Top Missed Coding Concepts on CPC®
Certification Exam
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®
CPT
Disclaimer
CPT copyright 2012 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not
assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The
AMA does not directly or indirectly practice medicine or dispense medical services. The AMA
assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
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Objectives
• Review top missed coding concepts
• Test tips to review with students
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Tips for Success
• Read, understand and know how to apply all coding
guidelines (ICD-9-CM, CPT ® and HCPCS Level II).
• Read, understand and know how to apply all CPT ®
parenthetical notes.
• Pay attention to the details in the question/scenario.
• Use the index if the code description does not
accurately describe the diagnosis.
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E/M
• Instruct students to add notes to the CPT ® E/M
coding guidelines to define:
–
–
–
–
Brief versus extended HPI
Problem pertinent, extended and complete ROS
Pertinent and complete PFSH
Number of body areas/organ systems for different
levels of the exam component
– Include details for the MDM table on page 10
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E/M
• Review the number of key components needed for
each E/M category.
– When three of the three key components are required,
select the code with the lowest level component
documented.
• New patient: expanded problem focused Hx, detailed
exam and moderate MDM
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E/M
• Review the number of key components needed for
each E/M category.
– When three of the three key components are required,
select the code with the lowest level component
documented.
• New patient: expanded problem focused Hx, detailed
exam and moderate MDM
99202
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E/M
• When two of the three key components are required, select
code based on the highest of the two key components. MDM
does not need to be one of the two key components to select
the E/M level. It can be supported with history and exam for
certification exam purposes. For day to day coding, review the
requirement for the MAC in your area.
– Established patient: detailed history, comprehensive exam, low
MDM
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E/M
• When two of the three key components are required, select
code based on the highest of the two key components. MDM
does not need to be one of the two key components to select
the E/M level. It can be supported with history and exam for
certification exam purposes. For day to day coding, review the
requirement for the MAC in your area.
– Established patient: detailed history, comprehensive exam, low
MDM
99214
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E/M Example
The service performed and documented for an
established patient includes six elements of HPI, five
elements of ROS, and a complete past, family, social
history (PFSH). Also supported by the documentation is
a complete examination of ten organ systems, one
established stable diagnosis, prescriptions reviewed
and renewed, and the physician orders blood tests and
a chest X-ray. The physician documents a low
complexity MDM.
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E/M Example
The service performed and documented for an
established patient includes six elements of HPI, five
elements of ROS, and a complete past, family, social
history (PFSH). Also supported by the documentation is
a complete examination of ten organ systems, one
established stable diagnosis, prescriptions reviewed
and renewed, and the physician orders blood tests and
a chest X-ray. The physician documents a low
complexity MDM. 99214
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E/M Nurse Visits
• Do not report 99211 when the reason for the patient
encounter is for vaccine administration(s) only.
• Do not report 99211 when the patient is being seen
for venipuncture only.
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Anesthesia
• Start and stop times
– Start time: anesthesia provider begins to prepare the
patient for induction.
– Stop time: anesthesia provider is no longer in
attendance.
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Anesthesia Example
PREOPERATIVE DIAGNOSIS: Symptomatic internal and external
hemorrhoids, bleeding and prolapsed.
POSTOPERATIVE DIAGNOSIS: Symptomatic internal and external
hemorrhoids with bleeding and prolapse.
PROCEDURE PERFORMED: Hemorrhoidectomy, two quadrants.
The anesthesiologist begins to prepare this patient for surgery at 1:00 PM.
The surgery begins at 1:15 PM and ends at 1:40 PM. The anesthesiologist
releases the patient to the recovery nurses at 1:45 PM.
Anesthesia time:
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Anesthesia Example
PREOPERATIVE DIAGNOSIS: Symptomatic internal and external
hemorrhoids, bleeding and prolapsed.
POSTOPERATIVE DIAGNOSIS: Symptomatic internal and external
hemorrhoids with bleeding and prolapse.
PROCEDURE PERFORMED: Hemorrhoidectomy, two quadrants.
The anesthesiologist begins to prepare this patient for surgery at 1:00 PM.
The surgery begins at 1:15 PM and ends at 1:40 PM. The anesthesiologist
releases the patient to the recovery nurses at 1:45 PM.
Anesthesia time: 45 minutes
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Anesthesia
• Surgical approach will determine the use of one
code versus another.
• The surgeon performs the removal of an electrode
from a dual lead pacing cardioverter-defibrillator via
transthoracic approach. General anesthesia is
required.
