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CHAPTER 7

CHAPTER 7. CPT Coding. Introduction. Chapter 7: Introduces assignment of Current Procedural Terminology CPT: Services and procedure codes reported on insurance claims. Overview of CPT. CPT

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CHAPTER 7

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  1. CHAPTER 7 CPT Coding

  2. Introduction • Chapter 7: • Introduces assignment of Current Procedural Terminology • CPT: • Services and procedure codes reported on insurance claims

  3. Overview of CPT • CPT • Provides a list of identifying and descriptive codes for reporting procedures and medical services • Uniform language that describes medical, surgical procedures and services

  4. Overview of CPT • CPT codes are used to report services and procedures • Submitted as claims with linked ICD-9-CM codes • Codes justify need for service or procedure

  5. Overview of CPT • Changes to CPT • CPT supports electronic data • Exchange (EDI), Computer-based patient • Record (CPR), or electronic medical • Record (EMC) and reference/research database

  6. Overview of CPT • Improvements to CPT are underway • In 2002 • AMA completed the CPT 5 Project, resulting in the establishment of three categories of CPT codes

  7. Overview of CPT • Category 1 • Procedures/services identified by a five digit CPT code and descriptor nomenclature • Codes traditionally associated with CPT organized in six sections

  8. Overview of CPT • Category 2 • Contain “performance measurements” tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A) • Codes located after Medicine section • Use is optional

  9. Overview of CPT • July 2007 • New program from Medicare utilizing these codes to justify documentation • “PQRI’s” will begin a project for physicians’ practices • Will receive additional percentage of revenue for documentation compliance

  10. Overview of CPT • Category 3 codes • Contain “emerging technology” temporary codes assigned for data purposes and assigned in alphanumeric with the letter in the last position

  11. Overview of CPT • Field 0001T • Codes are located after Medicine section • Archived after five years unless accepted for placement

  12. CPT Sections • Category I procedures and services • Evaluation and Management (E/M) 99201-99499 • Anesthesia (00100-01999, 99100-99140) • Surgery (10021-69990)

  13. CPT Sections • Radiology (70010-79999) • Pathology and laboratory (80048-89356) • Medicine (90281-99199, 99500-99602)

  14. CPT Sections • CPT code number format • Five-digit number and description identifying each procedure and service listed in CPT

  15. CPT Sections • CPT Appendices • CPT contains appendices located after the Medicine section and Index • Insurance specialist should become familiar with changes that affect the practice

  16. CPT Appendix Description • Appendix A • Detailed description of each CPT modifier • Appendix B • Annual CPT coding changes • Added, deleted, revised CPT codes

  17. CPT Appendix Description • Appendix C • Clinical examples for evaluation and Management (E/M) section codes • Appendix D • Add-on codes

  18. CPT Appendix Description • Appendix E • Codes exempt from modifier -51 reporting rules • Appendix F • CPT codes exempt from modifier -63 reporting rules • Appendix G • Summary of CPT codes that include moderate (conscious) sedation

  19. CPT Appendix Description • Appendix H • Alphabetic index of performance measures by clinical condition or topic • Serves as a crosswalk to the category II • Appendix I • Genetic testing code modifiers

  20. CPT Appendix Description • Appendix J • Electro diagnostic medicine listing of sensory, motor, and mixed nerves

  21. CPT Appendix Description • There is also a table that indicates “type of study and maximum of studies” • Generally performed for needle electromyogram (EMG) • Nerve conduction studies • Other EMG studies

  22. CPT Appendix Description • Appendix L • List of vascular families that is intended to assist in selection of first, second, third, and beyond third-order branch arteries • Appendix M • Crosswalk of deleted to new CPT codes

  23. CPT Symbols • Symbols are located throughout CPT coding book • Bullet located to left of a code number • Identifies new procedures and services added to CPT

  24. CPT Symbols • Triangle located to left of a code number • Identifies a code description that has been revised

  25. CPT Symbols • Horizontal triangles • Surround revised guidelines and notes • Not used for revised code descriptions • To save space in CPT • Code descriptions are not printed in their entirety next to a code number

  26. CPT Symbols • Plus sign • Identifies add-on codes • For procedures that are commonly, but not always, performed at the same time and by the same surgeon

  27. CPT Symbols • Circle with a line through it • Identifies codes that are not to be used with modifier • Bull’s-eye symbol • Indicates a procedure that includes moderate sedation

  28. Guidelines • Located at beginning of the CPT section • Should be reviewed each year before attempting to code from this section • Guidelines define and explain the assignment of codes, procedures, and services in a particular section

  29. Unlisted Procedures/Services • Unlisted procedure or service • Codes are assigned when a procedure or service is performed by a provider for which there is no CPT code

  30. Unlisted Procedures/Services • Special Report • When an unlisted procedure or service code is reported

  31. Unlisted Procedures/Services • Special Report • Narrative document must accompany claim to describe nature and extent of the need of service or procedure • Some practices place in Box 19 of CMS 1500 claim form the “unlisted code = the closest related code of XXXXX.”

  32. Unlisted Procedures/Services • Notes • Instructional notes are found throughout

  33. Unlisted Procedures/Services • Blocked unindented note: • Located below a subsection title and contains instructions that apply to all codes

  34. Unlisted Procedures/Services • Indented parenthetical note: • Located below a subsection title, code description, or code description that contains an example • Highlight and understand each of these notes

  35. CPT Modifiers • Clarify services and procedures performed by providers • Have always been reported on claims submitted for provider office services and procedures

  36. CPT Modifiers • Coding tip: • List of all CPT modifiers with brief descriptions is located inside front cover of coding manual

  37. CPT Modifiers • Documented history, examination, and medical decision making • Must “stand on its own” to justify reporting modifier -25 with the Evaluation and Management (E/M) code

  38. CPT Modifiers • E/M service: • Must be “above and beyond” what is normally performed during a procedure

  39. Coding Procedures and Services • Step 1: • Read introduction in CPT coding manual • Step 2: • Review guidelines at beginning of each section • Step 3: • Review procedure

  40. Coding Procedures and Services • Step 4: • Refer to CPT index • Locate main term for procedure or service documented • Main terms can be located by referring to the following:

  41. Coding Procedures and Services a. Procedure or service documented b. Organ or anatomic site c. Condition documented in the record d. Substance being tested

  42. Coding Procedures and Services • Synonym (term with similar meaning) • Eponym (procedures and diagnoses named for an individual) • Abbreviation

  43. Coding Procedures and Services • Step 5: • Locate sub terms and follow cross references • Step 6: • Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements

  44. Coding Procedures and Services • Step 7: • Assign applicable code number and any add-on (+) or additional codes needed to accurately classify statement being coded

  45. Surgery Section • Surgery section is organized by body system • Some subsections are further subdivided by procedure categories

  46. Surgery Section • Incision • Excision • Introduction or removal • Repair, revision, or reconstruction • Grafts

  47. Surgery Section • Suture • Other procedures

  48. Code Surgeries Properly • Three questions must be asked: • What body system was involved? • What anatomic site was involved? • What type of procedure was performed? • Carefully read the procedure outlined in the operative report

  49. Evaluation and Management • Evaluation and management • Located at the beginning of CPT because these codes describe services most frequently provided by physicians • Before assigning E/M codes • Make sure you review guidelines and apply any notes

  50. Evaluation and Management • For established patients • Two of three key components must be considered

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