ul><ul><li>ancillary services </li></ul><ul><li>bundling </li></ul><ul><li>Category I...
Key Terms (Continued) <ul><li>professional component (PC) </li></ul><ul><li>resequenced </li></ul><ul><li>secondary proced...
5.1 Current Procedural Terminology, Fourth Edition (CPT) <ul><li>Procedure codes for physicians’ and other health care pro...
5.2 Organization <ul><li>CPT contains the main text, which has six sections of Category I codes: </li></ul><ul><ul><li>Eva...
5.2 Organization (Continued) <ul><li>Section guidelines— usage notes at the beginnings of CPT sections </li></ul><ul><li>U...
5.3 Format and Symbols <ul><li>CPT uses a semicolon and indentions when a common part of a main entry applies to entries t...
5.3 Format and Symbols (Continued) <ul><li>Seven symbols are used in CPT: </li></ul><ul><ul><li>●  (a bullet or black circ...
5.3 Format and Symbols (Continued) <ul><li>Seven symbols are used in CPT (continued): </li></ul><ul><ul><li>5.   (a bulle...
5.3 Format and Symbols (Continued) <ul><li>Add-on code— procedure performed and reported in addition to a primary procedur...
5.4 CPT Modifiers <ul><li>A CPT  modifier  is a two-digit number that may be attached to most five-digit procedure codes <...
5.5 Coding Steps <ul><li>The six general steps for selecting correct CPT procedure codes: </li></ul><ul><ul><li>Step 1.  R...
5.6 Evaluation and Management Codes <ul><li>E/M codes  (evaluation and management codes)—cover physicians’ services perfor...
5.6 Evaluation and Management Codes (Continued) <ul><li>Consultation— service in which a physician advises a requesting ph...
5.7 Anesthesia Codes <ul><li>The codes in the Anesthesia section are used to report anesthesia services performed or super...
5.7 Anesthesia Codes (Continued) <ul><li>Patient’s physical status is selected from this list: </li></ul><ul><ul><li>P1: N...
5.8 Surgery Codes <ul><li>Codes in the Surgery section are used for surgical procedures performed by physicians </li></ul>...
5.8 Surgery Codes (Continued) <ul><li>Reporting surgical codes: </li></ul><ul><ul><li>Bundling— using a single payment for...
5.9 Radiology Codes <ul><li>The Radiology section of CPT contains codes reported for radiology procedures either performed...
5.10 Pathology and Laboratory Codes <ul><li>Cover services provided by physicians or by technicians under the supervision ...
5.11 Medicine Codes <ul><li>Codes for the many types of evaluative, therapeutic, and diagnostic procedures that physicians...
5.12 Category II and Category III Codes <ul><li>Category II and Category III codes both have five characters—four numbers ...
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Survey of Medical Insurance pp ch05

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 5.1 Discuss the purpose of the CPT code set. Pages: 168-170 Teaching Notes:   Look over the examples of Category I, II, and III codes on page 169 with your students.
  • Learning Outcome: 5.2 Describe the organization of the index, the main text, and the appendixes in CPT. Pages: 170-175 Teaching Notes:   With your class, examine the definition, structure, and key guidelines for the six sections of Category I codes found in Table 5.1.
  • Learning Outcome: 5.2 Describe the organization of the index, the main text, and the appendixes in CPT. Pages: 170-175 Teaching Notes:   Review an example of section guidelines with your class.
  • Learning Outcome: 5.3 Summarize the format and seven of the symbols that are used in CPT. Pages: 175-177 Teaching Notes:   Provide your students with some examples of see or use entries. (Use the example on page 176 as a reference.)
  • Learning Outcome: 5.3 Summarize the format and seven of the symbols that are used in CPT. Pages: 175-177 Teaching Notes:   Have your students create flash cards with the seven symbols that are used in CPT to help them memorize the symbols.
  • Learning Outcome: 5.3 Summarize the format and seven of the symbols that are used in CPT. Pages: 175-177 Teaching Notes:   Have your students create flash cards with the seven symbols that are used in CPT to help them memorize the symbols.
  • Learning Outcome: 5.3 Summarize the format and seven of the symbols that are used in CPT. Pages: 175-177 Teaching Notes:   Ask your students to explain the difference between primary procedures and secondary procedures. (A primary procedure is the most resource-intensive CPT procedure during an encounter, while a secondary procedure is an additional procedure that is performed.)
  • Learning Outcome: 5.4 Describe the purpose and correct use of CPT modifiers. Pages: 177-180 Teaching Notes:   Have your students explain the difference between a TC and a PC, in their own words.
  • Learning Outcome: 5.5 List the six general steps for selecting correct CPT procedure codes. Pages: 181-183 Teaching Notes:   Thoroughly examine the six steps for selecting correct CPT procedure codes with your students.