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Anesthesia Example
00534
00560
Anesthesia for transvenous insertion or
replacement of pacing cardioverterdefibrillator
(For transthoracic approach, use 00560)
Anesthesia for procedures on heart,
pericardial sac, and great vessels of
chest; without pump oxygenator
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Anesthesia Example
00534
00560
Anesthesia for transvenous insertion or
replacement of pacing cardioverterdefibrillator
(For transthoracic approach, use 00560)
Anesthesia for procedures on heart,
pericardial sac, and great vessels of
chest; without pump oxygenator
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Unlisted Codes
• Unlisted codes are reported when an existing code
does not describe the procedure or service. Follow
instructions in parenthetical notes when directed to
report an unlisted code.
– Example: Nonsurgical alcohol septal ablation
(For nonsurgical septal reduction therapy [eg,
alcohol ablation], use 93799)
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Hernia Repairs
• Pay attention to code descriptions
–
–
–
–
–
–
Anatomic site of hernia: inguinal, lumbar, ventral, etc
Approach: open or laparoscopic
Age of the patient
Incarcerated or strangulated, reducible
Initial or recurrent
Mesh: for hernias, only report with 49560-49566
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Hernia Repair Example
PREOPERATIVE DIAGNOSIS: Bilateral inguinal hernia
POSTOPERATIVE DIAGNOSIS: Bilateral inguinal hernia
TYPE OF PROCEDURE: Laparoscopic repair of bilateral
inguinal hernia
ANESTHESIA: General
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Hernia Repair Example
PREOPERATIVE DIAGNOSIS: Bilateral inguinal hernia
POSTOPERATIVE DIAGNOSIS: Bilateral inguinal hernia
TYPE OF PROCEDURE: Laparoscopic repair of bilateral
inguinal hernia
ANESTHESIA: General
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Hernia Repair Example
DESCRIPTION OF PROCEDURE: With the patient on the
operating table in the dorsal supine position under satisfactory
general endotracheal anesthesia, the abdomen was prepped
with Betadine and draped with sterile towels and sheets in a
standard manner. A subumbilical 2-cm midline incision was
made. The right anterior rectus sheath was exposed and
incised.
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Hernia Repair Example
The muscle was retracted laterally, and the dissecting balloon
trocar slid easily down to the pubis. It was insufflated to 750 cc,
deflated, and removed. The self-retaining trocar was then
placed, and the preperitoneal space thus created was
insufflated to 12 mmHg pressure. The laparoscopic telescope
with attached video camera was introduced. Under direct
vision, two 5-mm trocars were placed in the lower midline-one
suprapubically and one halfway between the umbilicus and the
pubis. The instruments were introduced. The right iliopectineal
area was dissected completely.
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Hernia Repair Example
The muscle was retracted laterally, and the dissecting balloon
trocar slid easily down to the pubis. It was insufflated to 750 cc,
deflated, and removed. The self-retaining trocar was then
placed, and the preperitoneal space thus created was
insufflated to 12 mmHg pressure. The laparoscopic telescope
with attached video camera was introduced. Under direct
vision, two 5-mm trocars were placed in the lower midline-one
suprapubically and one halfway between the umbilicus and the
pubis. The instruments were introduced. The right iliopectineal
area was dissected completely.
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Hernia Repair Example
Good coverage was obtained. Attention was then turned to the
left iliopectineal area. Similar dissection was carried out. A 4 x 6
portion of Atrium mesh was brought to lie over this area and
tacked across anteriorly and medially to the pubis and the
Cooper's ligament. No lateral or inferior tacks were applied.
Good coverage was obtained. Pneumo-insufflation was
resolved, and the instruments and trocars were removed. All
trocar sites were injected with 0.5% Marcaine with epinephrine.
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Hernia Repair Example
Good coverage was obtained. Attention was then turned to the
left iliopectineal area. Similar dissection was carried out. A 4 x 6
portion of Atrium mesh was brought to lie over this area and
tacked across anteriorly and medially to the pubis and the
Cooper's ligament. No lateral or inferior tacks were applied.
Good coverage was obtained. Pneumo-insufflation was
resolved, and the instruments and trocars were removed. All
trocar sites were injected with 0.5% Marcaine with epinephrine.
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Hernia Repair Example
The rectus incision was closed with a figure-of-eight suture of 0
Vicryl. The skin edges were approximated with clips. Sterile
dressings were applied. The patient tolerated the procedure
well and returned to the recovery room in satisfactory condition.
