Chapter 19 Vocabulary: Procedural Coding
The connection between diagnostic and procedural info is called code
Linkage
A code description containing a ___ is followed by a code with an indented description.
Semicolon
MODIFIER 32 - Mandated Services
Service (such as a consult) is required by the ins carrier, gov't agency, or regulatory agency.
Category III Codes
"Temporary" CPT codes for emerging technology, services, and procedures. (Ex. 0051T - Implantation of a total replacement heart system 'artificial heart' with recipient cardiectomy). *Cat II & III codes are both found directly after the last of the Medicine codes in the CPT manual.
Possible consequences of inaccurate coding and incorrect billing incl the following:
* Denied claims * Delays in processing claims and receiving payments * Reduced payments * Fines and other sanctions * Loss of hospital privileges * Exclusion from payers' programs * Prison sentences * Loss of the practitioner's license to practice med.
Why must each procedure be matched with its corresponding diagnosis?
* To prove medical necessity * To verify code linkage
What are some important things to remember when coding for the respiratory system?
- Incorporate the approach - be alert for the suffix -plasty
Which are key factors documented in a patient's medical record that help determine the level of service?
- extent of pt history taken - Complexity of Medical decision making - extent of the exam conducted.
Whaat are some elements of a pt history?
-History of present illness - Chief complaint - Review of systems
The development of a Compliance Plan is led by a compliance officer and committee with the intention to:
1) Audit and monitor compliance with gov't regs, esp in the area of coding and billing; 2) Develop consistent written procs and policies; 3) Provide for ongoing staff training and communication; and 4) Respond to and correct errors. Coding and billing compliance are the plan's major focus, but it covers all areas of gov't regulation of medical practices, such as EEO regs, for (ex. Hiring and promotion policies) and OSHA regs (for ex) fire safety and handling of hazardous materials like bloodborne pathogens).
Locating a CPT Code
1) Find the services listed on the superbill (if used) and in the pt's record. a) Check to see which services were documented. Note if pt is new or established and then look to see location of the service and the extent of the history, exam and medical decision making that were involved. 2) Look up the proc code(s) in the Alpha Index of the CPT manual. a) Verify the code # in the Tabular list b) If a code range is noted, look up each code in the range and choose the correct code given in the Tabular list. 3) Determine appropriate modifiers. a) Check section guidelines and Appendix A to choose a modifier if needed to explain a situation involving the proc being coded. 4) Carefully record the proc code(s) on the healthcare claim or, if the office is computerized, enter the codes into the office billing system for placement on an electronic health claim form. 5) Match each proc with its corresponding diagnosis. The primary proc is often (but not always) matched with the primary diagnosis.
What are the three key factors documented in the pt's medical rec that help determine the level of service?
1) The extent of the pt history taken 2) The extent of the examination conducted 3) The complexity of the medical decision making
Compliance Plans
A plan set in place to avoid the risk of fraud. The compliance plan is there to uncover compliance problems and correct them. A compliance plan is a process for finding, correcting, and preventing illegal medical office practices. Its goals are to: * Prevent fraud and abuse through a formal process to identify, investigate, fix and prevent repeat violations relating to reimbursement for healthcare services provided. * Ensure compliance with appl fed'l, state, and local laws, incl employment laws and environmental laws as well as anti fraud laws. * Help defend providers if they are investigated or prosecuted for fraud by showing the desire to behave compliantly and thus reduce any fines or criminal prosecution.
MODIFIER 23 (unusual anesthesia)
A procedure that normally does not require anesthesia or anesthetic will require general anesthesia bc of unusual situations.
Endocrine System Coding
A short sect, the endocrine system codes incl those for procs on the thyroid, parathyroid, thymus, adrenal glands, pancreas and carotid body. Procs incl incisions, excisions, and laparoscopies.
Problem-focused exam
A visit, history, or exam that focuses solely on the chief complaint
Code Linkage
Analysis of the connection between diagnostic and procedural information in order to evaluate the medical necessity of the reported charges.
MODIFIER 77 - Repeat Proc by Another Physician
As with modifier 76, a second proc is required, but in this case, a different physician provides the service.
