CHAPTER 13

1. CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

2. MEDICAL CODING Transforms services/procedures/ supplies/drugs into CPT/HCPCS codes Transforms diagnosis and procedures into ICD-9-CM codes

3. Levels of Service Codes Level I CPT—(Category 1: 99201-99607, Category III: 0017T-0259T) Level II HCPCS, National Codes—(A0021-V5364) Level III Local Codes—phased out due to HIPAA

4. Diagnosis Codes ICD-9-CM, Volumes 1 & 2 International Classification of Diseases, 9th Ed., Clinical Modification

5. ICD-9-CM Classification system Explains why service was provided Changes diagnoses into codes Diabetes becomes 250.XX (highest level of specificity)

6. Why Codes? Computers understand numbers Specific descriptions attached to each code

7. CPT Developed by the AMA in 1966 Five-digit codes Updated in November for use January 1

8. Examples of Types of CPT Codes Medical Surgical Diagnostic services Anesthesia, etc. Category II and Category III codes—alpha numeric Category II = performance measuring Category III = emerging technology

9. CPT Codes Allow For Communication that is both effective and efficient A mechanism to report a service not described by a specific CPT or Level II code

10. Consider Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) OR 50575

11. Codes Are Used to tell third-party payers about services/procedures provided Often used as basis of payment

12. Incorrect Coding Results in providers being paid inappropriately Either over or underpayment Decreases cash flow Liability risk

13. Codes Are Used By Clinics Hospitals Rehabilitation units Ambulance services Long-term care Wherever health care services are provided

14. Outpatient Services for Physicians Reported on insurance form CMS-1500 = universal form

15. CMS-1500 Figure: 13.1

16. CPT Format Symbols in CPT Used to convey information Bullseye, moderate (conscious) sedation included (full list in Appendix G, CPT) Example 45391, Colonoscopy with endoscopic ultrasound examination Lightning bolt, pending FDA approval (Appendix K, CPT) Example 90650, Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use

17. • Bullet = New Code Figure: 13.2 • Circle (○) = Reinstated or recycled code Figure: 13.6

18. ▲Triangle = Revised Code Figure: 13.3

19. ►◄ Right and Left Triangles = Beginning and Ending of Text Change Figure: 13.4

20. + Plus = Add-On Code Figure: 13.5

21. Add-On Code (…Cont’d) Can only be used with another specific code Never used alone No reduction for multiple services Full list in Appendix D of CPT

22. CPT Appendix E contains a listing of - 51 exempt codes Services typically exempt from multiple procedure reductions =Circle With Line, -51 Cannot Be Used With these Codes Figure: 13.7

23. Appendices of CPT Appendix A: Modifiers Appendix B: Additions, Deletions, Revisions Appendix C: Clinical Examples, E/M Codes Appendix D: Add-OnCodes Appendix E: -51 Exempt Codes Appendix F: -63 Exempt Codes Appendix G: Include Moderate (Conscious) Sedation (Cont’d…)

24. Appendices of CPT (…Cont’d) Appendix H: Performance Measures, Category II Codes, on website Appendix I: Genetic Testing 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 Appendix N: Summary of Resequenced CPT Codes

25. Six CPT Sections (like chapters) Evaluation & Management (E/M) Anesthesia Surgery Radiology Pathology & Laboratory Medicine Category II Codes Category III Codes Appendices A-M Index

26. Categorized By Sections Subsections Subheadings Categories

27. Categorized By (…Cont’d) Anatomy Knee or Shoulder Procedure Incision or Excision Condition Fracture or Dislocation Description Cast or Strap Surgical Approach Anterior Cranial Fossa or Middle Cranial Fossa

28. Categorized By, Example Figure: 13.9 (…Cont’d)

29. Guidelines Section-specific information begins each section Figure: 13.10

30. Notes Must-reading located throughout the CPT Figure: 13.12

31. Two Types of Codes Stand-alone: Full description Indented: Dependent on preceding stand-alone Verbiage before the semicolon applies to all indented codes that follow

32. Types of Codes, Example Figure: 13.14

33. Semicolon Indicates full description in preceding code You must return to the stand-alone for full description

34. Modifiers Add Information CPT Modifier Two digits 62 Two surgeons performed a surgical procedure Each surgeon applies his/her individual skill Each surgeon bills the procedure with modifier -62

35. Level II HCPCS Modifiers “-AS” Physician’s Assistant “-F1” Left hand, second digit All modifiers used on CPT or HCPCS

36. Example of Modifier 43820 Gastrojejunostomy -62 two surgeons -43820-62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity

37. Modifier on the CMS-1500 Modifiers are placed in 24D on CMS-1500

38. Unlisted Services Codes ending in “99” = “no specific Category I or III code” Used if no more specific code Special report must accompany submission

39. Special or Written Report Indicates: Nature Extent Need Time Effort Equipment Used Photos and medical journal articles if relevant

40. Category I Codes Category I codes (00100–99607) Approved by AMA and Food and Drug Administration Proven clinical effectiveness (efficacy)

41. Category II Codes—Supplemental Tracking Codes Used for performance measurements Codes collect data concerning quality of care and test(s) required Alphanumeric and end in the letter “F” (1006F) Location AMA Website

42. Category III Codes—New Technology Temporary codes—up to 5 years Identify emerging technology, services, and procedures Located after Medicine section Alphanumeric (0016T) May or may not receive future Category I code status

43. Category III Codes Category III codes have not been approved and have no proven clinical effectiveness Usage order Use Category III code instead of unlisted code Use unlisted code if no Category III code

44. The Index! Used to locate service/procedure terms and codes Speeds up code location Like a dictionary First entries and last entries

45. CPT Index Figure: 13.18

46. Presentation of Codes in Index Single code: 38115 Multiple codes: 26645, 26650 - Note comma Range of codes: 22305-22325 - Note hyphen

47. Location Methods With Examples Service/procedure: repair, excision Anatomic site: median nerve, elbow Condition or disease: cleft lip, clot Synonym: toe and interphalangeal joint Eponym: Jones procedure, Heller operation Abbreviation: ECG, PEEP (Pressure Breathing, Positive)

48. Always Reference index Locate code in main portion of CPT Read the entire description and any notes

49. “See” in Index Cross-reference terms “Look here for code” Index: Stem, Brain: See Brainstem

50. HCPCS Healthcare Common Procedure Coding System Developed by Centers for Medicare and Medicaid Services (CMS) Formerly HCFA HCPCS developed, 1983 CPT did not contain all codes necessary for Medicare services reporting