Connection between a service and a patient's condition or illness. On correct insurance claims, each reported service is connected to a diagnosis that supports the procedure as necessary to investigate or treat the patient's condition in that health care setting. Health plans analyze this connection between the diagnostic and procedural information, called code linkage, to evaluate the medical necessity of the reported charges.
Procedure codes must be verified and then used to report physician's services. Physician, a medical coder, clearinghouse coder, or a medical administrative assistant may be responsible for the selection of procedure codes. Note that it is the physician's responsibility to report the correct CPT code. To be sure that the procedure codes, and the diagnosis codes, are correctly linked and valid, a medical administrative assistant, coder, or clearinghouse would review the documentation in the patient's medical record to be sure it supports the codes. A query may be communicated to the physician to resolve outstanding questions. By verifying all information and following the rules of correct coding, medical administrative assistants ensure that the provider receives the maximum appropriate reimbursement for procedures and services.
Determine the category and subcategory of service based on the place of service and the patient's status. The list of E/M categories, such as office visits, hospital services, and preventive medicine services, is used to locate the appropriate place of service or type of service in the index. In the main text of the selected category, the subcategory -- such as new patient or established patient -- is then chosen. For most types of service, such as initial hospital care for an established patient, between three to five codes are listed. To select an appropriate code from this range, three key components are considered: (1) the history that the physician documented; (2) the examination that was documented, and (3) the medical decisions the physician documented.
The exception to this guideline is selecting a code for COUNSELING or COORDINATION OF CARE, where the amount of time the physician spends may be the only key component in some situations.
Determine the complexity of medical decision making that is documented. The complexity of the medical decisions that the physician makes involves how many possible diagnoses or treatment options were considered; how much data information (such as test results or previous records) was considered in analyzing the patient's problem; and how serious the illness is, meaning how much risk there is for significant complications, advanced illness, or death.
The decision-making process that the physician documents is categorized as one of four types on a scale from lesser to greater complexity: (1) Straightforward (minimal diagnoses options, a minimal amount of data, and minimum risk); (2) Low Complexity (limited diagnoses options, a low amount of data, and low risk); (3) Moderate Complexity (multiple diagnoses options, a moderate amount of data, and moderate risk); and (4) High Complexity (extensive diagnoses options, an extensive amount of data, and high risk).
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination. Many descriptors mention two additional components: (1) how severe the patient's condition is, referred to as the "nature of the presenting problem," and (2) how much time the physician typically spends directly treating the patient. These factors, while not the key components, help in selecting the correct E/M service level.
Counseling is a discussion with a patient regarding areas such as diagnostic results, instructions for follow-up treatment, and patient education. It is mentioned as a typical part of E/M service in the descriptor, but it is NOT required to be documented as a key component.
If a patient's visit is mainly about counseling and/or coordination of care regarding symptoms or illness, the length of time the physician spends is the controlling factor. If over 50 percent of the visit is spent counseling or coordinating care, time is the MAIN factor.
Codes in the Surgery section represent groups of procedures that include all routine elements. The combination of services is called a surgical package.
According to the Surgery section guidelines in the CPT, the procedure codes for surgical procedures include the following: (1) after the decision for surgery, one related E/M encounter on the date immediately before or on the date of the procedure; (2) the operation: preparing the patient for surgery, including injection of anesthesia by the surgeon (local infiltration, metacarpal/metatarsal/digital block or topical anesthesia), and performing the operation, including normal additional procedures, such as debridement; (3) immediate postoperative care, including dictating operative notes, talking with the family and other physicians; (4) writing orders; (5) evaluating the patient in the postanesthesia recovery area; and (6) typical postoperative follow-up care.
A complete procedures includes the operation, the use of a local anesthetic, and post-operative care, all covered under a single code.
Organ or disease-oriented panels listed in the Pathology and Laboratory section of the CPT include tests frequently ordered together.
A comprehensive metabolic panel, for example, includes tests for albumin, bilirubin, calcium, carbon dioxide, chloride, glucose, and other factors. Each element of the panel has its own procedure code in the Pathology and Laboratory section. However, when the tests are performed together, the code for the panel must be used, rather than listing each test separately.