CHAPTER 19 Procedure Coding © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-2 Learning Outcomes (cont.) 19.1 List the sections of the CPT manual, giving the code range for each. 19.2 Describe briefly each of the CPT’s general guidelines. 19.3 List the types of E/M Codes within the CPT. 19.4 List the areas included in the Surgical Coding Section. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-3 Learning Outcomes (cont.) 19.5 Locate a CPT code using the CPT manual. 19.6 Explain how to locate a HCPCS code using the HCPCS coding manual 19.7 Explain the importance of code linkage in avoiding coding fraud © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-4 Introduction • Procedural coding – Translate medical procedures and services into codes – Explains what services were provided • Code “linkage” with diagnostic codes • Maximum reimbursement © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-5 The CPT Manual • Procedure code • • Medical procedures and services Based on encounter form or patient record • Current Procedural Terminology (CPT) – HIPAA-required code set – Published by the AMA – Updated annually – Use the appropriate CPT based on date of service © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-6 Organization of the CPT Manual Section Range of Codes Evaluation and Management 99201 – 99499 Anesthesiology 00100 – 01999 99100 – 99140 Surgery 10021 – 69990 Radiology 70010 – 79999 Pathology and Laboratory 80048 – 89356 Medicine 90281 – 99602 99500 – 99602 © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-7 Organization of the CPT Manual (cont.) • Manual Introduction – General instructions – Information about common • Prefixes • Suffixes • Word roots • Guidelines for each section © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-8 Organization of the CPT Manual (cont.) • Sections • Page – Guidelines at beginning – Categories headings – Section name – Subsection name – Subheading – Category © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-9 Apply Your Knowledge Match CPT section to number range ANSWER: 70010-79999 Evaluation and management Anesthesiology 00100-01999 99100-99140 99201-99499 Surgery 90281-99199 99500-99602 Radiology 80048-89356 10021-69990 Pathology and Laboratory Medicine (except for Anesthesia) © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-10 General CPT Guidelines • Code format • Add-on codes – 5-digit numeric code – Stand-alone unless description contains a semicolon – Additional procedures – Indicated by plus sign (+) – Indented codes 25500 Closed treatment of radial shaft fracture; without manipulation 25505 with manipulation © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-11 Symbols Used in CPT Code description has been revised A new code # Codes are out of numeric sequence New or revised text information © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-12 Symbols Used in CPT (cont.) Does not require modifier of 51 FDA approval pending Moderate (conscious) sedation is included in the procedure © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-13 Organization of the CPT Manual (cont.) • Modifiers – Up to three per procedure – Indicate that special circumstance applies – Appendix A – Section guidelines © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-14 Category II, III, And Unlisted Procedure Codes • Category II – supplemental tracking codes • Category III – temporary codes • Unlisted codes – code not yet assigned – Include a description of service or procedure – Check with payers regarding use © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-15 Coding Terminology • Bundled codes – Read description carefully – Do not unbundle • Critical care – Provided to unstable patients – Documentation • Concurrent care – More than one physician – If different specialties, not considered duplication © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-16 Coding Terminology (cont.) • Consultations – Must have request, record of findings and recommendations, and report – Verify if payer is accepting these codes • Counseling – use codes if history or physical is not done © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-17 Coding Terminology (cont.) • Downcoding – Reimbursement on a lower code level than submitted – Lack of documentation most common cause • Unbundling • Upcoding © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-18 Apply Your Knowledge 2. The insurance representative has questioned the codes listed on three patient forms that were submitted last year. When re-checking these forms the office medical assistant should: ANSWER: a. Use the current book to validate accuracy of the codes b. Use last year’s book to validate accuracy of the codes c. Use next year’s book to validate accuracy of the codes © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-19 Evaluation and Management Services • E/M codes – Used by all physicians – New patient vs. established patient • New patients – require more time • Established patient – seen within 3 years © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-20 Evaluation and Management Services (cont.) • Key factors that help determine level of service Extent of patient history taken Extent of examination conducted Complexity of medical decision making © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-21 Evaluation and Management Services (cont.) Patient History • Elements • Coding descriptions – Chief complaint (CC) – Problem-focused – History of present illness (HPI) – Expanded problemfocused – Review of systems (ROS) – Detailed – Past, family and/of social history (PFSH) – Comprehensive © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-22 Evaluation and Management Services (cont.) Physical Exam • Elements • Coding description – Constitutional exam – Problem-focused – Body areas (BA) – Expanded problemfocused – Organ systems (OA) – Detailed – Comprehensive © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-23 Evaluation and Management Services (cont.) Medical Decision-Making • Elements for documentation – Number of diagnoses and management options – Amount or complexity of data to be reviewed – Risk of complication or death if untreated © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-24 Evaluation and Management Services (cont.) • Complexity level – Straightforward MDM – Low-complexity MDM – Moderate-complexity MDM – High-complexity MDM © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-25 Evaluation and Management Services (cont.) • Contributory factors in assigning codes 1. Counseling • Reason for encounter • 50% or more of time 2. Coordination of care © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-26 Evaluation and Management Services (cont.) 3. Nature of presenting problem • Minimal complaint • Self-limited complaint • Low severity complaint • Moderate severity complaint • High severity complaint © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-27 Evaluation and Management Services (cont.) • Additional considerations – Time • Average times • Not critical unless code choice is based on time – Location where services occurred © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-28 Apply Your Knowledge What are the 3 factors in determining how select E/M codes for different levels of service? ANSWER: – Extent of patient history taken – Extent of the examination conducted – Complexity of medical decision-making © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-29 Surgical Coding • The surgical package – All procedures normally a part of an operation • Preoperative exam and testing • Surgical procedure • Routine follow-up care • Global period – time period covered for follow-up care © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-30 Surgical Coding (cont.) • Integumentary System – Codes based on size and location – Read and follow instructions carefully • Musculoskeletal System – Subheadings • general • Head to toe – Fracture codes most common © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-31 Surgical Coding (cont.) • Respiratory System – Code to furthest extent of the procedure – Approach • Cardiovascular System – Complicated coding – Read instructions carefully • Scope • Incision – Incision vs. excision codes – Sequence codes correctly – Repair procedures © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-32 Surgical Coding (cont.) • Hemic/Lymphatic Systems and Mediastinum and Diaphragm • Digestive System – Upper – Lower • Urinary System – Kidneys and renal function – Diagnostic and therapeutic procedures – Laparoscopy vs. incision © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-33 Surgical Coding (cont.) • Male Genital System • Female Genital System/Maternity and Delivery • Nervous System – Subheadings by anatomic sites – Subdivided by procedure – Specialized guidelines • Endocrine System © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-34 Surgical Coding (cont.) • Eye and Ocular Adnexa • Radiology – Highly specialized procedures – Diagnostic and therapeutic procedures – Read instructions and guidelines carefully – Read all includes and excludes carefully • Auditory System © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-35 Surgical Coding (cont.) • Laboratory Procedures – panels • Medicine and Immunizations – Two codes • Procedure • Vaccine or toxoid © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-36 Apply Your Knowledge What do the terms surgical package and global period include? ANSWER: Surgical package includes preoperative exam and testing, the surgical procedure and local or regional anesthesia if used, and routine follow-up care. The global period is the time covered for follow-up care and included any care provided related to the surgical procedure. Bravo! © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-37 Using the CPT Manual • Become familiar with guidelines and notes for each section • Find the procedures and services provided by the office • Determine appropriate codes – E/M sections – Alphabetic listing – Check all codes listed © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-38 Using the CPT Manual • Determine appropriate modifiers – Required if available – Enhance reimbursement • Enter codes and modifiers on CMS-1500 form – Primary procedure first and match with appropriate diagnostic code – All other procedures matched with appropriate diagnostic code © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-39 Apply Your Knowledge What are the steps for locating a code in the CPT manual? ANSWER: 1. Determine if the patient is new or established 2. Find procedures and services provided (encounter form) 3. Verify information with the medical record 4. Locate the correct code in the CPT manual starting with the alphabetic index and verifying with the numeric index. 