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Surgery, Radiology, Pathology/Laboratory, and Medicine. CODING PROCEDURES Part II:. Chapter 6. PROCEDURAL CODING PART II. Learning Objectives Define procedure code terminology. Explain the purpose of coding for professional services. List all subsections of Surgery section.

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surgery radiology pathology laboratory and medicine

Surgery, Radiology, Pathology/Laboratory, and Medicine

CODING PROCEDURES Part II:

Chapter 6

Chapter 6

procedural coding part ii
PROCEDURAL CODING PART II
  • Learning Objectives
    • Define procedure code terminology.
    • Explain the purpose of coding for professional services.
    • List all subsections of Surgery section.
    • Compare comprehensive codes and component codes.

Chapter 6

procedural coding part ii1
PROCEDURAL CODING PART II
  • Learning Objectives
    • Distinguish between surgical package and Medicare global package rules.
    • Describe two ways to code for multiple procedures.
    • Demonstrate an understanding of surgical terminology.
    • Explain situations in which modifiers are applied to surgical codes.

Chapter 6

procedural coding part ii2
PROCEDURAL CODINGPART II
  • Performance Objective
    • Locate a code in the Surgery section by using the index.
    • Code scenarios presented in the worktext from all of CPT.
    • Apply CPT and HCPCS Level II modifiers when appropriate.

Chapter 6

key terms
Add-on code

Anesthesia

Bilateral Procedure

Bundled Code

Closed Fracture

Closed Treatment

Component Code

Comprehensive Code

Downcoding

Elective Surgery

Endoscopy

Fixation

Fracture Manipulation

Global Surgery Policy

Indented Code

Open Fracture

Open Treatment

Percutaneous Treatment

Professional Component (PC)

Key Terms

Chapter 6

key terms1
Key Terms
  • Test Panel
  • Unbundling
  • Upcoding
  • Qualitative Analysis
  • Quantitative Analysis
  • Separate Procedures
  • Stand-alone Codes
  • Surgical Package
  • Technical Component (TC)

Chapter 6

coding procedures services introduction to the surgery section 10040 69979
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Introduction to the Surgery Section
      • Largest Section of the CPT Codebook
      • 16 Subsections, divided according to Body Systems
      • Guidelines are found at the beginning of the Surgery Sections.
      • Subsection further divided into Categories based on Anatomic Site
      • Subcategories are within each Category which list the type of procedure or condition.

Chapter 6

coding procedures services introduction to the surgery section 10040 699791
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • How to Code Effectively
    • You must be able to analyze a proceduredescriptionand identify various terms that will direct you to the correct code.
    • To do this you must know the main categories under which services and procedures are listed according to their main term in the index.
    • After the procedure,service, or condition is identified in the index, search for asubterm and a sub-subterm that further defines the procedure.

Chapter 6

coding procedures services introduction to the surgery section 10040 699792
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • How to Code Effectively – Cont.
    • When a code range is found, turn to the correct section and read all descriptions listed under the code range before selecting a code.
  • Performance Exercise
        • Table 6-2/Page 138

Chapter 6

coding procedures services introduction to the surgery section 10040 699793
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • How to Code Effectively
      • Identify Main Term(s) in the Procedure Description of the Medical Record
      • LocateMain Term(s) in the Index & Document Code Range
      • Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
      • Select the Correct Code

Chapter 6

coding procedures services introduction to the surgery section 10040 69979 performance exercise
Coding Procedures & ServicesIntroduction to theSurgery Section/(10040-69979)PERFORMANCE EXERCISE
  • Excision of tendon, finger, flexor, single (separate procedure), each

26180

  • How to Code Effectively
      • Identify Main Term(s) in the Procedure Description of the Medical Record
      • LocateMain Term(s) in the Index & Document Code Range
      • Turn to the Correct Section of the CPT & Read all Description listed in the Code Range
      • Select the Correct Code

Chapter 6

coding procedures services introduction to the surgery section 10040 699794
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • How to Code Effectively – Cont.
      • Stand-alone Codes – are procedure codes that have a full description.
        • Comes before the (;)
        • Terminology after the (;) has a Dependent Status as the Subsequent Indented Entries
    • Performance Exercise
        • Figure 6-3/Page 138

