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Procedural Code Chapter 4

Terms in this set (106)

add-on-code
Procedures that are performed and reported only in addition to a primary procedure, indicated in CPT by a plus sign(+) next to the code
bundled code
Single procedure code used to report a group of related procedures
Category I code
Procedure codes in the six major sections of the CPT, evaluation and management, anesthesia, surgery, pathology/laboratory, radiology, and medicine.
Category II code
Optional CPT codes that track performance measures for a medical goal such as reducing tobacco use.
Category IIi Code
Temporary codes for emerging technology, services, and procedures, to be used, rather than an unlisted code when available.
Centers for Medicare and Medicaid Services (CMS)
Federal agency within the Department of Health and Human Services(HHS) that runs Medicare, Medicaid, Clincial Laboratories(Under the CLIA program) and other govermental health programs, Formally Health Care Financing Administration (HCFA)
code-Linkage
the connection between a service,procedure and diagnosis of a patient's condition or illness, establishes the medical necessity of the procedure
consultation
service performed by a physician to advise a requesting physician about a patients condition and care, the consultant does not assume responsibility for the patient's care and must send a written report back to the requestor.
Current Procedural Terminology (CPT)
Publication of the American Medical Association (AMA) containing the HIPAA-mandated standardized classification system for reporting medical procedures and services performed by physicians
E/m or evaluation and management codes
the physican uses TIME, EFFORT, AND SKILL, to plan treatments, diagnose conditions.
global period
the number of days surrounding a surgical procedure during which all services relating to the procedure-preoperative, during the surgery, and postoperative- are considered part of the surgical package and are not additionally reimbursed.
Health Care Common Procedure Coding System
HCPCS procedure codes for Medicare claims made up of CPT codes Level I and National codes Level II
Main Number
The five digit procedure code listed in the CPT
modifier
are wrtitten with a hypen b4 the 2 digit #, use this # when you need to shows that a special circumstance applies to the service or procedure, a number that is appended to a code to report particular facts. CPT modifiers report special circumstances involved with a procedure or service. HCPCS modifiers are often used to designate a body part such as left side or right side. Modifiers provides the means to report or indicate that a service or procedure has altered by some specific circumstance but not changed in its definition or code
New Patient
a patient who has not received professional services from a provider (or another provider with the same speciality in the same practice) within the past 3 years
Panel
in CPT, a single code grouping Laboratory tests that are frequently done together
primary procedure
the moser resource intensive (highest paid) CPT procedure done during a patients encounter
Procedure code
a standardized code that identifies medical treatment, surgeries, or diagnostic services
referral
transfer of patient care from one physician to another
surgical package
a combination of services included in a single procedure code for some surgical procedures in CPT
unbundle
the INCORRECT billing practice of breaking a panel or package or services/procedures into component parts and reporting the separately
unlisted procedure
a service that is not listed in CPT, reported with an unlisted procedure code and requires a special report when used found at the beginning of each section
established patient
one has recieved professional services from a provider(or another provider) within 3 years
Category II Codes 2nd
This code is listed at the end of the Category I, reporting this code is optional on health claims, are usually not paid for, they help in the development of best practices and improve documentation. They have a alpha code in 5th digit place such as 4000F
Category III Codes 2nd
This code is also listed at the end of Category I, If you can find a code for Category III list it, other wise list and unlisted code. *reporting code also has an alpha code in the 5th postion 0184T
Category III Code #3
This temporary code may become permanent and part of regular codes if the service it identifies proves effective and is widely performed.
modifiers #1
one or more 2 digit CPT modifiers may be assigned to a 5 digit main #. Modifiers are written with a Hypen B4 th 2 digit #
CPT #1
Is a HIPAA required system of procedure codes published by American Medical Assocation
CPT #2
Published every year to reflect changes in medical practices
Category 1 codes #1
are the most of the codes in CPT and are 5 digit codes
Category 1 codes #2
organized into 6 Sections and, Sections 2-6 are in numerical order & each section opens with important guidelines that apply to the proceedures
Evaluation & Mangement Section #1
is not in numerical order *is the first section of Category I codes and are used most often
CPT #3
the codes used are based on the date of service not the date the claim is prepared, so be sure you use the right CPT book based on year.
Step 1 in locating the CPT code
start with the CPT's index, an alphabetical list of procedures, organs,k and conditions in the back of the book
Step 2 in locating the CPT code
Boldface main terms may be followed by Descriptions of indented terms
Step 3 in locating the CPT Code
Review each description and indented term under main term.
Conscious Sedation
is a moderate, drug induced depression of consciousness during which the patients can respond to verbal commands.
A Lighting Bolt
a symbol used with vaccine codes that have been submitted to the Federal Drug Administration (FDA) and are expected to e approved for use soon. You CANNOT use this code until approved.
