Chapter 7 - CPT Coding Test

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OVERVIEW OF CPT

Current Procedual Terminology {CPT} is a listing of descriptive terms and indentifying codes for reporting medical services and procedures.

CPT

It provides a uniform language that describes medical, surgical and diagnostic services to facilitate communication among providers, patients and insurers.

AMA

American Medical Association first published CPT in 1966 and subsequent editions expanded its descriptive terms and codes for diagnostic and therapeutic procedures.

Five-digit codes

were introduced in 1970, replacing the four-digit classification.

CPT

adopted as part of the Healthcare Common Procedure Coding System {HCPCS}, mandated for reporting MEDICARE Part "B" services.

CPT Codes

are used to report services and procedures performed on patients:

CPT Codes {bullet 1}

By providers in OFFICES, CLINICS and PRIVATE HOMES.

CPT Codes {bullet 2}

By providers in INSTITUTIONAL settings such as HOSPITALS, NURSING facilities and HOSPICES.

CPT Codes {bullet 3}

When the provider is employed by the HEALTHCARE facility (e.g. many of the physicians associated with VETERANS ADMINISTRATION MEDICAL CENTERS ARE EMPLOYEES OF THAT ORGANIZATION

CPT Codes {bullet 4}

By a hospital outpatient department (e.g. ambulatory surgery, emergency dept and outpatient laboratory or radiographic procedures).

CPT Codes simplifies reporting

Reporting and assist in the accurate identification of procedures and services for {THIRD-PARTY} payer consideration.

CPT Codes and descriptions

are based on consistency with CONTEMPORARY MEDICAL PRACTICE as performed by clinical providers throughout the country.

CPT-5

HIPAAA's requirements that code sets and classification systems be implemented in a COST-EFFECIVE manner includes: LOW-COST, EFFICIENT distribution, and application to all users

CPT IDENTIFIED

as a procedure coding standard for the reporting of physicialn services in 2000, the May 7th, 1998 Federal Register reported that CPT is not always precise or unambiguous teh CPT-5 project was the AMA's response.

Changes to CPT

CPT supports Electronic Data Inerchange {EDD} hte computer-based patient record (CPR) or Electronic Medial record (EMR), reference/research databases.

CPT glossary

created to standarize definitions and differentiate teh use of synonymous terms: and searchable, Electronic CPT Index is under development, along with a computerized datebase to delinate relationships among CPT code descriptions.

CPT Improvements

are underway to address the needs of hospitals, managed care organizations and long-term care facilities.

CPT-5 Project

with changes phased in starting with CPT 2000 and concluding with CPT 2003; resulting in the establishment of (3) three categories of CPT Codes.

CPT Codes {bullet I}

procedures/services, identified by FIVE-DIGIT CPT code and descriptor nomenclature; these are codes traditionally associated with CPT and organized within (6) six sections.

CPT Codes {bullet II}

performance measurements tracking codes that are assigned an alphanumeric identifier with a letterin teh last field (e.g., 1234A) these codes will be located after the Medicine section, and their use is optional.

CPT Codes {bullet III}

contain "Emerging technology" temporary codes assigned for data collection purposes that are assigned an alphanumeric identifier with a letter in teh last field (e.g. 0001T); these codes are located after the Medicine section, and they will be archived after (5) five years unless accepted for placement within Category I sections of CPT

CPT Sections

Organizes Category I procedures/service within six sectons.

Evaluation and Management (E/M)

99201 - 99499

Anesthesia

00100 - 01999, 99100-99140

Surgery

10021-69990

Radiology

70010-79999

Pathology and Laboratory

80047-89356

Medicine

90281-99199, 99500-99607

CPT Code Number Format

FIVE-DIGIT code number and a narrative description identify each procedure and service listed in CPT Most precedure/service contain stand-alone descriptions.

