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CPT Coding

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Answer
CPT   Current Procedural Terminology  
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Level I of the Healthcare Common Procedure Coding System (HCPCS)   CPT  
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CPT is a listing   of descriptive terms and identifying codes for reporting medical services and procedures  
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MMA requires that   new, revised and deleted ICD-9-CM codes be implemented each October 1 and updated each April  
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Changes to HCPCS level II national codes implemented   January 1  
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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  
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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.  
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CPT supports   EDI, the computer-based patient record (CPR) or electronic medical record (EMR) and reference/research databases.  
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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  
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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  
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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)  
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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)  
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Appendix A   listing w/detailed descriptions of each CPT modifier  
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Appendix B   Annual CPT coding changes (added, deleted and revised CPT codes)  
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Appendix C   Clinical examples for codes found in Evaluation and management  
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Appendix D   add on codes; identified w/a + symbol  
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Appendix E   codes exempt from modifier -51 reporting rules  
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Appendix F   CPT codes exempt from modifier -63  
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Appendix G   Summary of CPT codes that include conscious sedation  
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Appendix H   genetic testing modifiers  
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Appendix I   Category II code modifiers  
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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.  
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The common portion of the code description   begins w/a capital letter and ends with ;  
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The abbreviated (or subordinate) descriptions   are indented and begin w/lower-case letters placed after the ;  
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Codes reported w/plus signs are never reported as stand-alone codes   they are not classified as add-on codes  
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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.  
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The bulls-eye symbol denotes   a procedure that includes conscious sedation  
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CPT Category I codes are organized   according to 6 sections that are subdivided into subsections, subcategories, and headings  
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Guidelines   are located at the beginning of each CPT section and should be carefully reviewed before attempting to code.  
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Guidelines   define terms and explain the assignment of codes for procedures and services located in a particular section in CPT  
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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  
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Two types of instructional notes   1 blocked unindented note and 2 indented parenthetical note  
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Blocked unindented note   located below a category (or subsection) title and contains instructions that apply to all codes in the category  
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Indented parenthetical note   located below a subsection title, code description, or code description that contains an example  
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Descriptive Qualifiers   terms that clarify the assignment of a CPT Code  
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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  
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A bullet left of the code   identifies new procedures and services added to the CPT  
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A triangle located to the left of the code   identifies a code description that has been revised  
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Horizontal triangles   surround revised guidelines and notes (this symbol is NOT used for revised code descriptions)  
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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)  
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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  
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Main terms in the CPT index   are printed in boldface type, along w/categories, subcategories, headings and code numbers  
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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  
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Before selecting a final code   the descriptions of all codes listed for a specific procedure must be carefully investigated  
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Coding must never   be performed solely from the index  
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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  
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A list of all CPT modifiers w/brief descriptions is located   inside the front cover of the coding manual as well as appendix A  
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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  
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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  
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The surgery section is organized by   body system  
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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?  
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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  
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Surgical package (or global surgery)   includes a variety of services provided by a surgeon  
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Global period   is the number of days associated with the surgical package and is designated by the payer as 0,10,90 days  
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Unbundling   means assigning multiple codes to procedures/services when just one comprehensive code should be reported. Unbundling is not allowed  
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Separate procedure   the parenthetical note follows a code description identifying procedures that are an integral part of another procedure or service  
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Multiple surgical procedures   two or more surgeries performed during the same operative session  
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The major surgical procedure   the procedure reimbursed at the highest level  
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The major surgical procedure should be listed first followed by   the lesser surgeries listed on the claim in descending order of expenses  
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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  
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Skin lesion   any alteration of the skin  
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Shaving   sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions, w/out full-thickness dermal excision  
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Excision   full-thickness dermal removal of a lesion; CPT code includes simple closure  
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Destruction   ablation of tissue using chemical treatment, cryosurgery, electrocautery or laser treatment  
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CPT codes for excursions are reported in cm   if reported in in, you have to convert from inches to cm  
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Simple repair   use of staples, sutures and/or tissue adhesives to repair superficial wounds involoving epidermis, dermis and/or subcutaneous tissues  
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Intermediate repair   layered closure of deeper layers of subcutaneous tissue and superficial fascia in addition to epidermis, dermis and subcutaneous tissues  
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Complex repair   reconstructive complicated wound repair that requires more than layered closure and includes debridement, scar revision, extensive undermining, retention sutures or stents  
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Created by: RobynTerry1977