Chapter 13 - Procedural, Evaluation Management, and HCPCS Coding

Terms in this set (38)

LEVEL 1 - MANUAL IS THE AMA CPT-4

Current Procedural Terminology;
A numeric code system maintained by the AMA
5-digit codes used by physicians to code procedures or services

LEVEL II - MANUAL IS THE HCPCS NATIONAL CODES

HCPCS are codes for products, supplies, and services not included in the CPT codes (wheelchairs, medications, ambulance)

PHYSICIAN'S CURRENT PROCEDUAL TERMINOLOGY (CPT-4)

Complete listing of descriptive terms and identifying codes used in reporting medical codes and procedures;
New every year;
Superbills must be updated with new codes each year;
Combination of HCPCS and CPT-4 is the HIPAA adopted standard for reporting physician services and other healthcare services on standard transactions.

There are 6 sections

SECTIONS-CHRONOLOGICAL

1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery
4. Radiology
5. Pathology and Laboratory
6. Medicine

ALPHABETIC INDEX

Organized by main terms;
Locate the code by finding the procedure, the location or the condition

WHICH BLOCK ON THE CMS-1500 CLAIM FORM WILL THIS CODE BE PLACE?

Code 11 in Block 24B

SECTION - GUIDELINES

Each sections begins with guidelines

UNLISTED PROCEDURES & SPECIAL REPORTS

Unlisted procedures are listed in the guidelines;
When an unlisted procedure, unusual, variable, or new procedure is done, a special report must be submitted with the claim.

EVALUATION AND MANGEMENT CODES

Five-digit number beginning with number 99;
Used the most frequent;
First section of the CPT Manual

A patient who has NOT received any medical treatment by the physician or any other physician in the office within the past 3 years.

ESTABLISHED PATIENT

A patient who has been previously seen or treated by the physician within the past three years.

One who has NOT been formally admitted to a healthcare facility (does not stay for longer than 24 hrs.)

One who has been formally admitted to a healthcare facility and stays longer than 24 hrs.

Determining the code;
Elements that make up a patient's visit;
Two of three required for an established patient;
Three of three required for a new patient

3 KEY COMPONENTS

1. History
2. Physical Examination
3. Medical Decision-(last of the 3 components)

Subjective information-what the patient tells the doctor.

CHIEF COMPLAINT (CC)

Reason the patient is seeing the doctor

1. Problem focused
2. Expanded problem focused
3. Detailed
4. Comprehensive

Review of systems and is a systematic way of assessing the body when doing a physical exam ( a series of questions the provide ask the patient to identify what body parts or body systems that are involved);
Level depends on how may body systems are examined.

MEDICAL DECISION MAKING (MDM)

Number of diagnosis, amount and complexity of data reviewed and risk of complications to the patient

CONTRIBUTING FACTORS

a. Counseling
b. Coordination of care
c. Nature of present problem
d. Time

ANESTHESIA SECTION-NEXT SECTION AFTER E/M CODES

Five-digit codes beginning with 0;
Divided by anatomic site and specific type of procedure;
Used to bill for providers who uses anesthesia

TWO TYPES OF MODIFIERS

Standard Modifiers;
Physical Status Modifiers

SURGERY SECTION

Organized by body systems;
5 digits codes that begin with 10000 through 6;
Generally, surgeries are bill in packages.

RADIOLOGY SECTION

5 digit number beginning with 7;
Seven subsections;
Arranged by anatomic site from the top of the body to the bottom.

FOUR SUBSECTIONS

Diagnostic radiology/Diagnostic imaging;
Diagnostic ultrasound;
Radiation oncology;
Nuclear Medicine

PATHOLOGY AND LAB SECTION

5 digit number beginning with 8;
Divided into sections

MEDICINE SECTION

5 digit number beginning with 9;
Divided into sections;
Immunizations, injections;
1. 2 codes needed for the administration of
injections and immunizations
2. Other miscellaneous services and procedures

Two additional digits added to the code to give additional information such as 99214-25;
Listed on the inside cover of the CPT Manual with complete definitions in Appendix A.

BASIC STEPS OF CPT CODING

Step 1 Identify the procedure/service/supply to the coded.
Step 2 Determine the main term
Step 3 Locate the main term in the alphabetic index
Step 4 Cross-reference the single code; in the Tabular Section of the manual
Step 5 Read and follow instructions or conventions
Step 6 Assign the appropriate code

HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) CODE

(aka Level II codes) alphanumeric codes in the Common Procedures Coding system;
Used by the Centers for Medicare and Medicaid Services (CMS) to report services provided to Medicare and Medicaid beneficiaries.

HCPCS CODE TYPICALLY DESCRIBE

Healthcare supplies
Equipment, drugs, and services not included in the CPT

If a CPT code and HCPCS Level II code are available for the service provided, CMS requires that the HCPSC Level II code be used.

HOSPITAL CODING

Working for a hospital are billing for the hospital coders working in a hospital will bill for inpatient services and emergency visits;
Diagnostic-Related Groups (DRGs);
Inpatients categories according to the similarity of diagnosis, treatment, and length of stay

Used to identify that a procedure was done on the same day as an office visit.

Indicates that there were multiple procedures on the same day

COMBINATION OF HCPCS AND CPT-4

is the HIPAA adopted standard for reporting physician services and other healthcare services on standard transactions.

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