  • Learning Outcome: 5.6 Explain how the key components are used as the basis for selection of CPT Evaluation and Management codes. Pages: 183-195 Teaching Notes:   Examine the E/M categories and subcategories (found in Table 5.3) with your students.
  • Learning Outcome: 5.6 Explain how the key components are used as the basis for selection of CPT Evaluation and Management codes. Pages: 183-195 Teaching Notes:   Ask your students to explain the occasional need for consultations.
  • Learning Outcome: 5.7 Describe the purpose and the physical status modifiers used in the Anesthesia section of CPT Category I codes. Pages: 196-198 Teaching Notes:   Review the complete usual services of an anesthesiologist with your students. (Usual preoperative visits for evaluation and planning, care during the procedures, and routine postoperative care.)
  • Learning Outcome: 5.7 Describe the purpose and the physical status modifiers used in the Anesthesia section of CPT Category I codes. Pages: 196-198 Teaching Notes:   Review the list of physical status modifiers with your students. (P1 - Normal, healthy patient; P2 - Patient with mild systemic disease; P3 - Patient with 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.)
  • Learning Outcome: 5.8 Recognize the concepts of the surgical package and of separate procedures in the Surgery section of CPT Category I codes. Pages: 198-203 Teaching Notes:   Review the modifiers that are commonly used to indicate special circumstances involved with surgical procedures with your students. (See pages 200-202.)
  • Learning Outcome: 5.8 Recognize the concepts of the surgical package and of separate procedures in the Surgery section of CPT Category I codes. Pages: 198-203 Teaching Notes:   Have your students explain the reason(s) why the acts of unbundling and fragmented billing are incorrect billing practices.
  • Learning Outcome: 5.9 State the purpose of the Radiology section of CPT Category I codes. Pages: 203-204 Teaching Notes:   Ask your students to differentiate between the technical and professional components for radiology codes.
  • Learning Outcome: 5.10 Describe the correct use of codes for laboratory panels in the pathology and laboratory of CPT Category I codes. Pages: 204-205 Teaching Notes:   Ask your students what a complete procedure under the Pathology and Laboratory section includes. (Ordering the test; taking and handling the sample; performing the actual test; analyzing and reporting on the test results.)
  • Learning Outcome: 5.11 Explain why two codes from the Medicine section of CPT Category I codes are reported for immunizations. Pages: 206-207 Teaching Notes:   Go over the commonly used codes in the Medicine section with your students. (- 22, -26, -32, -51, -52, -53, -55, -56, -57, -58, -59, -76, -77, -78, -79, -90, -91, and -99.)
  • Learning Outcome: 5.12 Compare the purpose of Category II and Category III codes. Page: 207 Teaching Notes:   Ask your students to summarize the purposes of Category II and Category III codes.
  • Survey of Medical Insurance pp ch05

    1. 1. 5 Procedural Coding: Introduction to CPT
    2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>5.1 Discuss the purpose of the CPT code set. </li></ul><ul><li>5.2 Describe the organization of the index, the main text, and the appendixes in CPT. </li></ul><ul><li>5.3 Summarize the format and seven of the symbols that are used in CPT. </li></ul><ul><li>5.4 Describe the purpose and correct use of CPT modifiers. </li></ul><ul><li>5.5 List the six general steps for selecting correct CPT procedure codes. </li></ul><ul><li>5.6 Explain how the key components are used as the basis for selection of CPT Evaluation and Management codes. </li></ul>5-2
    3. 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>5.7 Describe the purpose and the physical status modifiers used in the Anesthesia section of CPT Category I codes. </li></ul><ul><li>5.8 Recognize the concepts of the surgical package and of separate procedures in the Surgery section of CPT Category I codes. </li></ul><ul><li>5.9 State the purpose of the Radiology section of CPT Category I codes. </li></ul><ul><li>5.10 Describe the correct use of codes for laboratory panels in the Pathology and Laboratory section of CPT Category I codes. </li></ul>5-3
    4. 4. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>5.11 Explain why two codes from the Medicine section of CPT Category I codes are reported for immunizations. </li></ul><ul><li>5.12 Compare the purpose of Category II and Category III codes. </li></ul>5-4