CPT Appendices

CPT contains appendices located between the Medicine section and the index. Insurance specialists should carefully review these appendices to become familiar with coding changes that affect the practices annually:

CPT Appendice "C"

Clinical examples for Evaluation and Management (E/M) sectin codes.

CPT Appendice "D"

add-on codes

CPT Appendice "E"

Codes exempt from modifier - 51 reporting rules

CPT Appendice "F"

CPT codes exempt from modifier -63 reporting rules.

CPT Appendice "G"

Summary of CPT codes that include moderate (conscious) sedation. CODING TIP: Codes that include moderate CPT symbol.

CPT Appendice "J"

Electodiagnostic medicine listing of sensory, motor and mixed nerves that are reported for motor and nerve studies codes. Also a table that indicates the "type of study and maximum number of studies" generally performed for needle electromyogram (EMG), nerve conduction studies and other MG studies. The AMA's CPT Changes 2006

CPT Symbols {bullet}

located throughout the CPT coding book ; EXAMPLE: CPT code 84145 was added. 84145 Procalcitonin (PCT)

Triangle

located to the left of the code number identifies a code description that has been revised. EXAMPLE CPT code 24150 was revised to change "for" to "of" - 24150 Radial resection of tumor; clavicle

CPT Horizontal triangles

EXAMPLE: The special report guideline in each section of CPT: (Triangle) Concurrent Care and Transfer of Care.

CPT Semicolon

used to save in CPT and some cold description are not printed in their entirety next to a code number.

CPT Plus + symbol

identifies add-on codes

CPT Bull's-eye

symbol indicatea procedure that includes moderate (conscious) sedation.

CPT Flash symbol

indicates codes that classify products that are pending FDA aproval but have been assigned a cpt code.

CPT code # symbol

precedes CPT CODES that appear out of numerical order

Guidelines

define terms and explain the assignment of codes for procedures and services in a particular section.

Unlisted Procedures/Services

code is assigned when the provider performs a procedure or service for which there is NO CPT code.

Special Report

must accompany the claim to describe the nature, extent and need for the procedure or service along with time, effort and equipment necesary to provide the service

Instructional Notes

appear throughout CPT sections to clairfy the assignment of codes. Typeset in two patterns

Blocked unindented note

located below a subsection title and contains instructions that apply to all codes in the subsection.

Indented parenthetical note

located below a subsection title, code description, or code description that contains

Descriptive Qualifiers

clarify the assignment of a CPT code. They can occur in the middle of a main clause or after the semicolon and may or may not be enclosed in parenthesises.

CPT MODIFIERS

CPT modifiers clarify services and procedures performed by providers. Although the CPT code and description remain unchanged, modifiers indicate that the description of the service/procedure performed has been altered. CPT modifiers are reported as (2) two-digit numeric codes added to the (5) five-digit CPT code.

Special E/M cases -25

-25 significant, sparately identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Services.

Special E/M cases -57

Decision for surgery

Special E/M cases -22 (ABOVE/BEYOND)

increased Procedural Services

STEP 1

Read the introduction in the CPT coding Manual.

STEP 2

Review guidelines at the beginning of each section

STEP 3

Review the procedure/services listed in the source document (e.g. charge slip, progress note, operative report laboratory report, or pathology report). Code only what is documented in the source document; do not make assumptions about conditions, procedures/services not stated. if necessary, obtain clarification from the provider.

STEP 4

Refer to the CPT Index; and locate the main term for the procedure or service documented. Main terms can be located by referring to.

STEP 5

Locate subterms and follow cross references.

STEP 6

review descriptions of service/procedures codes, and compare all qualifiers to descriptive statements.

STEP 7

Assign the applicable code number and any add-on (+) or additional codes needed to accurately classify the statements.

EVALUATION AND MANAGEMENT SYSTEM

(E/M) section (code 99201-99499) is located at the beginning of CPT because these codes describe services most frequently provided by physicians. Accurate assignment of E/M codes in essential to the success of a physician's practice because most of the revenue generated by the office is based on provision of these services. Before assigning E/M codes, make sure you review the guidelines (located at the beginning of the E/M section) and apply any notes (located below category and subcategory titles).

