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Surgery, Radiology, Pathology/Laboratory, and Medicine

Surgery, Radiology, Pathology/Laboratory, and Medicine. CODING PROCEDURES Part II:. Chapter 6. PROCEDURAL CODING PART II. Learning Objectives Define procedure code terminology. Explain the purpose of coding for professional services. List all subsections of Surgery section.

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Surgery, Radiology, Pathology/Laboratory, and Medicine

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  1. Surgery, Radiology, Pathology/Laboratory, and Medicine CODING PROCEDURES Part II: Chapter 6 Chapter 6

  2. PROCEDURAL CODING PART II • Learning Objectives • Define procedure code terminology. • Explain the purpose of coding for professional services. • List all subsections of Surgery section. • Compare comprehensive codes and component codes. Chapter 6

  3. PROCEDURAL CODING PART II • Learning Objectives • Distinguish between surgical package and Medicare global package rules. • Describe two ways to code for multiple procedures. • Demonstrate an understanding of surgical terminology. • Explain situations in which modifiers are applied to surgical codes. Chapter 6

  4. PROCEDURAL CODINGPART II • Performance Objective • Locate a code in the Surgery section by using the index. • Code scenarios presented in the worktext from all of CPT. • Apply CPT and HCPCS Level II modifiers when appropriate. Chapter 6

  5. Add-on code Anesthesia Bilateral Procedure Bundled Code Closed Fracture Closed Treatment Component Code Comprehensive Code Downcoding Elective Surgery Endoscopy Fixation Fracture Manipulation Global Surgery Policy Indented Code Open Fracture Open Treatment Percutaneous Treatment Professional Component (PC) Key Terms Chapter 6

  6. Key Terms • Test Panel • Unbundling • Upcoding • Qualitative Analysis • Quantitative Analysis • Separate Procedures • Stand-alone Codes • Surgical Package • Technical Component (TC) Chapter 6

  7. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Introduction to the Surgery Section • Largest Section of the CPT Codebook • 16 Subsections, divided according to Body Systems • Guidelines are found at the beginning of the Surgery Sections. • Subsection further divided into Categories based on Anatomic Site • Subcategories are within each Category which list the type of procedure or condition. Chapter 6

  8. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • How to Code Effectively • You must be able to analyze a proceduredescriptionand identify various terms that will direct you to the correct code. • To do this you must know the main categories under which services and procedures are listed according to their main term in the index. • After the procedure,service, or condition is identified in the index, search for asubterm and a sub-subterm that further defines the procedure. Chapter 6

  9. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • How to Code Effectively – Cont. • When a code range is found, turn to the correct section and read all descriptions listed under the code range before selecting a code. • Performance Exercise • Table 6-2/Page 138 Chapter 6

  10. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • How to Code Effectively • Identify Main Term(s) in the Procedure Description of the Medical Record • LocateMain Term(s) in the Index & Document Code Range • Turn to the Correct Section of the CPT & Read all Description listed in the Code Range • Select the Correct Code Chapter 6

  11. Coding Procedures & ServicesIntroduction to theSurgery Section/(10040-69979)PERFORMANCE EXERCISE • Excision of tendon, finger, flexor, single (separate procedure), each 26180 • How to Code Effectively • Identify Main Term(s) in the Procedure Description of the Medical Record • LocateMain Term(s) in the Index & Document Code Range • Turn to the Correct Section of the CPT & Read all Description listed in the Code Range • Select the Correct Code Chapter 6

  12. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • How to Code Effectively – Cont. • Stand-alone Codes – are procedure codes that have a full description. • Comes before the (;) • Terminology after the (;) has a Dependent Status as the Subsequent Indented Entries • Performance Exercise • Figure 6-3/Page 138 Chapter 6

  13. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • How to Code Effectively – Cont. • Indented Codes – are listed after stand-alone codes whose descriptions have a dependent status. • To read the description, you must first read the description of the stand-alone code that comes before the semicolon (;)and, • then continue with the indented description listed by the subsequent code (indented code). • Performance Exercise • Figure 6-3/Page 138 Chapter 6

  14. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Integral Code Description • One Code is part of another based on language used in the description • Example 6-2/Page139 • Parentheses ( ) further define & tell where other services are located • Figure 6-4/Page 139 Chapter 6

  15. Coding Steps Step 1 Become familiar with CPT codes Step 2 Find the services listed on patient encounter form Step 3 Look up codes in index, then look up actual code Step 4 Determine appropriate modifiers Step 5Record the procedure code on the insurance claim; PROOFREAD numbers Chapter 6

  16. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Coding from the Operative Report • Read the Operative report thoroughly & code on documented operations • Determine Bundled or Unbundled Procedures • Never Code Verbal Procedures • Coding Rule:“Not Documented, Not Done”! Chapter 6

  17. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) Operative Report Date of Service: 5/17/03 Surgeon: Jeffrey Thompson, MD Assistant Surgeon: None Preoperative Diagnosis: RLQ pain, probable appendicitis Postoperative Diagnosis: Acute appendicitis Procedures Performed: Exploratory laparotomy, appendectomy Anesthesia: General Endotracheal Chapter 6

