Basics of Procedural Coding
This presentation is the property of its rightful owner.
Sponsored Links
1 / 24

Basics of Procedural Coding PowerPoint PPT Presentation


  • 111 Views
  • Uploaded on
  • Presentation posted in: General

Basics of Procedural Coding. Chapter 19. Consider the following while reading this chapter:. What will the medical assistant find similar to ICD-9-CM as she or he performs procedural coding? What will help in selecting the most specific and accurate CPT code?

Download Presentation

Basics of Procedural Coding

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Basics of procedural coding

Basics of Procedural Coding

Chapter 19


Consider the following while reading this chapter

Consider the following while reading this chapter:

What will the medical assistant find similar to ICD-9-CM as she or he performs procedural coding?

What will help in selecting the most specific and accurate CPT code?

What are the differences between coding for the CPT and coding for HCPCS?

What will be learned about the legal and compliance implications of improper coding?


What is procedural coding and how is it used

What is Procedural Coding and How Is It Used?

Procedural or CPT coding is defined as the transformation of verbal descriptions of medical services and procedures into numeric or alphanumeric designations.

The medical assistant facilitates accurate medical recordkeeping and the efficient processing of insurance claims by using the CPT and HCPCS

CPT and HCPCS are used in the claims submission process to receive reimbursement from payors as well as to track physician productivity and provide statistical data.


What is the purpose of cpt coding

What is the Purpose of CPT Coding?

Encourage the use of standard terms and descriptors to document procedures in the medical record

Help communicate accurate information on procedures and services to agencies concerned with insurance claims

Provide the basis for a computer-oriented system to evaluate operative procedures

Contribute basic information for actuarial and statistical purposes


The cpt code

The CPT Code

The CPT code is a five-digit code also known as a Category I code. Category I codes are located in the Tabular Index(Main Text) of the CPT coding manual and are arranged by Section

Category II codes are optional codes used by providers to assist in measuring performance and outcomes. Category II codes include the letter F as the fifth digit.

Category III codes are temporary codes assigned for emerging and new technology, services and procedures that have not been officially added to the Main Text of the CPT manual. The fifth digit of the Category III code is the letter T.

Modifiers provide a way for providers to indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition.


Format of the cpt coding manual

Format of the CPT Coding Manual

Each procedure or service is represented by a five-digit numeric code – a type of medical shorthand that saves enormous amounts of time and effort and helps to ensure the accuracy of information


Cpt content

CPT Content

Comprehensive instructions for use of the manual, including steps for coding

A complete Alphabetic Index

Main Text (Tabular Index)

Six sections

Guidelines and notes

Conventions

Thirteen appendixes


Cpt content1

CPT Content

The Tabular Index is divided into six sections, with codes listed in numeric or alphanumeric order within each section.

Evaluation and Management (E&M)

Anesthesia

Surgery (all body systems)

Radiology

Pathology and Laboratory

Medicine


Sections of the cpt main text

Sections of the CPT Main Text

A section is a broad category in the main text of the CPT manual, and each of the six sections is divided by the general type of service

Evaluation and Management (E&M)

Anesthesia

Surgery

Radiology

Pathology and Laboratory

Medicine


Sections of the cpt main text1

Sections of the CPT Main Text

The subsection of the CPT manual is indented two spaces below a section, and usually describes:

Anatomic Site

Organ System

Categories are indented two additional spaces below the subsection, and generally refer to:

a specific procedure or service

can also be a more specific anatomical site


Sections of the cpt main text2

Sections of the CPT Main Text

The subcategory is indented two spaces below a category, and provides even more specificity about an anatomical site or the procedure or service performed.


Appendixes

Appendixes

appendixes found in the CPT are as follows:

Appendix A: Modifiers

Appendix B: Summary of Additions, Deletions, and Revisions

Appendix C: Clinical Examples

Appendix D: Summary of CPT Add-on Codes

Appendix E: Summary of CPT Codes Exempt from Modifier -51

Appendix F: Summary of CPT Codes Exempt from Modifier -63


Appendixes1

Appendixes

Appendix G: Summary of CPT Codes that Include Moderate (Conscious) Sedation

Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or Topic

Appendix I: Genetic Testing Code Modifiers

Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves

Appendix K: Product Pending FDA Approval

Appendix L: Vascular Families


Beginning the coding process

Beginning the Coding Process

The steps for using the CPT manual actually begin with the medical documentation:

Encounter form, also known as a superbill, fee slip, or charge ticket

History and physical report (H&P)

Discharge summary

Operative report

Pathology report


Beginning the coding process1

Beginning the Coding Process

The basic steps in medical coding are to:

read

analyze

abstract the procedure or service documented

compare it with the encounter form, operative report, or other documentation


Using the alphabetic index to search

Using the Alphabetic Index to Search

Begin the search by using one or all of the four primary classifications (or types) of main and modifying term entries:

Procedure or service

Organ or anatomic site

Condition, illness, or injury

Eponym, synonym, abbreviation, or acronym


Steps for using the alphabetic index

Steps for Using the Alphabetic Index

Abstract the procedures and/or services performed from the medical documentation.

