Is the artificially induced loss of feeling & sensation with or without loss of consciousness.
Produces a state of unconsciousness. It may be brought about by inhalation of gases such as ether, nitrous oxide, & ethylene or by drugs administered intravenously; such as sodium pentothal.
Is the loss of sensation of a part of the body due to the interruption of nerve conduction.
Is applied directly to the surface of the area to be anesthetized. The conjunctiva & mucous membranes of the mouth, throat, urethra, & bladder are examples of areas that are most effectively anesthetized by a this application.
Refers to the nerves blocked in the this space. This anesthesia is frequently used for maternity claims.
This allow the patient to administer their own pain medication (or anesthetic). This is a machine which contains medication & administers a small dose when a button is depressed.
The admin of general anesthesia in a doctor's or dentist's office is considered very dangerous, although some specialists do so routinely.
Some patients will choose hypnosis rather than conventional forms of anesthesia. Most plans do not cover hypnosis services.
The basic or base anesthesia units are designed to allow for the usual pre & postoperative care, the admin of anesthesia, & the admin of fluids or blood incident to the anesthesia or surgery.
There are two ways of calculating the anesthesia time, depending on individual payer guidelines:
1) Actual time
2) Block time
Some carriers allow one time unit for each 15 mins, regardless of the amt of time a patient is under anesthesia. Any fractional portions of a 15 min bloce (i.e. 5 min) are calculated to the nearest tenth of a unit.
The anesthesia allowance is calculated by adding the basic units to the time units & multiply that amt by the conversion factor. This procedure applies to all schedules. (BU+TUxCF=AA)
For anesthesia claims with multiple procedures, the base units for the major procedure (the procedure with the greatest number of basic units) are the only basic units allowed.
Carriers which pay different % for network & nonnetwork providers will often pay the anesthesiologist at the network rate if the chosen surgeon is a network provider, regardless of whether the anesthesiologist is part of their network or not.
Occasionally the use of modifier -22 or -23 will indicate that unusual procedures were performed. This modifier is often used to explain why the amt of time shown on an anesthesia claim is greater than usual.
Monitored Anesthesia Care
In order for MAC to be reimbursed, the anesthesiologist must be present during the entire operative procedure.
Monitored Anesthesia Care
The modifier -QS on the claim will denote that the claim is for MAC services.
Medical Direction of Anesthesiology
At times, the actual monitoring of the patient will be performed by an anesthesia assistant or a Certified Registered Nurse Anesthetist (CRNA) under the direction of a physician.
Anesthesia Handling Procedures
Charges made by a hospital for the services of a staff anesthesiologist are usually covered as a hospital ancillary expense.
Because a procedure is listed in the surgery section of the CPT does not mean that the procedure is allowable under a benefit plan, nor does it mean that it will necessarily be coded as a surgical procedure. The coding of procedures varies from company to company.
These codes are used to bill for procedures done on the integumentary system or skin.
Hemic & Lymphatic Systems
These codes are used to bill for procedures of the spleen & lymph nodes, as well as bone marrow transplants.
The appropriate code for endoscopies is determined by the organs the endoscope is passed through. An endoscope which is only passed into the esophagus would receive one code.
Pelvic exams should not be coded separately when another pelvic region procedure is performed. D&C is considered to be an integral part of a pelvic exam; therefore, it is also not coded separately when another pelvic region procedure is performed.
These codes are used to bill for procedures on the organs of the nervous system, including the nerves, brain, & spine cord. Procedures on the pituitary glands & pineal glands are also included in this section sincy they are both located in the brain.
Any injections performed during cataract surgery are considered to be an integral part of the procedure & are not allowed separately.
These codes are used to bill for procedures performed on the organs of the auditory (hearing) system. This section includes surgical procedures only. Diagnostic procedures are reported using the medicine section of the CPT. Repairs to the outer ear are included in the surgery codes for the integumentary system.
Same Time, Same Operative Field
When multiple procedures are performed during the same operative session through the same incision, orifice, or operative field, the add'l procedures are usually considered to be incident.
It is important to look at the total billing so as not to penalize the claimant for the way the physician bills. Thus, the total amt allowed for UCR is used, even if the physician misallocates the billing for the procedures.
Some physicians practice what is know as "unbundling". The surgeon is considered to have "unbundled" when he bills separately for procedures that are a part of the major procedure. For example, hysterectomy can be performed with or without the removal of the ovaries and/or the fallopian tubes.
Delivery with Tubal Ligation
Sterilization is a surgical method to achieve permanent infertility. Sterilization procedures include tubal ligation for females & vasectomies for males. It is becoming more common for health plans to cover sterilization procedures.