Symbols used in CPT:
BLUE TRIANGLE: tells the user that the code description has been revised in some way from last year. This info is important, as the change could mean the procedure performed by the physician may now require a different code. (It could mean something as simple as the placement of a comma or semicolon has changed). RED DOT: Denotes a new code for this edition of the CPT. The # sign: Used to denote codes that are out of numeric sequence. This was done so code numbers would not be "reshuffled" every year. Note that each code is also found in red, in its "proper numeric place" with directions telling the coder in what code range to locate the out-of-sequenced" code. Triangles pointing towards each other with text between them denote new or revised text info. Traditionally these arrows have been GREEN. Circle with Diagonal Line: "Modifier 51 exempt" This is used when multiple procedures are performed in the same session. Mod 51 exempt codes are those to which the multiple proc modifier does not apply. Appendix E of the CPT manual lists the modifier 51 exempt codes. (Note: the modifier 51 is never appended to a designated add-on code). Lighting Bolt: Used to denote vaccines pending FDA approval. Appendix K in the CPT manual lists the vaccines affected by this symbol. When the vaccines are approved, these along with other current codes will be listed on the AMA site. Bull's eye: Denotes moderate (conscious) sedation and means it is understood that conscious sedation is necessary for the procedure performed, so conscious sedation is incl in the proc; it cannot be billed separately. Many endoscopic proc incl this symbol.
Musculoskeletal System Subheadings
Begin with general and then start with the head and work their way down to the foot and toes. This will be true for the rest of the CPT manual. Cast and strappings as well as endoscopy and arthroscopy are also found in this chapter. Probably the most common codes from this section incl the fracture codes. A couple of straightforward rules include: - A fracture treatment is closed unless stated otherwise; that is, treatment occurs without opening the skin. Open treatment means that surgery occurred to repair the fracture. Percutaneous treatment (fixation) immobilizes the fracture with hardware (pins) inserted using X-ray guidance. - Fracture repair assumes cast application and incl it. Cast application and removal for fractures are coded only when the physician applying or removing the cast did not initially treat the pt's fracture. - Last, any therapeutic procedure (like arthroscopy) incl the diagnostic proc, so if a diagnostic proc becomes a therapeutic (surgical) proc in the end, the therapeutic proc will be coded.
HCPCS Level 1 codes are more commonly known as
CPT Codes (In HCPCS, Level 1 Codes duplicate the CPT).
___ is the HIPPA-required code set that translates descriptions for physicians' Procedures into 5-digit codes.
CPT
CPT Code Format
CPT codes are 5 digit numeric codes. Most codes are standalone codes with the complete description listed next to the appropriate code. The exception to this rule is the code description containing a semicolon, which is then followed by the a code with an indented description.
CMS
Centers for Medicare and Medicaid Services
MODIFIER 58 - Staged or Related Procedure of Service by the Same Physician During the Postoperative Period.
Circumstances may incl staged (planned) proc, proc being more extensive than originally thought, or therapy following original proc.
Diagnosis code
Code used to communicate a diagnosis to the third-party payer on a healthcare claim
Nervous System Coding
Codes describing procs on the the brain, spinal cord, and peripheral nerves are all found in this sect. Anatomic sites create the subheadings, which are subdivided by the proc performed. Bc of the complicated nature of coding procedures related to this delicate system, multiple specialized guidelines are found within this chapter. The approach is an imp consideration when coding surgery on the brain (anterior, middle, or posterior cranial fossa), as is the definitive proc that describes the proc done to the lesion and the reconstruction or repair necessary at the end of the surgery. Lumbar punctures, CSF (Cerebrospinal fluid) shunt proc for hydrocephalus treatment, and all treatments for spinal column and cord defects and peripheral nerve repair and destruction are found in this chapter.
MODIFIER 78 - Unplanned Return to the OR by the Same Physician Following Initial Proc for Related Proc during the Postop period
Complications related to the initial proc are most often the reason for the return to surgery.
Which type of code is used instead of E/M code when a complete history and physical exam do not take place?
Counseling
unbundling
Defined as breaking a bundled code into its component parts for higher reimbursement and is not allowed.
DHHS
Department of Health and Human Services
Subheading
Describes the body area for the body system you are looking at.
Category
Describes the procedure area
Coding Audit (AKA..Code Review)
Done to avoid errors, codes on healthcare claims are checked against the medical documentation. These reviews check these key points: * Are the codes appr to the pt's profile (age, gender, condition; new or established), and is each coded service billable? * Is there a clear an correct link between each diagnosis and proc? * Have the payer's rules about the diagnosis and the proc been followed? * Does the documentation in the pt's medical rec support the reported services? * Do the reported services comply with all regulations?
MODIFIER 52 - Reduced Services
Due to circumstances, service is reduced or eliminated by the physician.