  18. Chapter 6

  19. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Decision for Surgery - • Criteria to Evaluate • Is patient new or established? • Is the E/M service significant and separately identifiable from the procedure? • What is the time lapse from the time the decision is made for surgery to the time when the procedure is performed? • Performance Exercise • Figure 6-4/Page 141 Chapter 6

  20. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Decision for Surgery • -57 (Modifier) – An E/M service that resulted in the initial decision to perform the surgery. • -25 (Modifier) - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Chapter 6

  21. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Surgical Package is a combination of services included in a single procedure code for some surgical procedures in the CPT. • Governmental Programs & Insurance Companies assign fees to surgical package codes that reimburse all services provided under them. • The period of time that is covered for follow-up care is referred to as the Global Period. • For Example, the Global Period for repairing a Tendon might be set at 15 days. Chapter 6

  22. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Surgical Package – Cont. • A Global Period for Major Surgery such as Appendectomy may be set at 100 days. • After the Global Period ends additional services that are provided can be reported separately for additional payment. Chapter 6

  23. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Surgical Package – Cont. • Surgical Package Includes • Combination of Services • Global Period • Surgical Procedures • Anesthesia • Related E/M Encounter • Postoperative Care • Private Carriers • May have an individual policy on what is included in the package. Chapter 6

  24. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • MedicareGlobal Package - Included • Preoperative E/M Services • Intraoperative Services • Postoperative Visits • Complications after surgery without addition trips to the operating room • Anesthesia • Supplies necessary for performance of the procedure Chapter 6

  25. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Medicare Global Package -Excluded • Initial Consultation or Evaluation • Diagnostic Tests & Procedures • Treatment required to stabilize a seriously ill patient before surgery • Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed (modifier –24) • Related Procedures for postoperative complications that requires a return trip to the operating room (modifier –78) • Immunosuppressive Therapy after transplant surgery • For services performed in a physician’s office, separate payment may be made for splints and casting supplies, and a surgical tray. Chapter 6

  26. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Follow-Up Days • Vary 0-day or 10-day for Minor Surgeries • 45-day or 90-day for Major Surgeries • Most States use Relative Value Studies fee schedule for Worker’s Compensation cases • List the follow-up days allowed for most surgical procedures • Federal Register • Published annually • List follow-up days for Medicare Services Chapter 6

  27. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Multiple Procedure Modifier –51 • Report the primary serviceor procedure(identified by the highest dollar value listed) • Identify all additional services or Procedures by appending code(s) with modifier–51or use the separate five-digit modifier09951 • Appendix E – Summary of CPT Codes Exempt from Modifier 51 Chapter 6

  28. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Add-on Code • Noted by a Cross (+)Symbol represents additional Procedure done with Primary Procedure • Found in Appendix D of CPT • Can not billed without the primary procedure • Add-on-Code Description start with: • “in addition” • “list separately • Or “second lesion” • Performance Exercise • Example 6-5/Example 6-6/Page 143 Chapter 6

  29. Coding Procedures & ServicesIntroduction to theSurgery Section(10040-69979) • Add-on Code – Cont. • Bilateral Procedures - is one procedure performed on two sides. • Two ways to Bill • List the CodeOncewith Modifier–50 & doublethe fee • List the CodeTwiceusing asinglefee & add thesecond listing with Modifier–50 • Performance Exercise • Example 6-7/Page 143 Chapter 6

  30. Coding Procedures & ServicesIntroduction to the Surgery Section(10000-19999) • Assistant At Surgery • Modifiers • -80 Assistant surgeon • -81 Minimum Assist Surgeon • -82 Assistant surgeon (when qualified resident surgeon not available) • -62 Two Surgeons • -66 Surgical Team The Surgeon who assist is usually paid a fee of 16 to 30 percent of the allowed fee of the primary Surgeon. • Performance Exercise • Example 6-8/Page 144 Chapter 6

  31. Coding Procedures & ServicesSurgery:Integumentary System(10000-19999) • Integumentary System • First Subsection listed in the Surgery Section • Contains Procedures performed on the Skin • Benign versus Malignant • Neoplasm – must indicate benign or malignant • Claim Form – should be delayed until the Pathologyreport can confirm or deny Benign vs Malignant • Lesion – is any discontinuity of the skin Biopsy – performed for the purpose of determining the morphology (shape, form, & structure) is reported separately. Biopsy of a lesion followed by excision would be included in the excision procedure code, and not reported separately. Chapter 6

  32. Coding Procedures & ServicesSurgery:Integumentary System(10000-19999) • Lesion –when coding removal of lesions note the: • Anatomic Site • Size, measured in centimeters • Number of lesions removed • Process used to remove the lesion (excision,destruction, paring, shaving) • Morphology(appearance of specimen’s shape and structure used to determine benign or malignant status) Chapter 6

