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Survey of Medical Insurance pp ch05
 

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 Survey of Medical Insurance pp ch05 Presentation Transcript

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