Chapter 6

coding procedures services introduction to the surgery section 10040 699795
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • How to Code Effectively – Cont.
      • Indented Codes – are listed after stand-alone codes whose descriptions have a dependent status.
      • To read the description, you must first read the description of the stand-alone code that comes before the semicolon (;)and,
      • then continue with the indented description listed by the subsequent code (indented code).
      • Performance Exercise
        • Figure 6-3/Page 138

Chapter 6

coding procedures services introduction to the surgery section 10040 699796
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Integral Code Description
        • One Code is part of another based on language used in the description
        • Example 6-2/Page139
    • Parentheses ( ) further define & tell where other services are located
        • Figure 6-4/Page 139

Chapter 6

coding steps
Coding Steps

Step 1 Become familiar with CPT codes

Step 2 Find the services listed on patient encounter form

Step 3 Look up codes in index, then look up actual code

Step 4 Determine appropriate modifiers

Step 5Record the procedure code on the insurance claim; PROOFREAD numbers

Chapter 6

coding procedures services introduction to the surgery section 10040 699797
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Coding from the Operative Report
        • Read the Operative report thoroughly & code on documented operations
        • Determine Bundled or Unbundled Procedures
        • Never Code Verbal Procedures
        • Coding Rule:“Not Documented, Not Done”!

Chapter 6

coding procedures services introduction to the surgery section 10040 699798
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)

Operative Report

Date of Service: 5/17/03

Surgeon: Jeffrey Thompson, MD

Assistant Surgeon: None

Preoperative Diagnosis: RLQ pain, probable appendicitis

Postoperative Diagnosis: Acute appendicitis

Procedures Performed: Exploratory laparotomy, appendectomy

Anesthesia: General Endotracheal

Chapter 6

coding procedures services introduction to the surgery section 10040 699799
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Decision for Surgery -
    • Criteria to Evaluate
      • Is patient new or established?
      • Is the E/M service significant and separately identifiable from the procedure?
      • What is the time lapse from the time the decision is made for surgery to the time when the procedure is performed?
    • Performance Exercise
        • Figure 6-4/Page 141

Chapter 6

coding procedures services introduction to the surgery section 10040 6997910
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Decision for Surgery
    • -57 (Modifier) – An E/M service that resulted in the initial decision to perform the surgery.
    • -25 (Modifier) - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

Chapter 6

coding procedures services introduction to the surgery section 10040 6997911
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Surgical Package is a combination of services included in a single procedure code for some surgical procedures in the CPT.
  • Governmental Programs & Insurance Companies assign fees to surgical package codes that reimburse all services provided under them.
    • The period of time that is covered for follow-up care is referred to as the Global Period.
  • For Example, the Global Period for repairing a Tendon might be set at 15 days.

Chapter 6

coding procedures services introduction to the surgery section 10040 6997912
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Surgical Package – Cont.
  • A Global Period for Major Surgery such as Appendectomy may be set at 100 days.
  • After the Global Period ends additional services that are provided can be reported separately for additional payment.

Chapter 6

coding procedures services introduction to the surgery section 10040 6997913
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Surgical Package – Cont.
  • Surgical Package Includes
      • Combination of Services
      • Global Period
      • Surgical Procedures
      • Anesthesia
      • Related E/M Encounter
      • Postoperative Care
  • Private Carriers
      • May have an individual policy on what is included in the package.

Chapter 6

coding procedures services introduction to the surgery section 10040 6997914
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • MedicareGlobal Package - Included
    • Preoperative E/M Services
    • Intraoperative Services
    • Postoperative Visits
    • Complications after surgery without addition trips to the operating room
    • Anesthesia
    • Supplies necessary for performance of the procedure

Chapter 6

coding procedures services introduction to the surgery section 10040 6997915
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Medicare Global Package -Excluded
    • Initial Consultation or Evaluation
    • Diagnostic Tests & Procedures
    • Treatment required to stabilize a seriously ill patient before surgery
    • Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed (modifier –24)
    • Related Procedures for postoperative complications that requires a return trip to the operating room (modifier –78)
    • Immunosuppressive Therapy after transplant surgery
    • For services performed in a physician’s office, separate payment may be made for splints and casting supplies, and a surgical tray.

