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CPT Coding

CPT Current Procedural Terminology
Level I of the Healthcare Common Procedure Coding System (HCPCS) CPT
CPT is a listing of descriptive terms and identifying codes for reporting medical services and procedures
MMA requires that new, revised and deleted ICD-9-CM codes be implemented each October 1 and updated each April
Changes to HCPCS level II national codes implemented January 1
CPT codes are used to report services and procedures performed on patients by providers in Offices, clinics, private homes and providers in institutional settings; when the provider is employed by the health care facility, by a hospital outpatient department
Procedures and services submitted on claim must be linked to ICD-9-CM code that justifies the need for the service or procedure the code must demonstrated medical necessity for the service or procedure to receive reimbursement consideration by payers.
CPT supports EDI, the computer-based patient record (CPR) or electronic medical record (EMR) and reference/research databases.
Category I codes procedures/services identified by a 5 digit code and descriptor nomenclature; these are traditionally associated w/CPT & organized w/in 6 sections
Category II Codes contain ‘performance measurements’ tracking codes that are assigned an alphanumeric identifier w/a letter in the last field (1234A); these codes will be located after the Medicine section, & their use is optional
Category III Codes contain ‘emerging technology’ temporary codes assigned for data collection purposes that are assigned an alphanumeric identifier w/a letter in the last field (0001T)
CPT Category Code 1 codes divided into 6 sections Evaluation & management (E/M) (99201-99600), Anesthesia (00100-01999), Surgery (10040-69990), Radiology (70010-79999), Pathology & Laboratory (80048-89399), Medicine (90281-99199)
Appendix A listing w/detailed descriptions of each CPT modifier
Appendix B Annual CPT coding changes (added, deleted and revised CPT codes)
Appendix C Clinical examples for codes found in Evaluation and management
Appendix D add on codes; identified w/a + symbol
Appendix E codes exempt from modifier -51 reporting rules
Appendix F CPT codes exempt from modifier -63
Appendix G Summary of CPT codes that include conscious sedation
Appendix H genetic testing modifiers
Appendix I Category II code modifiers
What must a coder do w/indented code descriptions the coder must refer back to the common portion of the code description that is located before the semicolon.
The common portion of the code description begins w/a capital letter and ends with ;
The abbreviated (or subordinate) descriptions are indented and begin w/lower-case letters placed after the ;
Codes reported w/plus signs are never reported as stand-alone codes they are not classified as add-on codes
Codes reported w/a circle and diagonal line going through it represent identifies codes that are not to be used w/modifies -51. These codes are reported in addition to other codes but are not classified as add-on codes.
The bulls-eye symbol denotes a procedure that includes conscious sedation
CPT Category I codes are organized according to 6 sections that are subdivided into subsections, subcategories, and headings
Guidelines are located at the beginning of each CPT section and should be carefully reviewed before attempting to code.
Guidelines define terms and explain the assignment of codes for procedures and services located in a particular section in CPT
Unlisted procedure or service code assigned when the provider performs a procedure or service for which there is no CPT code. A special report must accompany the claim to describe the nature, extent and need for the procedure or service
Two types of instructional notes 1 blocked unindented note and 2 indented parenthetical note
Blocked unindented note located below a category (or subsection) title and contains instructions that apply to all codes in the category
Indented parenthetical note located below a subsection title, code description, or code description that contains an example
Descriptive Qualifiers terms that clarify the assignment of a CPT Code
Coders working in a provider’s office should highlight descriptive qualifiers in CPT that pertain to the office’s specialty this insures that qualifiers are not overlooked when assigning codes
A bullet left of the code identifies new procedures and services added to the CPT
A triangle located to the left of the code identifies a code description that has been revised
Horizontal triangles surround revised guidelines and notes (this symbol is NOT used for revised code descriptions)
The CPT index is organized by alphabetical main terms printed in boldface which may be followed by indented terms that modify the main term (also called subterms)
Index code numbers for specific procedures may be represented as a single code number, a range of codes separated by a dash, a series of codes separated by commas, or a combination of single codes and ranges of codes
Main terms in the CPT index are printed in boldface type, along w/categories, subcategories, headings and code numbers
See a cross-reference that directs the coders to an index entry under which codes are listed. No code are listed under the original entry. It is printed in italicized type
Before selecting a final code the descriptions of all codes listed for a specific procedure must be carefully investigated
Coding must never be performed solely from the index
CPT modifiers clarify services and procedures performed by providers. Although the code & description remain unchanged, modifiers indicate the descr of the service has been altered
A list of all CPT modifiers w/brief descriptions is located inside the front cover of the coding manual as well as appendix A
If the last code description you read is located at the bottom of the index page, what should you do turn the page and check to see if the description continues
To find the main term in the index you may have to refer to synonyms, translate medical terms to ordinary english or substitute medical words for English terms documented in the provider’s statement
The surgery section is organized by body system
What are the three questions that must be asked to code surgeries correctly What body system is involved? What anatomic site was involved ? What type of procedure was performed?
Sometimes the discriminating factor between one code and another will be the surgical approach or type of procedure documented. Carefully read the procedure outlined in the operative report
Surgical package (or global surgery) includes a variety of services provided by a surgeon
Global period is the number of days associated with the surgical package and is designated by the payer as 0,10,90 days
Unbundling means assigning multiple codes to procedures/services when just one comprehensive code should be reported. Unbundling is not allowed
Separate procedure the parenthetical note follows a code description identifying procedures that are an integral part of another procedure or service
Multiple surgical procedures two or more surgeries performed during the same operative session
The major surgical procedure the procedure reimbursed at the highest level
The major surgical procedure should be listed first followed by the lesser surgeries listed on the claim in descending order of expenses
What code is added to each of the lesser surgical procedure that does not have the null or plus sign in front of the code modifier -51
Skin lesion any alteration of the skin
Shaving sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions, w/out full-thickness dermal excision
Excision full-thickness dermal removal of a lesion; CPT code includes simple closure
Destruction ablation of tissue using chemical treatment, cryosurgery, electrocautery or laser treatment
CPT codes for excursions are reported in cm if reported in in, you have to convert from inches to cm
Simple repair use of staples, sutures and/or tissue adhesives to repair superficial wounds involoving epidermis, dermis and/or subcutaneous tissues
Intermediate repair layered closure of deeper layers of subcutaneous tissue and superficial fascia in addition to epidermis, dermis and subcutaneous tissues
Complex repair reconstructive complicated wound repair that requires more than layered closure and includes debridement, scar revision, extensive undermining, retention sutures or stents
Created by: RobynTerry1977