NYU School of Medicine
Coding and Reimbursement Seminar Series
Gretchen L. Segado, MS, CPC
Director of Reimbursement Compliance
NYU School of Medicine
316 East 30 th Street
New York, NY 10016
(212) 263-2446
(212) 263-6445 fax
Gretchen.Segado@med.nyu.edu
Presented by the Office of Reimbursement Compliance




Systematic listing of procedures & services performed by physicians
Five-digit codes for procedures or services
Used to describe the physician’s services to a patient for diagnosis and treatment of the medical condition(s)
 Codes and descriptive terminology developed and copyrighted by AMA CPT Editorial Panel

 CPT-4 represents the “WHAT” was done to the patient
Procedure------------------- 93010 (EKG)
 ICD-9 represents the “WHY” it was done
Medical Necessity--------- 786.50
(Chest Pain)

Text organized in 6 major sections
 Evaluation and Management
 Anesthesiology
 Surgery
 Radiology
 Pathology and Laboratory
 Medicine
(99201 - 99499)
(00100 - 01999,
99100 - 99140)
(10040 - 69990)
(70010 - 79999)
(80049 - 89399)
(90281 - 99199)





Presented at the beginning of each of the six sections
Provide information necessary to appropriately interpret and report the procedures and services contained in that section
In addition to guidelines, several subheadings or subsections also have special instructions unique to that section
Reading the guidelines and notes are critical to using CPT correctly

Revised CPT Code-Description has been substantially altered
New CPT Code
Codes that never stand alone
Appears during the 1 st year that the text is revised or added
Codes exempt from the 51 modifier, but that do not have designated add-on procedures or services



Developed as a stand-alone descriptions of the procedures
To conserve space, some are not printed in their entirety but refer back to a common portion listed in a preceding entry**
Example:
25100
25105 arthrotomy, wrist joint; for biopsy for synovectomy
25105 arthrotomy, wrist joint; for synovectomy
**Commonly referred to as “Indented Codes”

 Who can tell me what CPT Code reads?
 The book says
24102 with synovectomy

What is the full description of each of these codes?



20600* arthrocentesis, aspiration &/or injection; small joint, bursa or ganglion cyst
(e.g., Fingers, toes)
20605* intermediate joint, bursa or ganglion cyst (e.g., Temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa
20610* major joint or bursa (e.g.,
Shoulder, hip, knee joint, subacromial bursa

 20661 application of halo, including removal; cranial


20662
20663 pelvic femoral



 Listed procedures in alphabetical order at the back of the manual
Index is organized by main terms
There are 4 primary classes of main entries:
– Procedure or service
–
–
–
Organ or anatomic site
Condition
Synonyms, eponyms or common abbreviation





Procedure or service
– Appendectomy
Organ or anatomic site
– Knee
Condition
– Renal Abscess
Synonyms, eponyms or common abbreviation
–
–
–
Bucca (cheek)
BAER (Brainstem Auditory Evoked Potential)
Whipple Procedure

 Select the name of the procedure or service that most accurately identifies the service performed:
– Example:
 Surgery: operations and minor procedures
 Medicine: diagnostic or therapeutic procedure
 Radiology: radiographic study
 Any physician can use any code in the CPT book.

 The alphabetical index is NOT a substitute for the main text of the CPT Manual. Even if only one code appears, the user must refer to the main text to ensure that the code selection is accurate

In short…NEVER CODE FROM THE INDEX@!@!

1.
2.
3.
4.
5.
Read the source document. Never assume!
Using information in the record, analyze procedure statement provided by physician.
Identify main term and modifying terms
Locate main term in the CPT index
Look for subterms indented below the main term
Jot down the tentative code range for each procedure.

6.
7.
8.
9.
10.
Locate each tentative code in the book
Read any instructional notes and watch for diagnoses or specific procedures within code descriptions
Verify that the code matches the procedure statement provided in the record
Assign a modifier if necessary
Assign the code

Now it’s your turn to use what you’ve learned…….
 Identify the service or procedure performed
 Identify the organ involved
 Identify the condition or key word

 What is the code for a Whipple Procedure?
 48150

 What is the code for an upper gastrointestinal endoscopy with biopsy?
 43239
 You can find the same code looking under any of the terms “gastrointestinal”
“endoscopy” or “biopsy”

 What is the code for a synovectomy of the metacarpophalangeal joint?
 26135
 Common mistakes made: carpometacarpal joint vs metacarpophlangeal joint

 What is the code for removal of a foreign body in the nose?
 Need more information, was this done under anesthetic? Did they have to cut into nose?