Chapter 6

coding procedures services introduction to the surgery section 10040 6997916
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Follow-Up Days
    • Vary 0-day or 10-day for Minor Surgeries
    • 45-day or 90-day for Major Surgeries
    • Most States use Relative Value Studies fee schedule for Worker’s Compensation cases
      • List the follow-up days allowed for most surgical procedures
    • Federal Register
      • Published annually
      • List follow-up days for Medicare Services

Chapter 6

coding procedures services introduction to the surgery section 10040 6997917
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Multiple Procedure Modifier –51
    • Report the primary serviceor procedure(identified by the highest dollar value listed)
    • Identify all additional services or Procedures by appending code(s) with modifier–51or use the separate five-digit modifier09951
    • Appendix E – Summary of CPT Codes Exempt from Modifier 51

Chapter 6

coding procedures services introduction to the surgery section 10040 6997918
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Add-on Code
    • Noted by a Cross (+)Symbol represents additional Procedure done with Primary Procedure
    • Found in Appendix D of CPT
    • Can not billed without the primary procedure
  • Add-on-Code Description start with:
    • “in addition”
    • “list separately
    • Or “second lesion”
  • Performance Exercise
    • Example 6-5/Example 6-6/Page 143

Chapter 6

coding procedures services introduction to the surgery section 10040 6997919
Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979)
  • Add-on Code – Cont.
    • Bilateral Procedures - is one procedure performed on two sides.
    • Two ways to Bill
        • List the CodeOncewith Modifier–50 & doublethe fee
        • List the CodeTwiceusing asinglefee & add thesecond listing with Modifier–50
    • Performance Exercise
        • Example 6-7/Page 143

Chapter 6

coding procedures services introduction to the surgery section 10000 19999
Coding Procedures & ServicesIntroduction to the Surgery Section(10000-19999)
  • Assistant At Surgery
    • Modifiers
      • -80 Assistant surgeon
      • -81 Minimum Assist Surgeon
      • -82 Assistant surgeon (when qualified resident surgeon not available)
      • -62 Two Surgeons
      • -66 Surgical Team

The Surgeon who assist is usually paid a fee of 16 to 30 percent of the allowed fee of the primary Surgeon.

    • Performance Exercise
        • Example 6-8/Page 144

Chapter 6

coding procedures services surgery integumentary system 10000 19999
Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)
  • Integumentary System
      • First Subsection listed in the Surgery Section
      • Contains Procedures performed on the Skin
  • Benign versus Malignant
    • Neoplasm – must indicate benign or malignant
    • Claim Form – should be delayed until the Pathologyreport can confirm or deny Benign vs Malignant
  • Lesion – is any discontinuity of the skin

Biopsy – performed for the purpose of determining the morphology (shape, form, & structure) is reported separately.

Biopsy of a lesion followed by excision would be included in the excision procedure code, and not reported separately.

Chapter 6

coding procedures services surgery integumentary system 10000 199991
Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)
  • Lesion –when coding removal of lesions note the:
    • Anatomic Site
    • Size, measured in centimeters
    • Number of lesions removed
    • Process used to remove the lesion (excision,destruction, paring, shaving)
    • Morphology(appearance of specimen’s shape and structure used to determine benign or malignant status)

Chapter 6

coding procedures services surgery integumentary system 10000 199992
Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)
  • Repair of Lacerations
    • Simple Closure – Superficial; involving the epidermis, dermis, or subcutaneous tissue.
    • Intermediate Closure – Requires layered closure of deeper subcutaneous tissue in addition to the simple closure.
    • Complex Closure – Requires more than one layered closure; debridement, scar revision, extensive undermining, stents, or retention sutures