Male Genital System Coding
Due to the many repair codes associated with it, the subheading "Penis" is the largest within the male genital section. Other proc codes found throughout this chapter incl excision, incision, biopsy, destruction (of lesions), incl laser surgery (treatment for BPH an prostrate cancer), and brachytherapy (radiotherapy). The 2 codes for intersex surgery are also found in this sect.
MODIFIER 57 - Decision for Surgery
During an E/M service, decision is made that surgery is required.
CPT Codes are organized into six main sections:
Evaluation and management: 99201 - 99499 Anesthesiology: 00100 - 01999. / 99100 - 99140 Surgery: 10021 - 69990 Radiology: 70010 - 79999 Pathology and Laboratory: 80047 - 89398 Medicine (except for anesthesia) 90281 - 99199. / 99500 - 99607
detailed examination
Extended examination of the affected body area(s) and other symptomatic or related organ system(s)
The coding SYSTEM developed by the Centers for Medicare and Medicaid Services that is used in coding services for Medicare pts is:
HCPCS - Healthcare Common Procedure Coding System
Expanded Problem Focused Examination
History includes the chief complaint, a brief history of the current problem, and a "problem-pertinent" review of systems.
Surgical Coding
Incl in most surgical pkgs are the preoperative exam and testing; the surgical procedure itself, incl local or regional anesthesia if used; and routine follow-up care for a set period of time. Payers assign a fee to each of these packaged codes that pays for all the services provided in this package. If using anesthesia other than local anesthesia, the anesthesiologist billing for her services would use an anesthesia code.
Organ Systems (OA)
Include the following Systems: ophthalmologic (eyes), otolaryngologic (ears, nose, throat and mouth), cardiovascular, respiratory, GI (gastrointestinal), GU (genitourinary), musculoskeletal, integumentary skin) neurologic, psychiatric, and hematologic / lymphatic /immunologic (blood, lymph, and immunity).
Body Areas (BA)
Include the head (incl face), neck, chest (incl breasts and axillae), abdomen, genitalia, groin and buttocks, back and extremity.
Constitutional Exam
Includes any of the following: BP sitting or lying, pulse, respirations, temperature, height, weight and general appearance.
Indented Description
Indented description means that you refer back to the previous code description, reading the information prior to the semicolon and adding the indented code information after the colon to complete the description.
MODIFIER 62 - Two Surgeons
Indicates that 2 surgeons performed a proc that normally is performed by one surgeon, each performing distinct aspects of the proc.
Meds and Immunizations Coding
Injections and infusions of immune globulins vaccines, toxoids, and other substances require two codes, one for giving the injection and one for particular vaccine or toxoid that is given. An E/M code is not used along with the codes for immunization unless a significant eval and management service is also performed (like a yearly physical exam) and documented appropriately by the doctor. Modifier 59 would be appended to the E/M code in this case, indicating the need for both procs.
Insurance Fraud
Investigators reviewing Physicians' billings look for patterns like these: * Reporting services that were not performed ***Ex) A lab bills Medicare for a gen'l health panel (CPT 80050) but fails to perform at least one of the tests on the panel. * Reporting services at a higher level than was carried out. *Performing and billing for procs not related to the pt's condition and therefore not medically necessary. * Billing separately for services bundled in a single proc code (unbundling) * Reporting the same service twice.
MODIFIER 50 - Bilateral Procedure
Modifier is used if the proc is not defined as bilateral but the proc is performed on both sides of the body.
Semi-colon in a code description:
Most codes are stand-alone codes with the complete description listed next to the appropriate code. The exception to this rule is the code description containing a semicolon, which is followed by a code with an indented description. An indented description means that you refer back to the previous code description, reading the info prior to the semicolon and adding the indented code information after the colon to complete the description.
When a compliance plan is in place, it demonstrates to payers that
Ongoing attempts are being made to find and fix weak areas of compliance.
Laboratory Procedures Coding
Organ or disease-oriented panels listed in pathology and lab section of the CPT incl tests frequently ordered together. An electrolyte panel, for example, incl tests for carbon dioxide, chloride, potassium, and sodium. Each element of the panel has its own proc code. However, when the tests are performed together, the code for the panel must be used, rather than separate proc codes. If a panel is appropriate but one or two lab tests are also ordered that are not incl in the panel, code the panel and then the add'l tests separately.
MODIFIER 55 (postoperative management only)
Physician provides post-op care only.
MODIFIER 56 - Preoperative Management Only
Physician provides pre-op care only.
