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PROCEDURAL CODING

Medical Assistant: PROCEDURAL CODING CPT AND HCPCS

QuestionAnswer
Current Procedural Terminology (CPT) contains the standardized classification system for reporting medical procedures and services
CPT first produced in 1966. Its wide use began in 1983. lists the procedures and services that physicians across the country commonly perform
categories of CPT codes Category I codes ▶ Category II codes ▶ Category III codes
Category I procedure codes found in the main body of CPT
Category II optional CPT codes that track performance measures
Category III temporary codes for emerging technology, services, and procedures
five types of main terms The name of the procedure or service, 2 The name of the organ or other anatomical site, 3 The name of the condition, such as wound, 4 A synonym or an eponym for the term, 5 The abbreviation for the term, such as CAT scan and ECMO
section guidelines usage notes at the beginning of CPT sections
unlisted procedure service not listed in CPT
special report note explaining the reasons for a new, variable, or unlisted procedure or service
three symbols ● bullet indicates a new procedure code. symbol appears next to the code only in the year that it is added. ▲ triangle indicates that the code’s descriptor has changed. ▶◀ Facing triangles (two triangles that face each other) enclose new or revised code.
add-on code procedure performed and reported in addition to a primary procedure
primary procedure most resource-intensive CPT procedure during an encounter
Moderate Sedation symbol
FDA Approval Pending symbol lightning bolt
resequenced CPT procedure codes that have been reassigned to another sequence
modifier number appended to a code to report particular facts. listed in appendix A
Codes that begin with ⃠ cannot use modifier 51
technical component (TC) reflects the technician’s work and the equipment and supplies used in performing it
professional component (PC) represents a physician’s skill, time, and expertise used in performing it
add-on code symbol (+)
evaluation and management codes (e/m) codes that cover physicians’ services performed to determine the optimum course for patient care
how are e/m codes organized? by the place of service, such as the office, the hospital, or a patient’s home. A few (for example, prolonged) are grouped by type of service
professional services the definitions of new and established patients means that the established category is used for a patient who had a face-to-face encounter with a physician
consultation service in which a physician advises a requesting physician about a patient’s condition and care
what types of codes are used for referrals require use of the regular office visit E/M service codes
Problem-focused Determining the patient’s chief complaint and obtaining a brief history of the present illness -- A limited examination of the affected body area or system
Expanded problem-focused Determining the patient’s chief complaint and obtaining a brief history of the present illness plus a problem-pertinent system review of the particular body system that is involved -- exam affected body area or system and other related areas
Detailed Determining the chief complaint; obtaining an extended history of the present illness; reviewing both the problem-pertinent system and additional systems; and taking pertinent past, family, and/or social history -- extended examination
Comprehensive Determining the chief complaint and taking an extended history of the present illness, a complete review of systems, and a complete past, family, and social history -- general multisystem exam or exam of single organ system
Straightforward Minimal diagnoses options, a minimal amount of data, and minimum risk
Low complexity Limited diagnoses options, a small amount of data, and low risk
Moderate complexity Multiple diagnoses options, a moderate amount of data, and moderate risk
High complexity Extensive diagnoses options, an extensive amount of data, and high risk
key component factor documented for various levels of evaluation and management services
Counseling a discussion with a patient regarding areas such as diagnostic results, instructions for follow-up treatment, and patient education.
Concurrent Care and Transfer of Care Coordination of care with other providers or agencies
outpatient patient who receives healthcare in a hospital setting without admission
surgical package combination of services included in a single procedure code
global surgery rule combination of services included in a single procedure code
global period days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package
Two types of services are not included in surgical package Complications or recurrences that arise after therapeutic surgical procedures. ▶ Care for the condition for which a diagnostic surgical procedure is performed. Routine follow-up care
separate procedure descriptor used for a procedure that is usually part of a surgical package but may also be performed separately
commonly used modifiers ▶ 22 Increased procedural services: ▶ 26 Professional component: ▶ 32 Mandated services: ▶ 33 Preventive services: ▶ 47 Anesthesia by surgeon: ▶ 50 Bilateral procedure:
bundled payment single payments to multiple providers involved in an episode of care, in which accountability is shared among providers
bundling using a single payment for two or more related procedure codes
unbundling incorrect billing practice of breaking a panel or package of services/procedures into component parts
fragmented billing incorrect billing practice in which procedures are unbundled and separately reported
Radiology procedures have two parts: technical component and professional component
with contrast only contrast materials given in the patient’s veins or arteries
panel single code grouping laboratory tests frequently done together
Healthcare Common Procedure Coding System HCPCS, procedure codes for Medicare claims
durable medical equipment DME, reusable physical supplies ordered by the provider for home use
Level II modifiers HCPCS national code set modifiers
never event situation for which a policy never pays a provider
Not Covered by or Valid for Medicare symbol
Special Coverage Instructions Apply
Carrier Discretion
Created by: baybro9933