Chapter 6

coding procedures services surgery integumentary system 10000 199993
Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)
  • Multiple Lesions
    • Modifier –51 (Multiple Procedures)
    • Read description & look for terms such as complicated, complex, more than, etc
    • Watch for Add-on-codes(+) VS Codes eligible for Modifier–51 & indented Codes
  • Surgical Supplies
    • Bundled into Surgical Code (99070) or HCPCS Level II Codes

Chapter 6

coding procedures services surgery integumentary system 10000 199994
Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)
  • Breast Category
    • Included within the Integumentary system because of the type of tissue involved.
    • Each Breast Considered Separate
    • If procedure occur on both sides useModifier –50 (bilateral)
  • Performance Exercise
      • Example 6-9, 6-10 & 6-11/Page 145-46

Chapter 6

coding procedures services surgery integumentary system 10000 19999 performance exercise
Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)PERFORMANCE EXERCISE
  • Breast reconstruction with free flap

19364

  • Preoperative placement of needle localization wire, breast:

19290

Chapter 6

coding procedures services surgery musculoskeletal system 20000 29999
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)
  • Musculoskeletal System
    • Arranged according to Anatomic Site
    • “General” first Category Contain Procedures & Subcategoriesfor different Anatomic Sites.
    • Remaining Categories Start from the “Head” to the “Toe”
  • Subcategories Under Each Anatomic Category Include:
    • Incision
    • Excision
    • Introduction/Removal

Chapter 6

coding procedures services surgery musculoskeletal system 20000 299991
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)
  • Subcategories Under Each Anatomic Category Include:
    • Fracture/Dislocation
    • Arthrodesis
    • Amputation
    • Unlisted Procedures
  • Fractures are:
    • Open/skin broken by the fragmented bone(Compound Fracture)
    • Closed/skin is not broken
    • Percutaneous/neither Opened or Closed

Chapter 6

coding procedures services surgery musculoskeletal system 20000 299992
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)
  • Coding Treatment of a Fracture
    • Locate the Anatomic Site
    • Find Subcategory“Fracture and/or Dislocation”
    • Then find the appropriate code
  • Description of Fractures are either:
    • “With Manipulation” or
    • “Without Manipulation”

Chapter 6

coding procedures services surgery musculoskeletal system 20000 299993
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)
  • Other Descriptive Terms Are:
    • “Internal Fixation”
    • “External Fixation”

Chapter 6

coding procedures services surgery musculoskeletal system 20000 299994
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)
  • Fracture Manipulation is:
    • The manual stretching or applying pressure or traction
    • to realign the broken (fractured) bone.
    • Referred to as “reduction”.
  • Fixation – is the use of hardware (instrumentation) to

keep a bone in place.

    • It can be applied internally(e.g., plates, rod, pin) or
    • Externally (e.g., pins that comes thru the skin to the

outside to keep the fractured bone from moving).

Chapter 6

coding procedures services surgery musculoskeletal system 20000 299995
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)
  • Fracture Follow-up Period:

 The surgical package rule applies.

All fracture code carry a 90-day follow-up

period.

  • Performance Exercise
      • Example 6-12/Page 147
      • Example 6-13/Page 147

Chapter 6

coding procedures services surgery musculoskeletal system 20000 29999 performance exercise
Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)PERFORMANCE EXERCISE
  • Closed treatment of mandibular fracture; without manipulation

21450

  • Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone.

26607

Chapter 6

coding procedures services surgery respiratory cardiovascular hemic lymphatic systems 30000 39999
Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)
  • Respiratory System
    • Organized by Anatomic Site
    • Then by Type of Procedure
    • Includes procedures of the nose, sinuses, larynx (voice box), trachea (windpipe), bronchial tubes, lungs, and pleura (membrane that surrounds the lung)

Chapter 6

coding procedures services surgery respiratory cardiovascular hemic lymphatic systems 30000 399991
Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)
  • Endoscopy –is the insertion of a flexible fiber-optic tube, called scope, through a small incision into a body cavity or into a natural body opening, such as the ears, nose, mouth, vagina, etc.
  • Diagnostic Endoscopy – is done for the purpose of visualization and determination of the disease process.
  • Diagnostic Endoscopy is always included in a surgical endoscopy and may not be billed separately