    5. 5. Key Terms <ul><li>add-on code </li></ul><ul><li>ancillary services </li></ul><ul><li>bundling </li></ul><ul><li>Category I codes </li></ul><ul><li>Category II codes </li></ul><ul><li>Category III codes </li></ul><ul><li>conscious sedation </li></ul><ul><li>consultation </li></ul><ul><li>Current Procedural Terminology (CPT) </li></ul><ul><li>descriptor </li></ul>5-5 <ul><li>E/M codes (evaluation and management codes) </li></ul><ul><li>fragmented billing </li></ul><ul><li>global period </li></ul><ul><li>global surgery rule </li></ul><ul><li>key component </li></ul><ul><li>modifier </li></ul><ul><li>outpatient </li></ul><ul><li>panel </li></ul><ul><li>physical status modifier </li></ul><ul><li>primary procedure </li></ul>
    6. 6. Key Terms (Continued) <ul><li>professional component (PC) </li></ul><ul><li>resequenced </li></ul><ul><li>secondary procedure </li></ul><ul><li>section guidelines </li></ul><ul><li>separate procedure </li></ul><ul><li>special report </li></ul><ul><li>surgical package </li></ul><ul><li>technical component (TC) </li></ul><ul><li>unbundling </li></ul>5-6 <ul><li>unlisted procedure </li></ul>
    7. 7. 5.1 Current Procedural Terminology, Fourth Edition (CPT) <ul><li>Procedure codes for physicians’ and other health care providers’ services are selected from the Current Procedural Terminology code set </li></ul><ul><li>Category I codes— five-digit procedure codes found in the main body of CPT </li></ul><ul><ul><li>Each code has a descriptor —a brief explanation of the procedure </li></ul></ul><ul><li>Category II codes— optional CPT codes that track performance measures </li></ul><ul><li>Category III codes— temporary codes for emerging technology, services, and procedures </li></ul>5-7
    8. 8. 5.2 Organization <ul><li>CPT contains the main text, which has six sections of Category I codes: </li></ul><ul><ul><li>Evaluation and Management </li></ul></ul><ul><ul><li>Anesthesia </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Radiology </li></ul></ul><ul><ul><li>Pathology and Laboratory </li></ul></ul><ul><ul><li>Medicine </li></ul></ul><ul><li>Category II and Category III codes have 14 appendixes and an index </li></ul>5-8
    9. 9. 5.2 Organization (Continued) <ul><li>Section guidelines— usage notes at the beginnings of CPT sections </li></ul><ul><li>Unlisted procedure— service not listed in CPT </li></ul><ul><li>Special report— note explaining the reasons for a new, variable, or unlisted procedure or service </li></ul>5-9
    10. 10. 5.3 Format and Symbols <ul><li>CPT uses a semicolon and indentions when a common part of a main entry applies to entries that follow </li></ul><ul><li>Some codes and descriptors are followed by indented see or use entries in parentheses, which refer the coder to other codes </li></ul><ul><li>Descriptors often contain clarifying examples in parentheses, sometimes with the abbreviation e.g. </li></ul>5-10
    11. 11. 5.3 Format and Symbols (Continued) <ul><li>Seven symbols are used in CPT: </li></ul><ul><ul><li>● (a bullet or black circle) indicates a new procedure code </li></ul></ul><ul><ul><li>▲ (a triangle) indicates that the code’s descriptor has changed </li></ul></ul><ul><ul><li>►◄ (facing triangles) enclose new or revised text other than the code’s descriptor </li></ul></ul><ul><ul><li>+ (a plus sign) before a code indicates an add-on code that is used only along with other codes for primary procedures </li></ul></ul>5-11
    12. 12. 5.3 Format and Symbols (Continued) <ul><li>Seven symbols are used in CPT (continued): </li></ul><ul><ul><li>5.  (a bullet in a circle) next to a code means that conscious sedation is a part of the procedure that the surgeon performs </li></ul></ul><ul><ul><li>6.  (a lightning bolt) is used for codes for vaccines that are pending FDA approval </li></ul></ul><ul><ul><li># (a number sign) indicates a resequenced code </li></ul></ul><ul><li>Resequenced— CPT procedure codes that have been reassigned to another sequence </li></ul>5-12
    13. 13. 5.3 Format and Symbols (Continued) <ul><li>Add-on code— procedure performed and reported in addition to a primary procedure </li></ul><ul><li>Primary procedure— most resource-intensive CPT procedure during an encounter </li></ul><ul><li>Secondary procedure— additional procedure performed </li></ul><ul><li>Conscious sedation— moderate, drug-induced depression of consciousness </li></ul>5-13
    14. 14. 5.4 CPT Modifiers <ul><li>A CPT modifier is a two-digit number that may be attached to most five-digit procedure codes </li></ul><ul><ul><li>Modifiers communicate special circumstances involved with procedures </li></ul></ul><ul><li>A procedure has two parts: </li></ul><ul><ul><li>Technical component (TC)— reflects the technician’s work and the equipment and supplies used in performing it </li></ul></ul><ul><ul><li>Professional component (PC)— represents a physician’s skill, time, and expertise used in performing it </li></ul></ul>5-14
    15. 15. 5.5 Coding Steps <ul><li>The six general steps for selecting correct CPT procedure codes: </li></ul><ul><ul><li>Step 1. Review complete medical documentation </li></ul></ul><ul><ul><li>Step 2. Abstract the medical procedures from the visit documentation </li></ul></ul><ul><ul><li>Step 3. Identify the main term for each procedure </li></ul></ul><ul><ul><li>Step 4. Locate the main terms in the CPT index </li></ul></ul><ul><ul><li>Step 5. Verify the code in the CPT main text </li></ul></ul><ul><ul><li>Step 6. Determine the need for modifiers </li></ul></ul>5-15