The structures of the nose responsible for airway obstruction are the septum & the nasal turbinates.
The objective of these codes is to handle multiple repetitions of the same service. This procedure consists of a primary code & subsequent modifying codes.
Are made by a process that uses multiple x-ray images to create three-dimensional images of body structures. Used to help identify tumor & cancers located in an organ. Are much more definitive that x-rays.
Provides a more definitive type of picture than x-rays. Instead of using radiation, sound waves are bounced off the desired structure to form a picture of the organ.
This treatment is used in conjunction with chemotherapy to treat malignant cancers. Is the use of radiation to treat a condition.
Combines the use of radioactive elements & x-rays to image an organ or body part. The purpose of this type of treatment is to determine whether an organ is working effectively or to see whether it is enlarged.
Are composed of multiple tests that are combined & run from one specimen. These tests can be requested from one or two specimens & cost substantially less than several tests ordered separately from separate specimens.
Is the study of microorganisms. These codes report the culture of microorganisms to determine their presence in the human body.
Is the study of changes in a cell, or the ability of an agent (i.e. virus, bacteria) to destroy a cell.
Papanicolaou (PAP) Smear
Is a diagnostic lab test for detecting the absence or presence of infection, viruses, trauma, or cancer.
The first service is the taking of the specimen or x-ray. This charge should include the expense for the personnel performing the test & the cost of the necessary equipment.
The second service is the interpretation or the reading of the results of the test. Also, denoted by adding modifier -26 to the CPT code.
It is important to establish whether the tests are being done as part of a routine check-up or because the patient has symptoms that are being diagnosed (for lab charges) . Also, the testing must be appropriate for the reported symptoms.
These codes are used to bill for the testing of bodily fluids to identify a specific class of drugs (i.e. amphetamines).
Hematology & Coagulation
These codes are used to report the testing of blood for its components (i.e. hemoglobin count).
The codes in this section report tests done in preparation for or during surgery.
Unbundling (Pit Falls)
Some providers will ________ by billing separately for each test performed even though all the tests came from the same specimen & were done simultaneously.
Papanicolaou (PAP) Smear
Usually, these routine test performed in conjunction with a routine physical exam are not covered unless the contract specifically indicates coverage, or the state mandates coverage.
Most Commonly used Modifiers for Pathology Codes
-22: Unusual Services
-26: Professional Component
-32: Mandated Services
-52: Rediced Services
-90: Reference (Outside) Lab
The purpose of this type of treatment is to determine whether an organ is working effectively or to see whether it is enlarged.
It is important to check the diagnosis when processing these types of claims, as overdoses may fall into the category of accidents (which may have add'l benefits), or attempted suicide or self-inflicted injury (for which benefits may be reduced or denied).
Hematology & Coagulation
These tests can allow a provider to track a patient's condition & to determine if there are any possible contraindications for surgery (i.e. slow blood clotting time).
A radioactive element is injected into the patient, & then pictures are taken of the organ at specified intervals to see how, where, & how much of the element collects in a specific organ.
Those performed by a licensed individual such as a medical doctor, physician's assistant, nurse, or chiropractor.
Second opinion/Confirmatory Consulation
Designed as a benefit to the patient by confirming the need for surgeries that have a reputation for being done needlessly.
Primarily for the purpose of meeting the personal daily needs of the patient & can be provided by personnel without medical care skills or training.
Eye care provided either by an optometrist or an ophthalmologist (MD). Most health plans do not cover routine vision care services related to the refraction & subsequent presecription of glasses or contact lens.
The manipulation & physical therapy associated with the nonsurgical care & treatment of the patient. The most common form of phyical medical is chiropractic manipulation of the spine (theoretically, any joint can be involved).
The ancient Chinese practice of inserting fine needles into various points in the body to relieve pain, induce anethesia, & to regulate & improve body functions.
Decision for Surgery. This procedure was necessary to determine the need for a subsequent surgical procedure. Depending on the amt of time which lapses between the visit.
CPT Coding Eval
The Medicine section of the CPT is usually found toward the back of the book & includes codes 90281-99602.
Modifier -32 is used to indicate that the consultation is rendered at the request of a third party (i.e. the insurer).
For SSO benefit to be payable, following is required:
1) the 2nd or 3rd opinion physician must be totally uninvolved with the original recommending physician. Therefore, he/she can't be part of the same medical group & will often be picked by the administrator, medical mgmt firm, or payer.
2) consultation must be completed before the scheduling of surgery.
3) second opinion physician can't perform the recommended surgery.
Emergency Dept Svc
Stat Fees (a charge for DXL services performed on an expedited priority basis) should also be combined with the actual lab or x-ray chgs.