Chapter 6

coding procedures services surgery respiratory cardiovascular hemic lymphatic systems 30000 399992
Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)
  • Endoscopy Procedures
    • Diagnostic Endoscopy
    • Surgical Endoscopy
  • Endoscopies
    • Named for body area being explored
      • e.g., brochial tube/bronchoscopy
  • Performance Exercise
      • Example 6-14/Page 149

Chapter 6

slide47
Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)PERFORMANCE EXERCISE
  • Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)

31231

  • Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure)

31622

Chapter 6

coding procedures services surgery respiratory cardiovascular hemic lymphatic systems 30000 399993
Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)
  • Cardiovascular System
    • Organized by Anatomic Site
    • Then by Type of Procedure
  • Procedures Include:
    • Heart & Blood Vessels, including Pacemaker Implantation and Coronary Artery Bypass Graft (CABG)
  • For Additional Studies Refer to: Medicine Sections Under:
    • Cardiovascular/Therapeutic Services for:
      • Cardiography, Echocardiography, Cardiac Catheterization & Other Vascular Studies

Chapter 6

slide49
Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)PERFORMANCE EXERCISE
  • Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract

33414

  • Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography

92975

Chapter 6

coding procedures services surgery digestive system 40000 49999
Coding Procedures & ServicesSurgery:Digestive System(40000-49999)
  • Digestive System
    • Organized by Anatomic Site
    • Start with Lip & Mouth
    • Then continues thru the Rectum and Anus
  • Major Organs of the digestive system include:
      • Stomach
      • Intestines/small/large
      • Liver, Pancreas & Gallbladder

Chapter 6

coding procedures services surgery digestive system 40000 499991
Coding Procedures & ServicesSurgery:Digestive System(40000-49999)
  • Digestive System
  • Endoscopic Procedures used through-out subsection(i.e. Laparoscopy Incision)
      • Endoscopic procedures are coded according to the anatomic site examined
      • Notes defining proctosigmoidoscopy, sigmoidoscopy & colonoscopy are included under Rectum: Endoscopy

Chapter 6

coding procedures services surgery digestive system 40000 49999 performance exercise
Coding Procedures & ServicesSurgery:Digestive System (40000-49999)PERFORMANCE EXERCISE
  • Repair of palate; up to 2 cm

42180

  • Laparoscopy, surgical, appendectomy

44970

Chapter 6

coding procedures services surgery urinary male genital female genital systems 50000 58999
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems (50000-58999)
  • Urinary System
    • Organized by Anatomic Site & Type of Procedure
    • Include organs such as Kidney, Ureter & Bladder
  • Endoscopies include:
    • Renal Endoscopy, Ureteral endoscopy, Cystoscopy, Urethroscopy & Cystourethroscopy
  • Urodynamics
    • Separate subcategory found under Bladder
  • Urodynamics proceduremeasure how well the bladder stores and holds urine as well as the rate at which urine moves out of the bladder

Chapter 6

coding procedures services surgery urinary male genital female genital systems 50000 589991
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems (50000-58999)
  • Male Genital System
    • Divided by Anatomic Categories of Penis, Testis, Spermatic Cord, Prostate, etc
  • Lesions
    • May have specific code assigned

Chapter 6

coding procedures services surgery urinary male genital female genital systems 50000 589992
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems (50000-58999)
  • Male Genital System – Cont.
  • Interset Surgery
    • Is a Subsection following“Male Genital System”
  • Consist of only 2 Codes
      • 55970 – Intersex survey; male to female
      • 55980 – Female to male
  • Performance Exercise
      • Example 6-15/Page 150

Chapter 6

coding procedures services surgery urinary male genital female genital systems 50000 589993
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems (50000-58999)
  • Female Genital System/Maternity Care & Delivery
    • Organized by Anatomic Site
    • Subsection starts with the external genitalia
    • Then progress upward thru the female genital system to the uterus, fallopian & uterine tubes & conclude with the ovary
    • The last category is In Vitro- Fertilization