  33. Coding Procedures & ServicesSurgery:Integumentary System(10000-19999) • Repair of Lacerations • Simple Closure – Superficial; involving the epidermis, dermis, or subcutaneous tissue. • Intermediate Closure – Requires layered closure of deeper subcutaneous tissue in addition to the simple closure. • Complex Closure – Requires more than one layered closure; debridement, scar revision, extensive undermining, stents, or retention sutures Chapter 6

  34. Coding Procedures & ServicesSurgery:Integumentary System(10000-19999) • Multiple Lesions • Modifier –51 (Multiple Procedures) • Read description & look for terms such as complicated, complex, more than, etc • Watch for Add-on-codes(+) VS Codes eligible for Modifier–51 & indented Codes • Surgical Supplies • Bundled into Surgical Code (99070) or HCPCS Level II Codes Chapter 6

  35. Coding Procedures & ServicesSurgery:Integumentary System(10000-19999) • Breast Category • Included within the Integumentary system because of the type of tissue involved. • Each Breast Considered Separate • If procedure occur on both sides useModifier –50 (bilateral) • Performance Exercise • Example 6-9, 6-10 & 6-11/Page 145-46 Chapter 6

  36. Coding Procedures & ServicesSurgery:Integumentary System(10000-19999)PERFORMANCE EXERCISE • Breast reconstruction with free flap 19364 • Preoperative placement of needle localization wire, breast: 19290 Chapter 6

  37. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999) • Musculoskeletal System • Arranged according to Anatomic Site • “General” first Category Contain Procedures & Subcategoriesfor different Anatomic Sites. • Remaining Categories Start from the “Head” to the “Toe” • Subcategories Under Each Anatomic Category Include: • Incision • Excision • Introduction/Removal Chapter 6

  38. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999) • Subcategories Under Each Anatomic Category Include: • Fracture/Dislocation • Arthrodesis • Amputation • Unlisted Procedures • Fractures are: • Open/skin broken by the fragmented bone(Compound Fracture) • Closed/skin is not broken • Percutaneous/neither Opened or Closed Chapter 6

  39. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999) • Coding Treatment of a Fracture • Locate the Anatomic Site • Find Subcategory“Fracture and/or Dislocation” • Then find the appropriate code • Description of Fractures are either: • “With Manipulation” or • “Without Manipulation” Chapter 6

  40. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999) • Other Descriptive Terms Are: • “Internal Fixation” • “External Fixation” Chapter 6

  41. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999) • Fracture Manipulation is: • The manual stretching or applying pressure or traction • to realign the broken (fractured) bone. • Referred to as “reduction”. • Fixation – is the use of hardware (instrumentation) to keep a bone in place. • It can be applied internally(e.g., plates, rod, pin) or • Externally (e.g., pins that comes thru the skin to the outside to keep the fractured bone from moving). Chapter 6

  42. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999) • Fracture Follow-up Period:  The surgical package rule applies. All fracture code carry a 90-day follow-up period. • Performance Exercise • Example 6-12/Page 147 • Example 6-13/Page 147 Chapter 6

  43. Coding Procedures & ServicesSurgery:Musculoskeletal System(20000-29999)PERFORMANCE EXERCISE • Closed treatment of mandibular fracture; without manipulation 21450 • Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone. 26607 Chapter 6

  44. Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999) • Respiratory System • Organized by Anatomic Site • Then by Type of Procedure • Includes procedures of the nose, sinuses, larynx (voice box), trachea (windpipe), bronchial tubes, lungs, and pleura (membrane that surrounds the lung) Chapter 6

  45. Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999) • Endoscopy –is the insertion of a flexible fiber-optic tube, called scope, through a small incision into a body cavity or into a natural body opening, such as the ears, nose, mouth, vagina, etc. • Diagnostic Endoscopy – is done for the purpose of visualization and determination of the disease process. • Diagnostic Endoscopy is always included in a surgical endoscopy and may not be billed separately Chapter 6

  46. Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999) • Endoscopy Procedures • Diagnostic Endoscopy • Surgical Endoscopy • Endoscopies • Named for body area being explored • e.g., brochial tube/bronchoscopy • Performance Exercise • Example 6-14/Page 149 Chapter 6

  47. Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)PERFORMANCE EXERCISE • Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 31231 • Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) 31622 Chapter 6

  48. Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999) • Cardiovascular System • Organized by Anatomic Site • Then by Type of Procedure • Procedures Include: • Heart & Blood Vessels, including Pacemaker Implantation and Coronary Artery Bypass Graft (CABG) • For Additional Studies Refer to: Medicine Sections Under: • Cardiovascular/Therapeutic Services for: • Cardiography, Echocardiography, Cardiac Catheterization & Other Vascular Studies Chapter 6

  49. Coding Procedures & ServicesSurgery:Respiratory, Cardiovascular, Hemic & Lymphatic Systems - (30000-39999)PERFORMANCE EXERCISE • Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract 33414 • Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography 92975 Chapter 6

  50. Coding Procedures & ServicesSurgery:Digestive System(40000-49999) • Digestive System • Organized by Anatomic Site • Start with Lip & Mouth • Then continues thru the Rectum and Anus • Major Organs of the digestive system include: • Stomach • Intestines/small/large • Liver, Pancreas & Gallbladder Chapter 6

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