Skilled Nurse Facility
A skilled nursing facility is a specially qualified facility that has the staff & equipment to provide skilled nursing care or rehabilitation services & other related health services.
These codes are used to bill for services provided to a patient in their home. Codes 99341-99350 are used by physicians to report evaluation & mgmt procedures. Codes 99500-99602 are used by nonphysician healthcare professionals to report medical services.
These codes are used to bill for prolonged or standby service that is beyond the usual service for inpatient or outpatient services. The service must be of at least 30 mins in duration for it to be considered a prolonged service.
These codes are reported in addition to the original services. Services which involve face-to-face contact are coded according to the amt of time spent with the patient, regardless of whether that time is continuous or not (i.e. a physician who checks in on their patient several times during a day).
Care Plan Oversight Svc
Care plan oversight is the reviewing of a patient's medical care & records usually for a patient under the care of a home health agency, hospice, or nursing home.
Preventive Medicine Svc
Thes codes are used to bill for the evaluation & mgmt of patients who do not have an illness or injury (i.e. annual checkup). The patient's age is often a factor in the codes in this section (i.e. checkup for an infant).
Special E/M Svc
These codes are used to bill for basic life or disability evaluations (i.e. follow-up evaluation for a work-related disability patient). These codes are used when the main purpose of the visit is to evaluate the patient, not to provide treatment. Code 99499 is used to bill for evaluation & mgmt services that are not listed elsewhere.
Therapeutic or Diagnostic Infusions
These codes are used to bill for infusion services provided by a physician who was in constant attendance during the infusion. Code 90780 indicates the first hr of infustion. Code 90781 indicates each add'l hr up to 8 hrs. No coding is available for infusions that take longer than 8 hrs.
Through conscious control, some body rhythms that control the constriction of blood vessels or the beating of the heart can be increased or decreased.
Gastroenterology service deal primarily with the esophagus, stomach, & intestines. Thses codes are used to bill for diagnostic servicers of the digestive system.
Otorhinolaryngologic Services are those services associated with the head, or more specifically, the ear, nose, & throat.
Cardiovascular services are services which treat the heart, arteries, & veins. Vascular studies are diagnostic procedures to determine the condition of, or bloold flow through an artery or vein. All cardiovascular codes should be listed in addition to the E/M services code describing the visit. This is a very large section, & it is heavily used by the examiner.
Photodynamic therapy (also called PDT) is a treatment method for some types of cancers. It uses light with a light-sensitive agent.
Special Services, Procedures, & Reports
These codes are used to bill for special circumstances regarding services performed, such as the handling of a laboratory specimen. These codes are used in add'l to the normal code that describes the procedure performed.
Moderate (Conscious) Sedation
This section is for the billing of conscious sedation (with or without analgesia) when the actual procedure is provided by the same physician.
Usual, Customary, & Resonable - UCR
Benefit plans define covered expenses as charges for the following service & supplies:
1) those that are medically necessary for the treatment or diagnosis of an injury or illness
2) those that are ordered or prescribed by a licensed provider
3) those that do not exceed the usual, customary, & reasonable (UCR) fee generally charged by like providers in the same geographic area for the same procedure
Eventually the RVS/Conversion Factor method was developed. This system bases amts on the procedure performed, the geographic location (zip code area) of the provider of service's office, & the date the service was performed.
There are several sources that compile & publish UCR data. Using this data or compiling their own date, third-party administrators & insurance carriers determine the UCR allowances for their plans or clients. Amts in excess of UCR are not considered to be an allowable expense under the plan & are therefore excluded from all benefit calculations.
Several reasons why a UCR amt will NOT be available, including the following:
a) CPT code is a BR (By Report) procedure. The value of this service is based on the operative or other lab reports because the service is too unusual or variable to be assigned a unit value
b) Code entered is an RNE (Relatively Not Established) procedure. This indicates new or infrequently performed services for which sufficient data have not been collected to allow an establishment of a relative value.
c) Code entered is not listed in the most recent Current Procedural Terminology (CPT) book because it is a new procedure
The RVS are to be adjusted for various locales by a geographic adjustment factor. These factors are often referred to as conversion factors.
In determinming UCR, the listed procedure unit value is multiplied by the plan's appropriate conversion factor or factors.
Basic-Major Medical ( Pitfalls)
the basic benefit usually has a dollar conversion factor specified in the plan document.
Regardless of the type of service provided, the UCR calculation is based on the medicine conversion factor category
For standard adjustments on modifiers, consult the CPT book. For those modifications not listed, the adjustment will vary according to the insurance carrier's policy & the contract provision.