Chapter 6

coding procedures services surgery urinary male genital female genital systems 50000 589994
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems (50000-58999)
  • Incision & Drainage (I&D)
    • Codes in the subsection with notes directing you to theIntegumentary Systemfor specific I&D procedures
    • Read Code Descriptionto determine surgical approach is Vaginal or abdominal
    • Many codes include bilateral descriptions as well as a variety of procedures bundled together and routinely performed at same time of the operative session.
    • Performance Exercise
        • Figure 6-17/Page 150
        • Table 6-3/Page 151

Chapter 6

coding procedures services surgery urinary male genital female genital systems 50000 589995
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems (50000-58999)
  • Maternity Care & Delivery
    • Subsection following the Female Genital System Includes:
      • Antepartum, Vaginal Delivery & Cesarean Delivery
  • Delivery After Previous Cesarean Delivery
    • Category following Cesarean Delivery
    • Referred to as VBAC, or vaginal birth after cesarean
  • Abortion
    • Last Category within the subsection
  • Performance Exercise
    • Example 6-17/Page 150 & Table 6-3/Page 151

Chapter 6

slide59
Coding Procedures & ServicesSurgery:Urinary, Male Genital & Female Genital Systems/ (50000-58999)PERFORMANCE EXERCISE
  • Biopsy, prostate; needle or punch, single or multiple, any approach

55700

  • Biopsy of ovary, unilateral or bilateral (separate procedure)

58900

  • Aspiration of bladder by needle

51000

Chapter 6

coding procedures services surgery endocrine nervous eye ocular adnexa auditory systems 60000 69999
Coding Procedures & ServicesSurgery:Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems (60000-69999)
  • Nervous System
    • Code in subsections deals with bothCentral & Peripheral Nervous System
  • Procedures
      • Brain, spinal cord, & all types of nerves
      • Organized by Anatomic site & then Procedure

Chapter 6

coding procedures services surgery endocrine nervous eye ocular adnexa auditory systems 60000 699991
Coding Procedures & ServicesSurgery:Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems (60000-69999)
  • Eye & Ocular Adnexa/Auditory System
    • Includes Surgical Codes of the Eye & related visual structures.
    • Modifier –50(bilateral procedure) appended all procedures when done on both eyes.
    • Extensive Notes such as“previous eye surgery”are found through-out this subsection
  • Auditory System/Subsection
    • Divided into categories of External Ear, Middle Ear, Inner Ear & Temporal Bone Middle Fossa Approach

Chapter 6

coding procedures services surgery operating microscope 69990
Coding Procedures & ServicesSurgery:Operating Microscope(69990)
  • Operating Microscope
    • Last subsection of the Surgical section
    • Has only one code (69990 - for use of a operating microscope when the surgical code does not contain the microscope as an inclusive component)
    • Code 69990 used in all Surgery Subsections where Microscope needs to be coded (i.e. 19364- breast reconstruction)

Chapter 6

slide63
Coding Procedures & ServicesSurgery:Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Systems (60000-69999) PERFORMANCE EXERCISE
  • Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device

61107

  • Biopsy of Cornea

65410

Chapter 6

coding procedures services radiology section 70000 79999
Coding Procedures & ServicesRadiology Section(70000-79999)
  • Radiology Section
    • Include Nuclear Medicine & Diagnostic Ultrasound
  • Subsections/References are:
    • Diagnostic Radiology/X-ray index
    • Diagnostic Ultrasound/Ultrasound index
    • Radiation Oncology/RadiationTherapy index
    • Nuclear Medicine/Nuclear Medicine index

Chapter 6

coding procedures services radiology section 70000 799991
Coding Procedures & ServicesRadiology Section (70000-79999)
  • Professional & Technical Components
    • Professional Components
      • Tests/Procedures performs by Physiciansuch as interpreting an Electrocardiogram (ECG), reading an X-ray, or making an observation and determination using a microscope.
    • Technical Component
      • The use of equipment and its operators that perform the test or procedure, that is, the ECG machine and technician, radiography machine and technician and microscope technician.
    • When the physician performs both the professional & technical component there is know need to modify the Code.