A bullet which looks like a black Circle in Parenthesis
symbol that indicates a new procedure code
A triangle
symbal that indicates a change in the code's description
Facing Triangle
symbol that means enclose other new or revised information
A bullet or dot inside a circle
a smbol that means a coder cannot bill for conscious sedation separtely for this procedure
2 services reported separately and reinbursed in addition to the Surgical Packagae
Complications or recurrances that arise after the surgery, 2. care for the condition for which a diagnostic surgical procedure is performed
Diagnosti surgical procedure
is covered in addition to the surgical package charge
2 Surgeries performed on same day
the health plan pays full amt for the first procedure and a portion of the 2nd procedure
2 surgeries performed on same day 1`
bill the most complex and highest level code first on the claim to get the maximum payout
2 surgeries performed on same day 2
Modifier -51 is used for multple procedures on the same body site or system
2 surgeries performed on same day 3
Modifier -59 indicates distinct procedures, each FULLY REIMBURSED. when surgeon performs procedures on 2 diff. body sites or organ systems
comprehensive metabolic PANEL
includes test for albumin,bilrubin,calcium,carbon dioxide,chloride,glucose, and other factors
Each test has it own code
but in a panel the code for the panel must be used *example panel for Basic Metabolic Panel code is 80048
Coding Injections
require 2 codes, one for giving the injection admistration code and one code for the particular vaccine or toxoid that is given
HCPCS
Health Care Common Procedure Coding System
HCPCS #1
was developed by the CENTERS FOR MEDICARE AND MEDICAID (CMS)
HCPCS LEVEL 1
CODES THAT DUPLICATE THOSE FROM THE CPT
HCPCS LEVEL 2
ARE CODES ISSUED BY (CMS), They are national codes and cover many supplies such as steril trays, drugs, and durable medical equipment and codes not found in the CPT
DME
durable medical equipment
CMS
CENTERS FOR MEDICARE AND MEDICAID SERVICES
HCPCS LEVEL 2 CODES
HAVE 5 characters, either numbers or letters or a combination
HCPCS MODIFIERS
may include social worker servics or equipment rentals
Category I
Evaluation & Management, Anesthesia, Surgery, Radiology, Pathology and Labortory, Medicine
Evaluation and Managment & Surgery
not in alphabetic order
Category 1 #2
each of the 6 sections opens with important guidelines that apply to those procedures
Category 1#3
each of the 6 section divided into subsections such as type of test, service performed, body system
CPT Listings
may alos contain notes which are explanations for categories and individual codes.
Notes
often appear in Parentheses after a code, and may suggest other codes to consider before chosing a final code
unlisted code in Anestheiology
found not at beginning of section but under Other Procedures
unlisted code #1
should not be reported until a through search of the CPT especially Category III is done
NP
new patient
EP
established patient
POS
placeof service cld be physicians office, a hosptial inpatient room, hosptial emergency room, nursing facility, extended care facility, patients home
E/M and Pos
there are different E/M codes depending upon POS
confirmatory consultation
when a patient and not a docter ask for a 2nd opinion or consultation
SOB
shortness of Breath
ECG
electrocardiogram
CPT HAS 5 LEVEL CODES
level 1-5 to determine E/M Codes
Steps to Coding E/M
NP or EP, POS, Referral, Consultation or Confirmatory Consultation, & Level of Service
Level of Service to code E&M
How much work, time and decision making were involved.
Work (level of Service)
the extent of the patient history taken
Time(level of Service)
THE extent of the eamination conducted
Decision Making(level of Service)
the complexity of the medical decision making
8 Steps tho assign E&M Step 1
Determine the Category and Subcategory of Service Based on the POS and the Patients Status
8 Steps tho assign E&M Step 2
Determine the extent of the History that is documented, History of present illness (HPI), review of systems (ROS), PMI past medical history, FH family history, SH or social history
8 Steps tho assign E&M Step 3
Determine the Extent of the Examination that is documented,
8 Steps tho assign E&M Step 4
Determine the Complexity of Medical Decision Making That is Documented. it involves how many possible dianoses or treatment options were considered, how much data was analyzed, how serious the illness is,
step 5
Step 5 Analyze the Coding Guideline Requirements to Report the Service Level
E&m coding steps
step 6 2 assign e&m Verify the Service Level Based on the Nature of the Presenting Problem, Time Counseling, and Care Coordination
8 Steps tho assign E&M Step 7
Verify that the documentation is complete
8 Steps tho assign E&M Step 8
Assign the code
Exception to Coding Step 1
is selection a code 4 counseling or coordination of care where the amount of time the physician spends may be the only key component in some situations
PFSH
past, family,social,history *this is the coding used after the initial HPI
SH
social history,martial status, employment, hobbies
Problem focused step 2 of e&m
determining the patients chief complaint and obtaining a brief history of the present illness
Expanded problem focused step 2 of E&M
determining the patients chief complaint, obtaining a brief history of the present illness, plus a problem pertinent ROS of the particular body system involved
Detailed problem focused step 2 of E&M
determining the patients chief complaint, obtaining a brief history of the present illness, plus a problem pertinent ROS of the particular body system involved and additional systems and taking pertinent past, family, and or social history
Comprehensive problem focused step 2 of e&M
determining the patients chief complaint, obtaining a brief history of the present illness, a COMPLETE (ROS) AND COMPLETE past, family, and social history
problem focused Step 3 of E&M
a limited examination of the affected body area or system
expanded problem focused Step 3 of E&M
a limited examination of the affected body area or system and other related systems
detailed problem focused Step 3 of E&M
a extended examination of the affected body area or system and other related areas
comprehensive problem focused Step 3 of E&M
a general multisystem examination or completed examination of a single organ system of the affected body area or system
Complexity of Medical Decision #4 *Straightforward
minimal diagnoses options, minimal amt of data, minimum risk
Complexity of Medical Decision #4 Low Complexitiy
limited diagnoses options, low amt of data, low risk
Complexity of Medical Decision #4 Moderate complexity
multiple diagnoses options, a moderate amt of data, moderate risk
Complexity of Medical Decision #4 High Complexity
extensive diagnoses options,k an extensive amt of data, and high risk
nature of the presenting problem
how severe the patient's condition is
how much time the physician typically spends directly treating the patient
counseling is a discussion with a patient regarding areas such as diagnostic test
coordination of care
if provided but patient is not present,Use code from the CASE MANAGEMENT AND CARE PLAN OVERSIGHT SERVICES SUBSECTIONS
THIS SET IS OFTEN IN FOLDERS WITH...