MODIFIER 76 (repeat procedure or service by same physician)
Proc is performed and complication requires repeat or related service. Used to explain this is not a duplicate service but is medically necessary.
Category II Codes
SUPPLEMENTAL tracking codes used to track healthcare performance measures, like programs and counseling to avoid tobacco use. Although these codes are intended to facilitate data collection about the quality of care, their use is OPTIONAL. Cat II codes are published twice a yr, Jan 1st and July 1st
Integumentary Subheadings
Skin, subcutaneous, and necessary structures; nails, pilonidal cyst, introduction; repair (closure), destruction, and breast. - Further subdivided by the procedures done within each subheading, such as I&D, EXCISION, PARING, and BIOPSY BENIGN and MALIGNANT LESIONS. - Many codes in this section are based on size and location. ** Simple closure is often incl in the main code, so often you will code closure only if they are intermediate (layered) or complex (greater than layered).
MODIFIER 26 - Professional Component
Some procedures (such as radiology) contain a combo of prof and technical components. If the physician provides only the professional component, mod 26 is added.
MODIFIER 80 - Assistant Surgeon
Surgeon acts as assistant to primary surgeon. (A PA may function in this role).
MODIFIER 47 - Anesthesia by Surgeon
Surgeon provides and administers anesthesia other than local anesthesia. Modifier is appended to the surgical procedure.
MODIFIER 54 - Surgical Care Only
Surgeon provides only the surgical care with other physician(s) providing pre- and post-op care.
Subsection name
The area within the section detailing the body system you are in.
Patient History (1 Key factor in determining Level of Service in E/M Sec'n guidelines)
The elements of a history incl the chief complaint (CC); history of present illness (HPI); review of symptoms (ROS); and past, family, and/or social history (PFSH). When coding, the history is described using one of the following terms: Problem-focused; Expanded problem-focused ; Detailed; or Comprehensive.
Physical Exam (Another Key factor in determining Level of Service in E/M Sec'n guidelines)
The elements of the physical exam incl the same terminology but relate to the level of examination performed. The physical exam has 3 elements: The constitutional exam, Body Areas (BA), and Organ Systems (OA)
Urinary System Coding
The most "intense" coding in the urinary system revolves around the kidneys and renal function and treatments, incl services for renal transplantation. In add'n to kidney proc, you will find diagnostic (incl urodynamics) and therapeutic proc for the ureters, bladder, and urethra.
Digestive System Coding
The most common procedures one in the upper digestive system are incisions and excisions followed by repairs. The lower digestive system (stomach, intestines, rectum) incl these as well as endoscopies (and laparoscopies). You will also find procedures on the liver, pancreas, biliary tract, abdomen and peritoneum.
Comprehensive History
The most complex of the histories; all four components of CC, HPI, ROS, and PFSH are documented.
Comprehensive exam
The most extensive exam; incl either a complete single-specialty exam or a complete multisystem examination.
Medical Decision Making (MDM)
The most important key component in establishing an E/M code, as well as the most difficult to document. It is based on the complexity of the decision making by the provider about the pt's care and diagnosis. The 3 elements that must be documented to establish MDM are: - The # of diagnoses or management options (minimal, limited, multiple, or extensive) - The amount or complexity of data to be reviewed (none or minimal, limited, moderate, or extensive) - Risk of complication or death if the condition is untreated (minimal, low, moderate, or high).
High-complexity MDM
The physician has extensive diagnosis and management opts with an extensive amount and complexity of data to review. The pt is at high risk for complication and/or death if not treated.
MODIFIER 53 (discontinued procedure)
The proc is discontinued due to pt condition becoming endangered.
Section Name
The section is the name used by CPT to denote each chapter.
Straightforward MDM
There are minimal diagnosis and management options with minimal amount or complexity of data to be reviewed and minimal risk to the pt of complication or death if the condition is left untreated.
Moderate-complexity MDM
There are mult diagnoses and management opts with a moderate amount or complexity of data to review. If not treated, the condition presents a moderate risk of complication or death to the pt.
Hemic / Lymphatic and Mediastinum and Diaphragm Coding
These two subsections of the surgery sect incl proc on the spleen, bone marrow, and lymph nodes as well as surgical procedures related to the mediastinum and diaphragm. (Coding in these areas is pretty straightforward IF you read carefully).
Counseling
This component is only considered critical for E/M codes when counseling is the reason for the encounter and constitutes 50% or more of the total time of the visit.