Chapter 6

coding procedures services radiology section 70000 799992
Coding Procedures & ServicesRadiology Section (70000-79999)
  • Professional & Technical Components – cont.
  • Modify Procedures
      • Modifier -26/professional element used when the physician performs only the professional component
      • Modifier –TC/technical element used only when billing for technical component
  • Performance Exercise
    • Example 6-18/Page 152

Chapter 6

coding procedures services radiology section 70000 799993
Coding Procedures & ServicesRadiology Section (70000-79999)
  • Professional & Technical Components Cont.
    • Combination Coding - Is a code from one section of the procedural code book combined with a code from another section that is used to completely describe a procedure performed.
    • Services that maybe combined are:
      • Injection of contrast materials
      • Placement of catheters
      • Placement of guidewires
      • Placement of stents

Chapter 6

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Coding Procedures & ServicesRadiology Section (70000-79999)
    • Radiology Procedure
      • When a radiology procedure is performed from the required combined services:
        • A Code from theRadiology Sectiondescribes the Procedure
        • A Code from theSurgery Sectiondescribe the Combination Procedure
  • Performance Exercise
    • Example 6-19/Page 153

Chapter 6

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Coding Procedures & ServicesRadiology Section (70000-79999) PERFORMANCE EXERCISE
  • Radiologic examination; forearm, two views

73090

  • Ultrasound, transvaginal

76830

  • Injection procedure for knee arthrography

Surgery 27370&Radiology 73580

Chapter 6

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Coding Procedures & ServicesPathology & Laboratory (80000-89999)
  • Pathology & Laboratory
    • Codes listed according to type of Test performed (i.e., Hematology Tests, Urinalysis, etc.)
  • Test Panels
    • Listed under first subsection“Organ or Disease Oriented Panels”
    • Single Codethat groups Lab Tests which are frequently done together.
    • To use a Panel Code, all test listed within the panel must be performed

Chapter 6

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Coding Procedures & ServicesPathology & Laboratory (80000-89999)
  • Qualitative/Quantitative Analysis
    • Qualitative Analysis test may determines the presence of an agent within the body
    • Quantitative Analysis measures how muchof the agent is within the body

Chapter 6

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Coding Procedures & ServicesPathology & Laboratory (80000-89999)
  • Surgical Pathology
    • Arranged according to Levels/In Alphabetical Order
      • Level I/Gross Exam only (which means the way the specimen looks to the naked eye before it is prepared for microscopic study.)
      • Level II/Gross & Microscopic Exam (it identification of tissue in the absence of disease)
      • Level III through Level VI/Gross & Microscopic Exam (Exam of diseased tissue and each level requires additional work of the pathologist.

Chapter 6

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Coding Procedures & ServicesPathology & Laboratory (80000-89999)PERFORMANCE EXERCISE
  • Acute hepatitis panel

80074

  • Insulin antibodies

86337

Chapter 6

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Coding Procedures & ServicesMedicine Section (90000-99199)
  • Medicine Section
    • List of codes used by Physician of different Specialties in conjunction with codes from different sections of the CPT
    • Diagnostic &Therapeutic Servicesthat are not surgically invasive are listed in this section, including many specialized testing
    • Notes in this section should be carefully read before coding a subsection, category or subcategory
    • Documentationmay be included with the claim form to justify the use of the code

Chapter 6

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Coding Procedures & ServicesMedicine Section (90000-99199)
  • Drugs & Injections
    • Five Codes (90782, 90783, 90784, 90788 & 90799) in the subsection: “Therapeutic, Prophylactic or Diagnostic Injections”, which:
    • Represents all subcutaneous, intramuscular, intra-arterial, and intravenous injections
      • Insurance may require additional information on the substance being injected and communicated by:
        • Listing the name, amount, & strengthof the medication
        • A NDC (national drug code)may be used to specify the drug, dosage, and the manufacturer
        • HCPCS Level II Codemay be used to specify the injected drug

Chapter 6

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Coding Procedures & ServicesMedicine Section (90000-99199)
  • Special Services, Procedures, and Reports
    • Additional codes are found under the category“Miscellaneous Services”
    • Codes provide physician with means of identifyingSpecial Services & Reportsthat are an addition to basic services provided
    • Two commonly used codes are:
      • 99000 – Handling and/or conveyance of specimen
      • 99070 – Supplies and materials (except spectacles)