 How would you bill for a removal of a pylenoidal cyst?
 Do I need more information to code it correctly? If so, where do I get the info?
 Is it simple? extensive? complicated?
 Answer: 11770-11772

 Endoscopic biopsy of the urethra
–
This is a tricky one….beware
 Answer: 52204

 Exploration of a penetrating wound of the abdomen
 Answer: 20102

 Exploration of nasolacrimal duct with tube insertion
 Answer: 68815

 Exploration of the knee with removal of a nail
 Answer: 27310







Appendix A Modifiers
Appendix B Summary of additions, deletions and revisions
Appendix C Update to short descriptor
Appendix D Clinical examples supplement
Appendix E Summary of add on codes
Appendix F Summary of CPT codes exempt from modifier -51

 Preoperative visits - beginning with the day before the day of surgery for major procedures and the day of the surgery for minor procedures
– Document pre-op evaluation/exam in medical record
– Document pre-op evaluation in op report

 Also known as the global surgical package
 No one standard definition
 Per CPT guidelines,
The following services are always included in addition to the operation per se:
 local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;





 subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical); immediate postoperative care, including dictating operative notes, talking with the family and other physicians; writing orders; evaluating the patient in the post-anesthesia recovery area; typical postoperative follow-up care.

Examples of Services Included in the
Global Period
 Removal of staples 10 days after a surgical procedure
 A visit with a patient prior to surgery to answer any last minute questions
 A post-operative visit in the office to check on wound healing

Examples of Services NOT Included in the Global Package
 The visit where the decision to perform a procedure or surgery was made, even if on the same day as the procedure
 A visit during the post-op period for a problem unrelated to the surgery

CPT code 33512 - coronary artery bypass, vein
Only; 3 coronary venous grafts
Allowed payment (80%) = $2,001.40
Pre-op 9% $180.00
Intra-op
Post-op
84%
7%
$1,681.00
$140.00

 Commonly known as CCI
 Purpose:
–
–
Develop a correct coding methodologies
Control improper coding that leads to inappropriate increased in payment in Part B
–
–
Promote correct coding nationwide
Assist physicians in correctly coding their services for payment

Definitions in the Correct Coding
Initiative



Correct Coding means the reporting of a group of procedures with the appropriate comprehensive codes.
Unbundling is the billing of multiple procedure codes for a group of procedures that are covered by a single comprehensive code.
Mutually Exclusive Codes are those codes that represent services that cannot reasonably be performed in the same session

 Fragmenting one service into component parts and coding each as a separate service.
 Reporting separate codes for related services when one comprehensive code includes all related services.
 Breaking out bilateral procedures when one code is appropriate.

 Down coding a service in order to use an additional code when one higher code level, more comprehensive code is appropriate.
 Separating a surgical approach from a major surgical service.

Examples of Bundled Services
Component Codes
 52005- Cystourethroscopy, with urethral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiological service.
– Bundled services:
 51700- Bladder irrigation, simple, lavage &/or instillation
 52000- Cystoeruthroscopy (separate procedure)
 53670- Catheterization, urethra, simple

Examples of Bundled Services
Mutually Exclusive Codes



63045 Laminectomy, facetectomy and foraminotomy
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; cervical
63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical
First code would be paid and the second denied without use of an appropriate modifier

–
Services “should not be reported in addition to code for total procedure or service of which it is considered an integral component”
– If the service is performed independently, unrelated or distinct from other procedures provided at the time, it may be reported by itself or in addition to other services by attaching modifier -59 (indicates service is distinct, independent procedure)

Example of Separate Procedures
Example:
44005 - Enterolysis (freeing intestinal adhesion) (separate procedure)
(Do not report 44005 in addition to 45136) is included in
45136 Excision of ileoanal reservoir with ileostomy

– Carried out in addition to a primary procedure
 Exempt from -51 modifier
 CPT descriptors “list separately in addition to primary procedure” or
“each additional”
 Must never be reported as a stand-alone code



64831 Suture of digital nerve, hand or foot; one nerve
+ 64832 each additional digital nerve (list separately in addition to code for primary procedure)


22325 Open tmt and/or reduction of vertebral fx and/or dislocation(s), posterior approach, one fx vertebrae or dislocated segment; lumbar
+ 22328 each additional fractured vertebrae or dislocated segment (list separately in addition to code for primary procedure)

 Learned CPT Nomenclature (how to read the book)
–
–
Reading the guidelines
Use of Symbols, Appendices, Indexes
 Learned never to code from the index
 Learned the importance of linking CPT with an appropriate diagnosis (ICD-9) code
 Learned about Correct Coding Initiative




An Advanced E&M/Chart Auditing Workshop
Seminar Series Classes on
– ICD-9 Coding
–
–
–
Billing for Non-physician Practitioners
How to Use Modifiers
Evaluation and Management Coding
A Special Session on Advance Beneficiary Notices


Sign up for classes via the School of Medicine Calendar at http://calendar.med.nyu.edu
– Select Department Calendars, Find Compliance Office under
“miscellanous” category