Nature of Presenting Problem
This is another term for the severity of the pt's chief complaint. - A minimal complaint may not require the presence of a physician, but service is provided under the licensed clinician's supervision such as a BP reading or dressing change.. - A self-limited complaint is a minor problem that will run a "known" course and is transient in nature. A problem with a good prognosis when the pt is compliant also may be considered self-limiting. - Low-severity complaints are those with a low risk of morbidity and mortality if there is no treatment. Full recovery is expected. - Moderate-severity complaints have a moderate risk of morbidity and mortality if there is not treatment . Prognosis is uncertain and there is risk of impairment. - High-severity complaints are those of high to extreme risk. Risk of death is moderate to high and there is risk of prolonged functional impairment.
MODIFIER TC - Technical Component
This is the HCPCS modifier that is the "reverse" of modifier 26. It designates the provision of the technical component only.
Coordination of Care
This is the time the licensed practitioner uses to coordinate pt care with other healthcare agencies like home care or nursing home care.
Time - component to some codes
This was incorporated in 1992 as a component to come codes to assist with the code choice. The times listed are considered averages and unless the code choice, such as with face-to-face contact codes, is based on time, time should not be considered a critical factor when choosing an E/M code. The location of service is also important bc different E/M codes apply to services performed in a provider's office or other outpatient location, a hospital impatient room, a hospital ER dept, a nursing facility, an extended-care facility or a pt's home.
Clean claims are
Those in which each reported service is connected to a diagnosis that supports the proc as necessary to investigate or treat the pt's condition. Ins Co. representatives analyze this connection between the diagnostic and the procedural info, called CODE LINKAGE, to evaluate the medical necessity of the reported changes.
MODIFIER 24
Unrelated E/M Services by the Same Physician During a Postoperative Period. (Pt may require the services of the physician for treatment of an unrelated condition during a global surgical period.
Female Genital System / Maternity and Delivery Coding
Used almost exclusively by OB?GYN providers. This chapter is set up from "the outside in," starting with introitus (vaginal opening) moving to the ovaries within the pelvis, with a separate subsection devoted to labor and delivery.
MODIFIER 92 - Alternative Laboratory Platform Testing
Used for disposable kit testing such as HIV testing.
MODIFIER 82 - Ass't Surgeon (When Qualified Resident Surgeon is Not Available)
Used only in teaching hospitals where resident surgeons are normally available.
MODIFIER 81 (minimum assistant surgeon)
Used only when minimal assistance during surgery is required.
MODIFIER 66 - Surgical Team
Used when a team of surgeons is required for a complicated proc.
MODIFIER 99 - Multiple Modifiers
Used when more than three modifiers are appl to CPT code being used and the payer only accepts one modifier one modifier per code.
MODIFIER 90 - Reference (Outside) Laboratory
Used when physician is billing for services provided by an outside lab. (Not allowed by Medicare).
MODIFIER 91 - Repeat Clinical Diagnostic Lab Test
Used when serial (multiple) labs are required on the same day to monitor the pt's condition.
MODIFIER 59 - Distinct Procedural Service
Used when the secondary proc is identified as different session, different proc/surgery, different site or organ system. Separate incision/excision, separate lesion, separate injury or area of injury when injuries are extensive.
MODIFIER 79 - Unrelated Procedure or Service by the Same Physician During the Postop Period
Usually, pt undergoes a primary proc and , for an unrelated issue, requires a second surgery or proc during the post-op period.
Using the CPT manual
When choosing the E/M codes you must know whether the pt is a new or established pt and where the services took place. When using the alphabetic listing of procs, the # or # range in the index to the right of the description represents the coding possibilities for the description. If a hyphen is between 2 codes, this indicates a code range and each code in the range will need to be checked in the numeric index to choose the correct code. Code #'s with commas between them indicate that there is more than one possible correct location for the code required.
Unlisted procedure code
When no code is available to completely describe a proc, a code for unlisted proc is selected. Unlisted proc codes are used for new services or proc that have not yet been assigned codes in CPT. When these codes are used, (which is rare) a proc or service description (usually from the medical rec) is sent with the claim submission.
MODIFIER 51 - Multiple Procedures
When the same provider performs mult proc (other than E/M, PT, and Rehab or supply provision) in the same session, the first proc is listed as usual, and subsequent procedures should incl the add'n of mod 51.
MODIFIER 22 (Increased procedural services)
When the work required to complete the service is much more than usually required, modifier 22 may be added to the CPT code. Med rec documentation will be required.