OVERVIEW OF EVALUATION & MANAGEMENT

CPT 1992 introduced the E/M level of service codes, replacing the brief, limited office visit codes included in the Medicine section of past CPT revisions.

E/M Evaluation and Management System

organized according to place of service (POS) - hospital, home, nursing facility [NF], emergency dept [ED] or critical care), type of service [TOS]

E/M Level of Service

reflects the amount of work involved in providing health care to a patient, and correct coding requires determining the extent of history and examination performed as well as the complexity of medical decision making. Between (3) three and (5) five levels of service are included in E/M categories and documentation in the patient's chart must support the level of service reported.

Place of Service

[POS] - refers to the PHYSICAL location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, NFs, home health care, or EDs).

Type of Service

[TOS] - refers to the kind of healthcare services provided to patients. It includes critical care, consultation, initial hospital care, subsequent hospital care, and confirmatory consultation.

New patient

is one who has not received any professional services from the physician, or form another physician of the same speciality who belongs to the same group practice, within the PAST THREE YEARS.

Established Patient

one who has received professional services from the physician, or from another physcian of the same specialty who belongs to hte same group practive. within the PAST THREE YEARS.

Unbundling CPT Codes

Providers are responsible for reporting the CPT (and HCPCS level II) code that most comprehensively describes the services provided. NCCI edits determine appropriateness of CPT code combinations for claims submitted to Medicare administrative contractors {NCCI} edits are designed to detect unbundling, which involves reporting multiple codes for a service when a single comprehensive code should be assigned.

PRACTICE UNBUNDLING (bullet I)

occurs because: Provider's coding staff unintentionally reports multiple codes based on misinterpreted coding guidelines.

PRACTICE UNBUNDLING (bullet II}

Reporting multiple codes is intentional and is done to maximize reimbursement.

STUDY CHECKLIST - No. 1

read this textbook chapter, and highlight key concepts.

STUDY CHECKLIST - No. 2

create an index card for each key term

STUDY CHECKLIST - No. 3

Access the chapter internet links to learn more about concepts.

STUDY CHECKLIST - No. 4

Complete the chapter review, verifying answers with your instructor.

STUDY CHECKLIST - No. 5

Complete WEBTUTOR assignments and take online quizzes.

STUDY CHECKLIST - No. 6

complete workbook chapter assignments, verifying answers with your instructior.

STUDY CHECKLIST - No. 7

complete the StudyWare activities to receive immediately feedback.

STUDY CHECKLIST - No. 8

Form a study group with classmates in discuss chapter concepts in preparation for an exam.

Extent of Examination No. 1

problem-focused examination (limited examination of the affected body area or organ system).

Extent of Examination No. 2

Expanded problem-focused examination (limited examination of the affected body area or organ system and other symptomatic or related organ systems.

Extent of Examination No. 3

Detailed examination (extended examination of the affected body area(s) and other symptomatic or related organ systems.

Extent of Examination No. 4

Comprehensive examination (general multisystem examination or a complete examination of a single organ system.

Complexity of Medical Decision Making #1

Number of diagnoses or management options.

Complexity of Medical Decision Making #2

Amount and/or complexity of data to be reviewed

Complexity of Medical Decision Making #3

Risk of complications and/or morbidity or mortality.

Complexity of Medical Decision-making #1

Laboratory imaging, and other test results that are significant to the management of the patient's care.

Complexity of Medical Decision Making #2

List of known diagnoses as well as those that are suspected

Complexity of Medical Decision Making #3

Opinions of other physicians who have been consulted.

Complexity of Medical Decision Making #4

Planned course of action for the patient's treatment (plan of treatment)

Complexity of Medical Decision Making #5

Review of patient records obtained from other facilities.

