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Procedural Coding: Introduction to CPT Chapter 5

Chapter 5. 2. Learning Outcomes. After studying this chapter, you should be able to:5.1Discuss the purpose of the CPT code set.5.2Explain how to locate the periodic updates to CPT codes.5.3Describe the structure and content of the index and the main text in CPT.5.4Interpret the formats, co

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Procedural Coding: Introduction to CPT Chapter 5

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    1. Chapter 5 1 Procedural Coding: Introduction to CPT Chapter 5

    2. Chapter 5 2 Learning Outcomes After studying this chapter, you should be able to: 5.1 Discuss the purpose of the CPT code set. 5.2 Explain how to locate the periodic updates to CPT codes. 5.3 Describe the structure and content of the index and the main text in CPT. 5.4 Interpret the formats, conventions, and symbols used in CPT.

    3. Chapter 5 3 Learning Outcomes (Continued) 5.5 Describe the purpose and correct use of CPT modifiers. 5.6 List the three general steps for selecting correct CPT procedure codes. 5.7 Discuss the purpose, structure, and key guidelines for each of the six sections of CPT Category I codes.

    4. Chapter 5 4 Learning Outcomes (Continued) 5.8 Discuss the key components that are the basis for selection of CPT Evaluation and Management codes, and describe the steps for selecting correct codes. 5.9 Analyze procedural statements, apply appropriate physician practice coding guidelines, and assign correct CPT codes.

    5. Chapter 5 5 Key Terms Add-on code Ancillary services Bundling Category I codes Category II and III codes Conscious sedation Consultation Current Procedural Terminology (CPT)

    6. Chapter 5 6 Key Terms (Continued) Physical status modifier Primary procedure Professional component (PC) Secondary procedure Section guidelines

    7. Chapter 5 7 CPT HIPAA-mandated codes from the American Medical Association Used to report physician services and procedures on

    8. Chapter 5 8 CPT Accurate procedural coding ensures maximum reimbursement for services

    9. Chapter 5 9 CPT Category I Codes Five-digit (no decimals) codes Two-digit modifiers may be added to indicate special circumstances Category II Codes Track performance measures Four digits and one alphabetic character Category III Codes Temporary codes for emerging technologies Four digits and one alphabetic character

    10. Chapter 5 10 CPT Organization and Format CPT contains : six sections of Category I codes thirteen appendices an index

    11. Chapter 5 11 Six Sections of Category I Codes Evaluation and Management (E&M) (99201-99499) Anesthesia (00100-01999) Surgery (10021-69990) Radiology (70010-79999) Pathology and Laboratory (80048-89356) Medicine (90281-99602)

    12. Chapter 5 12 CPT Updates Category I Codes Major changes announced October 1st for use the following January 1st Categories II and III Codes Released by the AMA every six months Can be used when released

    13. Chapter 5 13 The Index Terms are listed alphabetically by Name of the procedure or service Name of the organ or site Name of the condition Synonym or eponym for the term Abbreviation for the term

    14. Chapter 5 14 The Index The index may use two types of cross-references See is a mandatory instruction to look under a different listing See also refers the coder elsewhere if the procedure is not listed here The main text contains additional entries and important guidelines.

    15. Chapter 5 15 Look it Up! Mitchell Procedure Exercise Stress Test Adhesions, pelvic, lysis PKU ECG Monitoring

    16. Chapter 5 16 Look it Up! Radical resection of the distal humerus with autograft (Hint - look under resection)

    17. Chapter 5 17 The Main Text Each section begins with coding guidelines unique to that section

    18. Chapter 5 18 The Main Text When a main entry has more than one code a semicolon ; follows the common part of the descriptor in the main heading unique descriptions of the main entry are indented below it

    19. Chapter 5 19 Chemical peel, facial ;epidermal ;dermal Look it Up!

    20. Chapter 5 20 The Main Text Special symbols: • New procedure ? Change in code’s description ?? New or revised information + Add-on codes (procedures carried out in addition to other procedures) Code cannot be used with -51 modifier ? Code includes conscious sedation ? Pending FDA approval

    21. Chapter 5 21 CPT Modifiers

    22. Chapter 5 22 CPT Modifiers CPT modifiers are two-digit numbers that communicate special circumstances involved with a service/procedure. A modifier affects the normal level of reimbursement for the code to which it is attached.

