Medical assisting Administrative and clinical procedures (5e) Chapter 19 Procedure coding

The learning objectives for this chapter include: List the sections of the CPT manual, giving the code range for each, describe briefly each of the CPT’s general guidelines, list the types of EM Codes within the CPT, list the areas included in the Surgical Coding Section,...

Procedure Coding

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.

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

• Procedural coding

– Translate medical procedures and services into codes

– Explains what services were provided

• Code “linkage” with diagnostic codes

• Maximum reimbursement

The CPT Manual

• Procedure code

• Current Procedural Terminology (CPT)

– HIPAA-required code set

– Published by the AMA

– Updated annually

– Use the appropriate CPT based on date of service

Organization of the CPT Manual

Section Range of Codes

Organization of the CPT Manual (cont.)

Organization of the CPT Manual (cont.)

• Sections

– Guidelines at

beginning – Categories 

headings

• Page

– Section name – Subsection name – Subheading

– Category

Apply Your Knowledge

Match CPT section to number range ANSWER:

Evaluation and management

Anesthesiology

Surgery

Radiology

Pathology and Laboratory

Medicine (except for Anesthesia)

70010-79999 00100-01999 99100-99140

90281-99199 99500-99602 80048-89356 99201-99499

10021-69990

• Add-on codes

– Additional procedures– Indicated by plus sign (+)

– Indented codes

25500 Closed treatment of radial shaft

fracture; without manipulation

25505 with manipulation

Symbols Used in CPT

Symbols Used in CPT (cont.)

FDA approval pending

procedure

Organization of the CPT Manual (cont.)

• Modifiers

– Up to three per procedure

– Indicate that special circumstance applies

– Appendix A

– Section guidelines

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

Coding Terminology

• Concurrent care

– More than one physician– If different specialties, not considered

duplication

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

Coding Terminology (cont.)

• Downcoding

– Reimbursement on a lower code level than submitted

– Lack of documentation most common cause

• Unbundling

• Upcoding

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:

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

Apply Your Knowledge

ANSWER:

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

• Key factors that help determine level of service

problem-– Detailed– Comprehensive

Patient History

• Elements

– Constitutional exam

– Body areas (BA)

– Organ systems (OA)

• Coding description

– Problem-focused

– Expanded focused

problem-– Detailed– Comprehensive

Physical Exam

• Elements for documentation

– Number of diagnoses and management options

– Amount or complexity of data to be reviewed

– Risk of complication or death if untreated

Medical Decision-Making

Evaluation and Management Services

Evaluation and Management Services

(cont.)

3 Nature of presenting problem

• Minimal complaint

• Self-limited complaint

• Low severity complaint

• Moderate severity complaint

• High severity complaint

Evaluation and Management Services

Apply Your Knowledge

ANSWER:

– Extent of patient history taken

– Extent of the examination conducted

– Complexity of medical decision-making

What are the 3 factors in determining how select

E/M codes for different levels of service?

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

Surgical Coding (cont.)

Surgical Coding (cont.)

• Respiratory System

– Code to furthest extent

of the procedure– Approach

• Scope

• Incision

– Incision vs excision

codes– Repair procedures

• Cardiovascular System

– Complicated coding

– Read instructions carefully

– Sequence codes correctly

Surgical Coding (cont.)

procedures– Laparoscopy vs

incision

Surgical Coding (cont.)

• Male Genital System

– Subdivided by procedure

– Specialized guidelines

Surgical Coding (cont.)

• Eye and Ocular

procedures– Read all includes and excludes carefully

Surgical Coding (cont.)

• Medicine and Immunizations

– Two codes

• Procedure

• Vaccine or toxoid

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!

Using the CPT Manual

• Become familiar with guidelines and notes for

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

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

The HCPCS Coding Manual

• Health Care Common Procedure Coding System

• Use for coding services for Medicare patient

• HCPCS Level I codes – CPT codes

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

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

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).

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

Code Linkage

• Analysis of the connection

between diagnostic and

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?

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

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

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

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

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.

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 describedAlways 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

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

19.5 Students should be able to select an accurate code

using the CPT manual for simple, straightforward coding scenarios

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

Things gained through unjust fraud are never

secure

~ Sophocles

End of Chapter 19

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