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.
LAYOUT OF CPT
There are 6 sections
1. Evaluation and Management (E/M)
5. Pathology and Laboratory
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.
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
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
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
b. Coordination of care
c. Nature of present problem
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
Physical Status Modifiers
Organized by body systems;
5 digits codes that begin with 10000 through 6;
Generally, surgeries are bill in packages.
5 digit number beginning with 7;
Arranged by anatomic site from the top of the body to the bottom.
Diagnostic radiology/Diagnostic imaging;
PATHOLOGY AND LAB SECTION
5 digit number beginning with 8;
Divided into sections
5 digit number beginning with 9;
Divided into sections;
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
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.
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.