    16. 16. 5.6 Evaluation and Management Codes <ul><li>E/M codes (evaluation and management codes)—cover physicians’ services performed to determine the optimum course for patient care </li></ul><ul><li>Key component— factor documented for various levels of evaluation and management services </li></ul><ul><li>Key components for selecting E/M codes: </li></ul><ul><ul><li>The extent of the history documented </li></ul></ul><ul><ul><li>The extent of the examination documented </li></ul></ul><ul><ul><li>The complexity of the medical decision making </li></ul></ul>5-16
    17. 17. 5.6 Evaluation and Management Codes (Continued) <ul><li>Consultation— service in which a physician advises a requesting physician about a patient’s condition and care </li></ul><ul><li>Outpatient— patient who receives health care in a hospital setting without admission </li></ul>5-17
    18. 18. 5.7 Anesthesia Codes <ul><li>The codes in the Anesthesia section are used to report anesthesia services performed or supervised by a physician </li></ul><ul><li>Two types of modifiers are used with anesthesia codes: </li></ul><ul><ul><li>Modifier that describes the patient’s health status </li></ul></ul><ul><ul><li>Standard modifiers </li></ul></ul><ul><li>Physical status modifier —code used with procedure codes to indicate a patient’s health status </li></ul>5-18
    19. 19. 5.7 Anesthesia Codes (Continued) <ul><li>Patient’s physical status is selected from this list: </li></ul><ul><ul><li>P1: Normal, healthy patient </li></ul></ul><ul><ul><li>P2: Patient with mild systemic disease </li></ul></ul><ul><ul><li>P3: Patient with severe systemic disease </li></ul></ul><ul><ul><li>P4: Patient with severe systemic disease that is a constant threat to life </li></ul></ul><ul><ul><li>P5: Moribund patient who is not expected to survive without the operation </li></ul></ul><ul><ul><li>P6: Declared brain-dead patient whose organs are being removed for donation purposes </li></ul></ul>5-19
    20. 20. 5.8 Surgery Codes <ul><li>Codes in the Surgery section are used for surgical procedures performed by physicians </li></ul><ul><li>Surgical package ( or global surgery rule)– combination of services included in a single procedure code </li></ul><ul><ul><li>Global period— days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package </li></ul></ul><ul><ul><li>Separate procedure— descriptor used for a procedure that is usually part of a surgical package but may also be performed separately </li></ul></ul>5-20
    21. 21. 5.8 Surgery Codes (Continued) <ul><li>Reporting surgical codes: </li></ul><ul><ul><li>Bundling— using a single payment for two or more related procedure codes </li></ul></ul><ul><ul><li>Unbundling— incorrect billing practice of breaking a panel or package of services/procedures into component parts </li></ul></ul><ul><ul><li>Fragmented billing— incorrect billing practice in which procedures are unbundled and separately reported </li></ul></ul>5-21
    22. 22. 5.9 Radiology Codes <ul><li>The Radiology section of CPT contains codes reported for radiology procedures either performed by or supervised by a physician </li></ul><ul><li>Radiology codes follow the same types of guidelines as noted in the Surgery section </li></ul><ul><ul><li>Contain a technical component and a professional component </li></ul></ul>5-22
    23. 23. 5.10 Pathology and Laboratory Codes <ul><li>Cover services provided by physicians or by technicians under the supervision of physicians </li></ul><ul><li>Panel— single code grouping laboratory tests frequently done together </li></ul><ul><ul><li>To report a panel code, all the indicated tests must have been done, and any additional test is coded separately </li></ul></ul>5-23
    24. 24. 5.11 Medicine Codes <ul><li>Codes for the many types of evaluative, therapeutic, and diagnostic procedures that physicians perform </li></ul><ul><ul><li>Immunizations require two codes from the Medicine section, one for administering the immunization and the other for the particular vaccine or toxoid that is given </li></ul></ul><ul><li>Ancillary services— services used to support a diagnosis </li></ul>5-24
    25. 25. 5.12 Category II and Category III Codes <ul><li>Category II and Category III codes both have five characters—four numbers and a letter </li></ul><ul><ul><li>Category II codes are for tracking performance measures to improve patients’ health </li></ul></ul><ul><ul><li>Category III codes are temporary codes for new procedures that may enter the Category I code set if they become widely used in the future </li></ul></ul>5-25
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