Chapter 6

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Coding Procedures & ServicesMedicine Section (90000-99199) PERFORMANCE EXERCISE
  • Lyme disease vaccine, adult dosage, for intramuscular use

90665

  • Measles and rubella virus vaccine, live for subcutaneous use

90708

Chapter 6

coding procedures services coding terminology
Coding Procedures & ServicesCoding Terminology
  • Bundled Code
    • Single Procedure Code used to report group of related procedures
  • Unbundling
    • The practice of using numerous CPT Codes to identify procedures normally covered by a single code
    • Also known as: Itemizing, Exploding, Charges, Fragmented Billing or Surgery, or A La Carte Medicine
    • Considered “Fraud” if done intentionally for increased reimbursement (Can result in Claim Audit)

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Unbundling Examples are:
    • Fragmenting one service into component parts and coding each component as if it were a separate service
      • Example 6-20/156
    • Reporting separate codes for related services when oneComprehensive Codesincludes all related services
      • Example 6-21/156
    • CodingBilateral Proceduresas two codes when one code is inclusive
      • Example 6-22/156

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Unbundling Examples Cont.
    • Separating aSurgical Approachfrom a major surgical service that includes the same approach
      • Example 6-23/156
  • Downcoding occurs when:
    • The PhysicianCoding Systemdoes not match the Coding System of the Insurance Company receiving the Claim
      • Example 6-24/156

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Upcoding
    • Deliberate manipulation of CPT Codes for increased payment
    • Upcoding can be spotted in Insurance Carrier’s software screens, such as theprepayment, postpayment or stop alert screens

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Code Edits (Software)
    • Correct Coding Initiative (CCI) – was implemented by Medicare on 01/01/96
    • Contain a code edit system consistent with Medicare policies
    • Its function is to eliminate improper reporting of CPT Codes.
    • When online edit is performed, the computer software program checks:
      • Codes on an Insurance Form
      • Detect improper code submissions
    • Similar software is used by private payers, other Federal programs and State Medicare programs.

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Code Edits (Software) – Cont.
    • Code editswillhelp you obtain maximum reimbursement for each service rendered
    • Will also Help to avoid denials, lowered reimbursement & possible audit
  • Code Edit Examples are:
    • Comprehensive/Component Edits
    • Separate Code Edits
    • Mutually Exclusive Code Edits

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Type of Code Edits
    • Comprehensive/Component Edits
      • Single Procedural code that describes or covers two or more CPT component codes that are bundled together as one unit
      • Comprehensive Codes are never indentedand the basis for its description appears before the semicolon (;)

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Type of Code Edits – Cont.
    • Component Code
      • The portion of a service described before the semicolon (;) of a CPT comprehensive code, together with the portion of a service described by the indented (component) code
      • Component Code is indented
      • Should be used only be used if both portions of the service were performed
  • Performance Exercise
    • Example 6-25/157

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Separate Procedure Code Edits
      • Integral part of a large procedure and does not need a separate code, unless performed independently and not immediately related to other service
  • Performance Exercise
      • Example 6-26/157

Chapter 6

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Coding Procedures & ServicesCoding Terminology
  • Mutually Exclusive Code Edits
    • Procedures that meet any of the following criteria:
    • Code combinations that are restricted by the guidelines outlined in CPT
      • Procedures that cannot be reasonably done during the same session
      • Procedures that represent medically impossible or improbable code combinations
      • Procedures that represent two methods of performing the same service
  • Performance Exercise
      • Example 6-27/157

Chapter 6

coding procedures services coding terminology10
Coding Procedures & ServicesCoding Terminology
  • Illegal or Unethical Coding
      • To avoid Illegal Or unethical coding: follow Coding Guidelines & Individual Coding Policies from various Insurance Carriers
  • Modifiers
    • Additional Modifiers:
      • Figure 6-6A & B - Page 160 & 161
      • Complete List of Modifier/in Appendix A

Chapter 6

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