Anesthesia Section

Anesthesia services are associate with the ADMINISTRATION of ANALGESIA and/or anesthesia as provided by an anethesiologist (physcian) or certified registered nurse anesthetist {CRNA} services include the administration of local, regional, epidural, general anesthesia, Monitored Anethesia Care {MAC},

{MAC} MONITORED ANESTHESIA CARE

Adminisration of ANXIOLYTICS (drug that relieves anxiety) or amnesia-inducing medications.

Qualifying Circumstances for Anesthesia

Qualifying Circumstances code form CPT Medicine section (in addition to the anesthesia code).

QUALIFYING CIRCUMSTANCES CODES #1

99100 (Anesthesia for patient of extreme age, under one year and over 70)

QUALIFYING CIRCUMSTANCES CODES #2

99116 (Anesthesia complicated by utilization of total body hypothermia)

QUALIFYING CIRCUMSTANCES CODES #3

99135 (Anesthesia complicated by utilization of controlled hypotension

QUALIFYING CIRCUMSTANCES CODES #4

99140 (Anesthesia complicated by emergency conditions (specity). (An emergency condition results when a delay in treatment of the patient would lead to a significant increase in threat to life or body part).

Anesthesia Modifiers #1

Physical status modifiers

Anesthesia Modifiers #2

HCPCS Level II modifiers

Anesthesia Modifiers #3

CPT modifiers

Physical Status Modifiers

is added to each reported anesthesia code to indicate the patient's condition at the time anesthesia was administered. THe modifier also serves to identify the complexity of services provided. The physical status modifier is determined by the anestheasiologist or CRNA and is documented as such.

CPT Modifiers #1 {-23}

-23 (unusual anesthesia) (When a patient's circumstances warrant the administration of general or regional anesthesia instead of the usual local anesthesia, add modifier -23 to the anesthesia code (extremely apprehensive patients, mentally handicapped individuals, patients who have a physical condition, such as spasticity or tremors).

CPT Modifiers #2 {-53}

-53 (discontinued procedure}

CPT Modifiers #3 {-59}

-59 (distinct procedural service)

CPT Modifiers #4 {-74}

-74 (discontinued outpatient hosptial/ambulatory surgery center procedure after anesthesia administration).

CPT Modifiers #5 {-99}

-99 (multiple modifiers).

Anesthesia Time Units

when reporting Anesthesia codes, be sure to report the time units in "Block 24G of the CMS-1500. (An anesthesia time unit is ONE 15 MINUTE INCREMENTS)

Anesthesia Time Units #1

Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesia (if surgery is canceled, report an appropriate code from the CPT evaluation and management section. Usually, a consultation code is reported.

Anesthesia Time Units #2

Non-monitored interval time (e.g. period of time when patient does not require monitored anesthesia care, period of time during which anesthesiologist or CRNA leaves operating room to assist with another procedure).

Anesthesia Time Units #3

Recovery room time. (The anesthesiologist or CRNA is responsible for monitoring patient in the recovery room as part of the anesthesia service provided.

Anesthesia Time Units #4

Routine postoperative evaluation by the anesthesiologist or CRNA. When post-operative evaluation and management services are significant, separately identifiable services, such as postoperative pain management services or extensive unrelated ventilator management, report an appropriate code from the CPT evaluation and management section. I

SURGERY SECTION

The surgery section contains subsections that are organized by body system. Each subsection is subdivided into categories by specific organ or anatomic, site. Some categories are further subdivided by procedure subcategories in the following order:

SURGERY SECTION #1

incision

SURGERY SECTION #2

Excision

SURGERY SECTION #3

introduction or Removal

SURGERY SECTION #4

Repair, Endoscopy

SURGERY SECTION #5

Revision or Reconstruction

SURGERY SECTION #6

Destruction

SURGERY SECTION #7

Grafts

SURGERY SECTION #8

Suture

SURGERY SECTION #9

Other Procedures

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