INTRODUCTION TO
CPT CODING
Doctors Hospital Family Practice Residency Program
Practice Management
Overview of the Course
◦ Why Use CPT
◦ How CPT code book is broken down
◦ Evaluation and Management Codes:
1.
STEP #1 to coding E/M: Type of visit
2.
STEP #2 to coding E/M: Components of the visit
3.
a)
Using History to Code
b)
Using Examination to Code
c)
Using Medical Decision Making to Code
STEP #3 to coding E/M: Determining the final code
Why use?
◦ Physicians and healthcare providers provide services and perform procedures that need to be
documented in a standardized fashion
◦ Includes office visits (evaluating a patient – and making a diagnosis)
◦ Includes other procedures performed (for example – skin biopsies, injections etc.)
◦ Services should be captured and billed appropriately for financial success
◦ There should be a standard method for determining the level of services provided
◦ Using numbers is the easiest and best way for information to be standardized and passed along to
other associated healthcare providers/insurance carriers
◦ (sound familiar?)
What is CPT?
◦ Stands for “Current Procedural Terminology”
◦ It is a list of numeric codes that can be used to bill for services or
procedures rendered to a patient
◦ The CPT is a product of/owned by the American Medical Association
(AMA)
How is CPT book broken down?
◦ Has various sections:
1. E/M (evaluation and management)
◦ These are codes to use to get paid for seeing a patient in the office or hospital setting
◦ We will spend most of our time in this course going into detail how to derive the E/M code
2. Anesthesia – codes used to perform anesthesia services
3. Surgery – codes used to perform surgical procedures
4. Radiology – codes used for performing x-rays, reading films, and interventional radiology procedures
5. Pathology/Lab – codes used to make slides/prepare and read specimens
6. Medicine – everything else
◦ Has index in the back that will help locate a general area of the CPT code – organized by the name of
procedure
◦ For example – “Destruction,” “Injection,” “Biopsy”
◦ Use the front part to help further specify a code
How is CPT broken down?
◦ Take some time to Explore the CPT Book now
◦ What would the CPT code be for epicondylitis injection of elbow?
◦ What would the CPT code be for destruction of an AK by
cryotherapy?
◦ What would the CPT code be for punch biopsy of one benign skin
lesion?
E/M codes (evaluation and management)
◦ Evaluation and management codes are used for billing for the work done in
evaluating and managing a patient:
◦ There are various “levels” to consider – based on the complexity of the
workup and/or time spent with the patient
◦ Level 1 - Low Complexity, typically a nursing visit
◦ Level 2 - Problem Focused visit – typically one simple problem
◦ Level 3 - Expanded Problem Focused – a typical problem that requires treatment
◦ Level 4 - Detailed – typically a more complex problem, or several problems
◦ Level 5 – Comprehensive Visit – the most complex visit
STEP #1: Type of E/M code
◦ The first step of selecting an appropriate E/M code – is to determine the TYPE of visit for E/M code using the
following factors:
◦ Location (hospital vs. outpatient)
◦ Wellness vs. Illness
◦ Wellness visits arranged by age
◦ New Vs. Established patients
The new patient is one that has not has an encounter with the practice (or partners) for the last 3 years
The Established patient is one that HAS had an encounter within the previous 3 years
◦ Consultation codes (examples:)
Use for Preadmission Testing
Use for OMT Consults from another doc
◦ Time allotted
◦ Specific Medicare Visits (Medicare wellness, or Medicare PAP)
◦ Counseling only visits
◦ Transition of Care visits
STEP #2: E/M components:
◦ The next step is to use the factors listed below to help determine
the appropriate E/M code to give to the patient for each visit
(*** the stared being the most important)
1. History taking ***
2. Exam complexity ***
3. Medical Decision making ***
4. Counseling given
5. Coordination of Care
6. Nature of the Presenting Problem
7. Time spent seeing the patient
◦ This emphasizes the importance of good documentation to help
meet the criteria of a specific E/M level visit
REVIEW:
◦What are the 3 most important E/M
components used to help determine a level of
office visit?
A) E/M: History
◦ The complexity of the visit (the level of E/M coding) is FIRST partially determined by using the following
components in the HISTORY taking:
◦ Chief Complaint – the nature of the complaint (is it abdominal pain, or a cold)
◦ History of Present Illness – the number HPI elements reviewed (pain quality, timing, radiation, palliative, provocative
factors etc.)