MODIFIER 25 - Significant, separately identifiable E/M service by the same Physician on the same day of the procedure or other service:
While in the office for a specific procedure, the pt may require an E/M service above and beyond that normally provided during the usual pre- and/or post-procedure period.
Cardiovascular System Coding
You must know not only whether veins or arteries (or both) are used in bypass but also the correct coding sequence; the right codes in the wrong order will also hold up a claim. Injection codes will be used for diagnostic and therapeutic proc and you will also find embolectomy SNF thrombectomy codes in this section. Nonsurgical cardiography procedures incl ECG's, Holter monitors, and exercise tests. The echocardiography area incl all cardiac ultrasound procedures as well as vascular Doppler procedures for noncardiac vascular areas, such as the extremities. (Use as many coes as necessary).
add-on code
a code indicating procedures that are usually carried out in addition to another procedure. Add-on codes are used together with the primary code. A plus (+) sign is used for Add-on codes.
healthcare common procedure coding system (HCPCS)
a coding system developed by the Centers for Medicare and Medicaid Services that is used in coding services for Medicare patients.
established patient
a patient who has seen the physician within the past 3 years. This determination is important when using E/M codes.
current procedural terminology (CPT)
a ref manual published by the American Med Ass'n (AMA) with the most commonly used system of procedure codes. It is the HIPAA-required code set for physicians' procedures; it translates descriptions for physicians' and other providers' healthcare-related procedures into 5-digit codes. The manual is updated yearly; the new codes are used for services provided beginning January 1 of each new year. Any changes made are also available in an electronic file for computerized medical offices. As with ICD codes, the choice of which set of codes to use is based on the date of service, not the date of the claim. Medical claims are often denied if current codes are not used when filing. Previous editions of each coding manual should be kept for at least several months after the new edition is released for use with claims for dates of service in the prior year, and for ref in case questions arise regarding previously submitted claims.
Contributory factors
additional components that can be considered when selecting an evaluation and management code: time, nature of presenting problem, counseling and coordination of care
concurrent care
care being provided by more than one physician, such as with specialists.
critical care
care provided to unstable, critically ill patients. Constant bedside attention is needed in order to code critical care.
procedure code
code that represents a medical procedure, such as surgery and diagnostic tests, and medical services, such as an examination to evaluate a patient's condition.
HCPCS level II codes
codes that cover many supplies such as sterile trays, drugs, and durable medical equipment; also referred to as national codes. They also cover services and procedures not included in the CPT. HCPCS codes have FIVE characters, either numbers, letters, or a combo of both. At times there are also two-character modifiers, either 2 letters or a letter with a number.
upcoding
coding to a higher level of service than that provided to obtain higher reimbursements.
E/M codes
evaluation and management codes that are often considered the most important of all CPT codes because they can be used by all Physicians in any medical specialty. The E/M section guidelines explain how to code different levels of services.
Category 1 Codes
for the most part, define professional services.
Detailed History
history still focuses on the chief complaint but incl an extensive history of the current problem and an extended review of systems and pertinent past, family, and/or social history.
new patient
patient that, for CPT reporting purposes, has not received professional services from the physician within the past 3 years.
ICD Codes
international classification of diseases
consultation
meeting of two or more physicians or surgeons to evaluate the nature and progress of disease in a particular patient and to establish diagnosis, prognosis, and /or therapy. A service can only be considered a consultation if the 3R's are present: Request: from another practitioner; Record (documentation) findings and recommendations; Report to the referring practitioner.
modifier
one or more 2-digit codes assigned to the 5-digit main code to show that some special circumstance applied to the service or procedure that the physician performed.
counseling
provision of advice and instruction by a healthcare professional to patients. It is considered part of E/M services, but if complete history and physical exam does not take place (making an E/M code inappropriate), counseling codes may be used. These codes may be used when discussing with the pt and family questions or concerns re one or more of the following: diagnostic results and recommendations; prognosis, risks, and benefits of opts; instructions for treatment and/or follow-up; importance of compliance; risk factor reduction; and pt/family ed.
panel
tests frequently ordered together that are organ or disease oriented.
downcoding
the insurance carrier bases reimbursement on a code level lower than the one submitted by the provider.
global period
the period of time that is covered for follow-up care of a procedure or surgical service.
Low-complexity MDM
there are a limited # of diagnoses and management opts with a limited amount or complexity of data to be reviewed and ow risk of complication or death if the pt is left untreated.
bundled codes
when healthcare services that are usually separate are considered as a single entity for purposes of classification and payment.
