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CHAPTER 13

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  1. CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

  2. Medical Coding Transforms services/procedures/ supplies/drugs into CPT/HCPCS codes Transforms diagnosis and procedures into diagnosis codes

  3. Levels of Service Codes Level I CPT—(Category 1: 99201-99607, Category III: 0017T-0259T) Level II HCPCS, National Codes—(A0021-V5364) Level III Local Codes—phased out due to HIPAA

  4. Diagnosis Codes ICD-10-CM/ICD-9-CM International Classification of Diseases, 10th revision, Clinical Modification International Classification of Diseases, 9th revision, Clinical Modification

  5. Why Codes? Computers understand numbers Specific descriptions attached to each code

  6. CPT Developed by the AMA in 1966 Updated in November for use January 1 Divided into Category I, II, and III codes

  7. Examples of Types of CPT Codes Medical Surgical Diagnostic services Anesthesia, etc. Category II and Category III codes—alpha numeric Category II = performance measuring Category III = emerging technology

  8. CPT Codes Allow For Communication that is both effective and efficient A mechanism to report a service not described by a specific CPT or Level II code

  9. Consider 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) OR 50575

  10. Codes Are Used to tell third-party payers about services/procedures provided Often used as basis of payment

  11. Incorrect Coding Results in providers being paid inappropriately Either over or underpayment Decreases cash flow Liability risk

  12. Codes Are Used By Clinics Hospitals Rehabilitation units Ambulance services Long-term care Wherever health care services are provided

  13. Outpatient Services for Physicians Reported on insurance form CMS-1500 = universal form

  14. CMS-1500 Figure: 13.1 (Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.)

  15. CPT Format Symbols in CPT Used to convey information Bullseye, moderate (conscious) sedation included (full list in Appendix G, CPT) Lightning bolt, pending FDA approval (Appendix K, CPT)

  16. • Bullet = New Code Figure: 13.2 • Pound Symbol (#) = resequenced code Figure: 13.9

  17. ▲Triangle = Revised Code Figure: 13.3

  18. ►◄ Right and Left Triangles = Beginning and Ending of Text Change Figure: 13.4

  19. + Plus = Add-On Code Figure: 13.7

  20. Add-On Code (…Cont’d) Full list in Appendix D of CPT Can only be used with another specific code Never used alone

  21. CPT Appendix E contains a listing of -51 exempt codes Services typically exempt from multiple procedure reductions =Circle With Line,-51 Cannot BeUsed With these Codes Figure: 13.8

  22. Circle = Recycled or Reinstated Code • Circle symbol identifies codes previously published in CPT

  23. Appendices of CPT Appendix A: Modifiers Appendix B: Additions, Deletions, Revisions Appendix C: Clinical Examples, E/M Codes Appendix D: Add-On Codes Appendix E: -51 Exempt Codes Appendix F: -63 Exempt Codes Appendix G: Include Moderate (Conscious) Sedation (Cont’d…)

  24. (…Cont’d) Appendix H: Performance Measures, Category II Codes, on website Appendix I: Genetic Testing Modifiers Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix K: Product Pending FDA Approval Appendix L: Vascular Families Appendix M: Crosswalk to Deleted CPT Codes Appendix N: Summary of Resequenced CPT Codes Appendices of CPT

  25. Six CPT Sections (like chapters) Evaluation & Management (E/M) Anesthesia Surgery Radiology Pathology & Laboratory Medicine Category II Codes Category III Codes Appendices A-M Index

  26. Categorized By Sections Subsections Subheadings Categories (Cont’d…)

  27. Categorized By (…Cont’d) Anatomy Knee or Shoulder Procedure Incision or Excision Condition Fracture or Dislocation Description Cast or Strap Surgical Approach Anterior Cranial Fossa or Middle Cranial Fossa (Cont’d…)

  28. Categorized By, Example Figure: 13.6 (…Cont’d)

  29. Guidelines Section-specific information begins each section Figure: 13.10

  30. Notes Must-reading located throughout the CPT Figure: 13.12

  31. Two Types of Codes Stand-alone: Full description Indented: Dependent on preceding stand-alone Verbiage before the semicolon applies to all indented codes that follow

  32. Types of Codes, Example Figure: 13.14

  33. Semicolon Indicates full description in preceding code You must return to the stand-alone for full description

  34. Modifiers Add Information CPT Modifier Two digits 62 Two surgeons performed a surgical procedure Each surgeon applies his/her individual skill Each surgeon bills the procedure with modifier -62

  35. Level II HCPCS Modifiers “-AS” Physician’s Assistant “-F1” Left hand, second digit All modifiers used on CPT or HCPCS

  36. Example of Modifier 43820 Gastrojejunostomy -62 two surgeons -43820-62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity

  37. Modifiers are placed in 24D on CMS-1500 or 837 Modifier on the CMS-1500

  38. Unlisted Services Codes ending in “99” = “no specific Category I or III code” Used if no more specific code Special report must accompany submission

  39. Special or Written Report Indicates: Nature Extent Need Time Effort Equipment Used Photos and medical journal articles if relevant

  40. Category I Codes Category I codes (00100–99607) Approved by AMA and Food and Drug Administration Proven clinical effectiveness (efficacy)

  41. Category II Codes—Supplemental Tracking Codes Used for performance measurements Codes collect data concerning quality of care and test(s) required Alphanumeric and end in the letter “F” (1006F) Location AMA Website

  42. Category III Codes—New Technology Temporary codes—up to _ years Identify emerging technology, services, and procedures Located after Medicine section Alphanumeric (0016T) May or may not receive future Category I code status 5

  43. Category III Codes Category III codes have not been approved and have no proven clinical effectiveness Usage order Use Category III code instead of unlisted code Use unlisted code if no Category III code

  44. The Index! Used to locate service/procedure terms and codes Speeds up code location Like a dictionary First entries and last entries

  45. CPT Index Figure: 13.18

  46. Presentation of Codes in Index Single code: 38115 Multiple codes: 26645, 26650 - Note comma Range of codes: 22305-22325 - Note hyphen

  47. Service/procedure: repair, excision Anatomic site: median nerve, elbow Condition or disease: cleft lip, clot Synonym: toe and interphalangeal joint Eponym: Jones procedure, Heller operation Abbreviation: ECG, PEEP (Pressure Breathing, Positive) Location Methods with Examples

  48. Always Reference index Locate code in main portion of CPT Read the entire description and any notes

  49. “See” in Index Cross-reference terms “Look here for code” Index: Stem, Brain: See Brainstem

  50. HCPCS Healthcare Common Procedure Coding System Developed by Centers for Medicare and Medicaid Services (CMS) Formerly HCFA HCPCS developed in 1983 CPT did not contain all codes necessary for Medicare services reporting