Correct codes:
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Hernia Repair Example
The rectus incision was closed with a figure-of-eight suture of 0
Vicryl. The skin edges were approximated with clips. Sterile
dressings were applied. The patient tolerated the procedure
well and returned to the recovery room in satisfactory condition.
Correct codes: 49650-50 Laparoscopy, surgical; repair initial
inguinal hernia
550.92 Inguinal hernia without mention of obstruction or
gangrene, bilateral, (not specified as recurrent)
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Orchiopexy
• Code determined based on the approach
– 54640 Orchiopexy, inguinal approach, with or without
hernia repair
– 54650 Orchiopexy, abdominal approach, for intraabdominal testis (eg, Fowler-Stephens)
– 54692 Laparoscopy, surgical; orchiopexy for intraabdominal testis
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Imaging Guidance
• Pay close attention when imaging guidance is
included.
– Is imaging guidance reported separately?
– If imaging guidance is included-what is the type of
imaging?
• Review the coding guidelines and parenthetical notes
• Append modifier 26 if the service is performed by the
provider in the facility setting
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Imaging Guidance Example
Using ultrasound guidance, an anesthesiologist
injects an analgesic and a steroid mixture into the L2L3 paravertebral facet joint on the right side.
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Imaging Guidance Example
Using ultrasound guidance, an anesthesiologist
injects an analgesic and a steroid mixture into the L2L3 paravertebral facet joint on the right side.
Correct codes: 0216T-RT Injection(s), diagnostic or
therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint)
with ultrasound guidance, lumbar or sacral; single
level
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Imaging Guidance
(Image guidance [fluoroscopy or CT] and any injection
of contrast are inclusive components of 64490-64495.
Imaging guidance and localization are required for the
performance of paravertebral facet joint injections
described by codes 64490-64495. If imaging is not
used, report 20552-20553. If ultrasound guidance is
used, report 0213T-0218T)
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Radiology
• Cervical X-rays selected on the number of views:
–
–
–
–
–
–
–
Anterior/Posterior (AP)
Lateral
Flexion and extension
Oblique
Odontoid
Pillar
Prevertebral soft tissue and stress
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Radiology
72040 Radiologic examination, spine, cervical; 3
views or less
72050 …4 or 5 views
72052 …6 or more views
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Modifiers
• Proper use of surgical modifiers
– Modifier 58: staged or related
– Modifier 59: distinct service
– Modifier 78: unplanned return to the OR for related
procedure
– Modifier 79: unrelated procedure
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Modifier Example
38-year-old male had a hernia repair and then about six days
later, he started to have swelling of the pocket and redness.
The patient was brought to the operating room. A skin incision
was made through the midline in which there was an infection
of large amount of purulent material that escaped under high
pressure. Multiple cultures were taken. A 3-L of ortho irrigation
was used to Pulsavac out the wound, any remaining sutures
were removed. The wound was packed with iodoform gauze
and dressing applied.
Correct code and modifier:
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Modifier Example
38-year-old male had a hernia repair and then about six days
later, he started to have swelling of the pocket and redness.
The patient was brought to the operating room. A skin incision
was made through the midline in which there was an infection
of large amount of purulent material that escaped under high
pressure. Multiple cultures were taken. A 3-L of ortho irrigation
was used to Pulsavac out the wound, any remaining sutures
were removed. The wound was packed with iodoform gauze
and dressing applied.
Correct code and modifier: 10180-78
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ICD-9-CM
• Complications of pregnancy, childbirth and the
puerperium
– Codes in Chapter 11 have sequencing priority
– Example: One week postpartum, the patient is
diagnosed with rubella.
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ICD-9-CM
Example: One week postpartum, the patient is
diagnosed with rubella.
Correct code(s): 647.54 Maternal rubella complicating
pregnancy, childbirth, or the puerperium, postpartum
condition or complication
056.9 Rubella without mention of complication
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ICD-9-CM
• Drug and alcohol use, abuse or dependence
– Determined based on the diagnosis documented
– Fifth digit: unspecified, continuous, episodic or in
remission
– Report all diagnoses treated and documented.
• Example: Patient treated for cocaine dependence and
anxiety caused by cocaine use.
Correct code(s):
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ICD-9-CM
Example: Patient treated for cocaine dependence and
anxiety caused by cocaine use.
Correct code(s): 292.89 Other specified drug-induced
mental disorder
304.20 Cocaine dependence, unspecified
Use additional code for any associated drug dependence
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HIPAA
•
•
•
•
Code sets required under HIPAA
Covered entities
Privacy Rule
Security Rule
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Questions?
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