Determine the main and modifying terms from the abstracted information.

Select the most appropriate main term to begin the search in the Alphabetic Index.

Select modifying term(s), if needed, once the main term is located to narrow down the search.

If no main or modifying term produces an appropriate code or code range, repeat steps 2, 3, and 4, using a different main term.

Find code or code ranges that include all or most of the medical record procedure or service description.

Disregard any code or code range containing additional descriptions or modifying terms not found in the abstracted information or the medical documentation.

Write down the code or code ranges that best match the medical documentation.


Steps for using the main text

Steps for Using the Main Text

Turn to the Main Text and find the first code or code range found while searching the Alphabetic Index.

Compare the description of the code with the medical documentation. Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation.

Read the guidelines and notes for the section, subsection, and code to ensure there are no contraindications to the use of the code.

Evaluate the conventions, especially add-on codes (+) and exemption from modifier -51.

Determine if there are special circumstances that require the use of a modifier.

Determine if a Special Report is required.

Record the CPT code selected in the medical record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form.


Surgery coding

Surgery coding

There are some guidelines and notes related to surgery coding that must be considered when researching and selecting a procedure or service code:

Surgical Package Definition

Follow Up Care for Diagnostic Procedures

Materials Supplied by the Physician

Surgical Destruction


Surgery coding1

Surgery Coding

Endoscopy

X-ray Imaging/Fluoroscopy

Excision of Lesions – Benign or Malignant

Repair (Closure)

Musculoskeletal System

Respiratory System

Maternity Care and Delivery


Understanding evaluation and management

Understanding Evaluation and Management

The first two steps in choosing an E&M code are:

Identifying the place of service (POS)

Identifying the patient status

Determining the level of service provided

There are three components for determining the level of service for E&M:

history

examination

medical decision making

four contributing factors:

counseling

nature of the presenting problem

coordination of care

time


Anesthesia coding

Anesthesia Coding

STEPS FOR ANESTHESIA CODING

Read the medical documentation to determine what procedure or service was provided.

Determine the anatomic site or organ system involved.

In the Alphabetic Index, go to the heading “Anesthesia” and find the code or code range that includes all or most of the medical record procedure or service.

Write down the code or code range found in the Alphabetic Index, under the Anesthesia heading, that best matches the medical documentation.

Turn to the Main Text, Anesthesia Section, and find the code or code range found while searching the Alphabetic Index.

Read the guidelines and notes for the section, subsection, category, or subcategory.

Evaluate the conventions, especially add-on codes (+) and modifier -51 exemptions.

Document the code selected.

Determine the Basic Unit Value from the Relative Value Guide.

Determine the patient’s physical status and document the appropriate modifier.

Determine if any qualifying circumstance modifier should be used. If yes, document the modifier.

Determine the total anesthesia time, divide by 15 (minutes), and document the time.

Select the appropriate geographic conversion factor.

Calculate the charge for the anesthesia service using the anesthesia formula.

Document the anesthesia charge and the code in the medical record and on the encounter form or charge ticket.


Healthcare common procedure coding system hcpcs

Healthcare Common Procedure Coding System (HCPCS)

Steps for Using HCPCS Codes

Read the medical documentation to determine what procedures or services were provided.

Determine the main and modifying terms from the abstracted information.

Select modifying term(s) if needed once the main term is located.

Select the most appropriate main term to begin the search in the Alphabetic Index.

If no modifying term produces an appropriate code or code range, repeat steps 2 and 3 using a different main term classification.

Find code or code ranges that include all or most of the medical record procedure or service description.

Disregard any code or code range containing additional descriptions or modifying terms not found in the medical record.

Write down the code or code ranges that best match the medical documentation.

Turn to the Main Text and find the first code or code range found while searching the Alphabetic Index.

Compare the description of the code with the medical documentation. Verify that all or most of the medical record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation.

Read the guidelines for the section, subsection, and code to ensure there are no contraindications to the use of the code.

Evaluate the HCPCS manual conventions.

Determine if there are special circumstances that require the use of a modifier.

Record the HCPCS code selected in the medical record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form.


Compliance and legal issues

Compliance and Legal Issues

Medical assistants should also ensure that proper precautions are taken to avoid incorrect coding, data entry errors, and false claims submissions.

Downcoding, in which lower level codes are used even when the diagnostic statement indicates a higher level procedure or service, usually affects reimbursement only by lowering the amount received, but may have civil and criminal penalty implications if it is done to disregard insurance policy restrictions or preexisting condition clauses.

Upcoding, on the other hand, in which a procedure or service code is used that is of a higher level than is supported by the medical documentation, can result in civil and criminal penalties, including fines, loss of privileges as a participating provider, and even prison time.


  • Login