    23. Chapter 5 23 CPT Modifiers All modifiers are listed in Appendix A Some modifiers apply only to certain sections Modifiers are shown by appending them with a hyphen: 71020-26

    24. Chapter 5 24 The Appendixes The thirteen appendixes contain information helpful to the coding process: Appendix A – Modifiers Appendix B – Summary of Additions, Deletions, and Revisions Appendix C – Clinical Examples Appendix D – Summary of CPT Add-on Codes Appendix E – Summary of CPT Codes Exempt from Modifier – 51 Appendix F – Summary of CPT Codes Exempt from Modifier – 63

    25. Chapter 5 25 The Appendixes Appendix G – Summary of CPT Codes Which Include Conscious Sedation Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I – Genetic Testing Code Modifiers Appendix J – Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix K – Product Pending FDA Approval Appendix L – Vascular Families Appendix M – Crosswalk to Deleted CPT Codes

    26. Chapter 5 26 Coding Steps Determine the procedures and services to report

    27. Chapter 5 27 Three Steps to CPT Coding Determine the procedures and services to report

    28. Chapter 5 28 Three Steps to CPT Coding Identify the correct codes

    29. Chapter 5 29 Three Steps to CPT Coding Determine the need for modifiers

    30. Chapter 5 30 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    31. Chapter 5 31 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    32. Chapter 5 32 Evaluation and Management Codes Definition

    33. Chapter 5 33 Selecting E&M Codes Key Components History Examination Medical decision making

    34. Chapter 5 34 Selecting E&M Codes Additional Components Counseling Coordination of care Nature of presenting problem Time

    35. Chapter 5 35 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    36. Chapter 5 36 1) Determine the category and subcategory of service based on the place of service and the patient’s status Categories are based on place or type of service Subcategories provide further definition

    37. Chapter 5 37 1) Determine the category and subcategory of service based on the place of service and the patient’s status Categories are based on place or type of service Subcategories provide further definition

    38. Chapter 5 38 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    39. Chapter 5 39 2) Determine the extent of the history that is documented Problem -focused Expanded problem-focused Detailed Comprehensive

    40. Chapter 5 40 2) Determine the extent of the history that is documented

    41. Chapter 5 41 2) Determine the extent of the history that is documented

    42. Chapter 5 42 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    43. Chapter 5 43 3) Determine the extent of the examination that is documented Problem-focused Expanded problem-focused Detailed Comprehensive

    44. Chapter 5 44 3) Determine the extent of the examination that is documented Problem-focused Expanded problem-focused Detailed Comprehensive

    45. Chapter 5 45 3) Determine the extent of the examination that is documented Problem-focused Expanded problem-focused Detailed Comprehensive

    46. Chapter 5 46 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    47. Chapter 5 47 4) Determine the complexity of medical decision making that is documented Straightforward Low-complexity Moderate complexity High complexity

    48. Chapter 5 48 4) Determine the complexity of medical decision making that is documented Straightforward Low-complexity Moderate complexity High complexity

    49. Chapter 5 49 4) Determine the complexity of medical decision making that is documented Straightforward Low-complexity Moderate complexity High complexity

    50. Chapter 5 50 4) Determine the complexity of medical decision making that is documented Straightforward Low-complexity Moderate complexity High complexity

    51. Chapter 5 51 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    52. Chapter 5 52

    53. Chapter 5 53 5) Analyze the requirements to report the service level Examples of when all three key components must be met: New patient, office Initial visits, inpatient Examples of when two of the three key components are required: Established patients, office Subsequent visits, inpatient

    54. Chapter 5 54 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    55. Chapter 5 55 Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination 7) Verify that the documentation is complete

    56. Chapter 5 56 Steps for Selecting E&M Codes Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

    57. Chapter 5 57 8) Assign the code The appropriate code is assigned. The need for any further modifiers is also reviewed.

    58. Chapter 5 58 Office Visit for an established six-year-old patient with a sore throat Look it Up!

    59. Chapter 5 59 History and physical exam of a normal newborn Look it Up!

    60. Chapter 5 60 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    61. Chapter 5 61 The Six Sections Anesthesia Codes Definition

    62. Chapter 5 62 Anesthesia for procedure of the upper anterior abdominal wall Look it Up!

    63. Chapter 5 63 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    64. Chapter 5 64 The Six Sections Surgery Codes

    65. Chapter 5 65 Anesthesia for total hip replacement Surgical procedure for total hip replacement Look it Up!

    66. Chapter 5 66 Tympanostomy bilateral with insertion of ventilating tubes with general anesthesia Look it Up!

    67. Chapter 5 67 Co-surgeon for total abdominal hysterectomy Look it Up!

    68. Chapter 5 68 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    69. Chapter 5 69 The Six Sections Radiology Codes

    70. Chapter 5 70 Professional reading of chest x-ray, two views, PA and lateral Look it Up!

    71. Chapter 5 71 Radiological exam of the wrist; complete, three views Professional reading of bilateral mammogram Look it Up!

    72. Chapter 5 72 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    73. Chapter 5 73 The Six Sections Pathology and Laboratory Codes Definition

    74. Chapter 5 74 Hepatic function laboratory panel Professional reading of TSH Look it Up!

    75. Chapter 5 75 The Six Sections Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

    76. Chapter 5 76 The Six Sections Medicine Codes Definition

    77. Chapter 5 77 Determination of refractive state Right heart catheterization Look it Up!

    78. Chapter 5 78 Category II Codes Track performance measures 0004F Tobacco use cessation intervention, counseling

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