◦ Review of Systems (how many systems reviewed)
◦ Past Medical/Surgical/Family/Social history components reviewed (the number of these elements reviewed with the
patient)
◦ Documentation required for various levels:
◦
◦
◦
◦
Problem focused: chief complaint and 1-3 HPI elements
Expanded problem focused: Chief complaint, 1-3 HPI elements, 1 ROS element
Detailed – Chief complaint, 4-8 HPI elements, 2-9 ROS elements, PFSH: 1 element
Comprehensive – Chief complaint, 4-8 HPI elements, 10-14 ROS elements, PFSH: 1 element from each area
Chart for E/M: History component:
PF = problem focused (2), EPF = expanded problem focused (3), D =
detailed (4), C = complex (5)
REVIEW:
Determine the level of E/M for the following
history:
 34 y/o presents to office for 3 days of cough. Associated symptoms include
congestion and drainage. Mucinex DM does not help. Patient reports no chest
pain or palpitations.
B) E/M: Examination
◦ The level of complexity of the E/M examination component is SECONDLY based on the number of body
systems that are EXAMINED during the encounter
◦ These systems are clearly outlined by coding criteria
◦ With the EXAM component – the provider has an option to follow one of 2 different guidelines
◦ The provider can use EITHER the 1995 guidelines/arrangement of systems, or the 1997 guidelines/arrangement of
systems
◦ 1995 – uses whole body systems (Most providers follow the 1995 criteria – since it is simpler)
◦ 1997 – uses bullets/sections identified as parts of body systems
1995 Arrangement of Organ Systems:
◦ Constitutional (e.g., vital signs, general appearance)
◦ Eyes
◦ Ears, nose, mouth, and throat
◦ Cardiovascular
◦ Respiratory
◦ Gastrointestinal
◦ Genitourinary
◦ Musculoskeletal
◦ Skin
◦ Neurologic
◦ Psychiatric
◦ Hematologic/lymphatic/immunologic
1997 Arrangement of Organ Systems:
B) E/M: Examination
◦ 1995 Examination Guidelines:
◦ Problem Focused: examination of at least one body organ system
◦ Expanded Problem Focused: A limited examination of the affected body area or organ system (2-4 body systems
examined)
◦ Detailed – An extended exam of the affected body area and other symptomatic or related organ systems (5-7 body
systems examined)
◦ Comprehensive – General multi-system review (8-12 systems – a full body exam)
B) E/M: Examination
◦ 1997 Examination guidelines:
◦ Problem focused: < 6 bullets
◦ Expanded problems focused: 6-12 bullets
◦ Detailed: 12 or more bullets
◦ Comprehensive: at least 2 elements identified by bullets for at least 9 organ systems or body areas
REVIEW:
Determine the level of E/M for the following
examination:
 Constitutional: well developed and well nourished and in NAD
 ENT: reveals congestion, inflamed turbinates, with posterior pharyngeal
cobblestoning, no pharyngeal erythema, mmm
 Lungs: CTABL, no w/r/r
 Heart: reg, no m/g/r
C) E/M: Medical Decision Making
◦ Determining an E/M code THIRDLY is based on 2/3 components of DECISION MAKING:
1.
The number of diagnoses &/or management options
2.
The amount &/or complexity of data (the amount of information that is reviewed)
◦ Diagnostic tests (x-rays, labs)
◦ Complexity of the data reviewed
◦ Consult notes, or directly speaking with a consultant
3.
The risks of complications, morbidity or mortality from the diagnosis for the encounter
◦ Charts are used to determine the level of the complexity of the decision making based on the 3 components
(refer to next slide)
Medical Decision Making – Scoring Dx/Mx
Medical Decision Making – Data complexity
Medical Decision Making – Risk level
Medical Decision Making = Final Risk assess
(overall risk is the middle column of the 3)
S=straightforward, LC = Low complexity
MC = moderate complexity, HC = high complexity
REVIEW:
Determine the level of E/M for the following
Medical Decision Making:
 45 y/o female smoker reports to the office after visit to the UC for cough 4 days ago. Was dx with
pneumonia, placed on antibiotics, but CXR at UC was concerning for lung mass. You look at old
reports of CXR done 2 years ago – which was clear. You obtain the CXR records and the report has
unfamiliar terminology, so you call the reading radiologist to discuss. Upon reporting the previously
normal CXR - He recommends immediate CT of chest for suspicion for cancer. You discuss these
things with the patient, order the CT scan, and refer the patient to smoking cessation counseling per her
request
STEP #3: Determining the final code
◦ Once the choices for the level of code are made for each component (history, exam and decision making) –
you can use the chart to determine the correct final E/M code
◦ The code would be the middle column of the 3 for an established patient
◦ The code would be the lower level column for a new patient
Final Code selection for E/M
References:
◦ CPT Standard Edition by AMA
◦ “Introduction to Coding” – by Todd Frieze, MD, FACP, FACE, ECNU, CEC; found at:
https://www.aace.com/files/pm101_frieze_introcoding.pdf
◦ “Pocket Guide to the Documentation Guidelines,” From the American Academy of Family Physicians.
1996.
◦ 1997 Updates in Coding by the Centers for Medicare and Medicaid Services