5. Check for modifiers 6. Document on CMS-1505 or in the billing program © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-40 The HCPCS Coding Manual • Health Care Common Procedure Coding System • Use for coding services for Medicare patient • HCPCS Level I codes – CPT codes © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-41 The HCPCS Coding Manual (cont.) • HCPCS Level II codes – National codes for supplies and DME – Cover services and procedures not in CPT – 5 characters ~ numbers, letters, or a combination of both – Modifiers © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-42 The HCPCS Coding Manual (cont.) • Coding procedures – Locate service in the Alphabetic Index – Verify description in the alphanumeric Index – Choose code that matches service, procedure, or item supplied – Enter on CMS-1505 form or into the billing program © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-43 Apply Your Knowledge What are HCPCS Level II codes and who issues them? ANSWER: HCPCS Level II codes are national codes used for supplies, DME, and services not included in the CPT. They are issued by Centers for Medicare and Medicaid Services (CMS). © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-44 Coding Compliance • Physician – ultimate responsibility • Medical assistants – Submit correct claims – Help ensure maximum appropriate reimbursement • Claims must comply with – Federal and state law – Payer requirements © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-45 Code Linkage • Analysis of the connection between diagnostic and procedural information to evaluate medical necessity Diagnostic Codes Procedural Codes © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-46 Code Linkage (cont.) • Codes are checked against the medical documentation • Coding audit: – Are codes appropriate and is each coded service billable? – Is code linkage correct? – Have rules ben followed? – Does documentation support services? – Do reported services comply with regulations? © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-47 Insurance Fraud • Investigators look for patterns such as – Reporting services that were not performed – Reporting services at a higher level – Performing and billing for procedures not related to the patient’s condition and therefore not medically necessary © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-48 Insurance Fraud (cont.) • Patterns (cont.) – Unbundling – Reporting the same service twice • Copayments – Waiver may violate payer policies – Ensure policies are consistent with law and requirements of payers © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-49 Compliance Plans • Process for finding, correcting, and preventing illegal medical practices • Goals of compliance plan – Prevent fraud and abuse – Ensure compliance with applicable laws – Help defend physicians if investigation occurs © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-50 Compliance Plans (cont.) • Developed by a compliance officer and committee who also: – Audit and monitor compliance with government regulations – Develop consistent written policies and procedures – Provide ongoing staff training and communication – Respond to and correct errors © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-51 Apply Your Knowledge Why is code linkage important? ANSWER: Code linkage will ensure clean claims in which each reported service is connected to a supporting diagnosis. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-52 In Summary 19.1 The sections for the CPT manual are Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology and Laboratory, and Medicine with code ranges from 00100-99602. 19.2 A CPT code is a 5-digit code representing the service provided to the patient. The CPT manual general guidelines include symbols which represents important information about the code being described Always begin coding by looking up the description in the Alphabetic Index and verifying in the Tabular (numeric) List. Carefully read all guidelines and information surrounding the codes. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-53 In Summary (cont.) 19.3 The E/M code types include: office and other outpatient services as well as other E/M services. 19.4 Surgical Coding sections include major body systems, radiology, pathology and lab, and medicine. 19.5 Students should be able to select an accurate code using the CPT manual for simple, straightforward coding scenarios. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-54 In Summary (cont.) 19.6 Students should be able to select an accurate code using the HCPCS manual for simple, straightforward coding scenarios. 19.7 Code linkage demonstrates the medical necessity of services provided to the patient by accurately linking each procedure code to its appropriate diagnosis. All procedures, services, and diagnoses must be documented in the patient’s medical record to be used on any health insurance claim form. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 19-55 End of Chapter 19 Things gained through unjust fraud are never secure. ~ Sophocles Screen captures of SpringCharts™ Electronic Health Records software are reprinted with permission from Spring Medical Systems, Inc. All rights reserved. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.