Chapter 7: CPT coding

order of Anesthesia coding

code-HCPCS Level II Anesthesia Modifiers-Physical Status Modifiers-CPT Modifiers exp: 00872-AA-P2-23.

Category III codes

contain "emerging technology" temporary codes assigned for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0075T); these codes are located after the Medicine section, and they will be archived after five years unless accepted for placement within Category I sections of CPT

Category II codes

contain "evidence-based performance measurements" tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0012F); these codes will be located after the Medicine section, and their use is optional

The Surgery section

contains subsections that are organized by body system. Each subsection is subdivided into categories by specific organ or anatomic site. Some categories are further subdivided by procedure subcategories in the following order: Incision Excision Introduction or Removal Repair, Endoscopy Revision or Reconstruction Destruction Grafts Suture Other Procedures

Guidelines

define terms and explain the assignment of codes for procedures and services located in a particular section.

nature of the presenting problem

defined by CPT as a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.

cross-reference

directs coders to a different CPT index entry because no codes are found under the original entry.

counseling

discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) options; instructions for management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.

detailed examination

extended examination of the affected body area(s) and other symptomatic or related organ system(s).

key components

extent of history, extent of examination, and complexity of medical decision making required when selecting an E/M level of service code.

Evaluation and Management Documentation Guidelines

federal (CMS) guidelines that explain how E/M codes are assigned according to elements associated with comprehensive multisystem and single-system examinations.

established patient

one who has received professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

CPT index

organized by alphabetical main terms printed in boldface.

Medicare physician fee schedule payments are based on:

payment components multiplied by conversion factors and geographical adjustments.

Medical decision making

refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: -the number of diagnoses or management options, -amount and/or complexity of data to be reviewed, and -risk of complications and/or morbidity or mortality.

Type of service (TOS)

refers to the kind of health care services provided to patients; including critical care, consultation, initial hospital care, subsequent hospital care, and confirmatory consultation. a code required by Medicare to denote anesthesia services.

E/M level of service

reflects the amount of work involved in providing health care to a patient, and correct coding requires determining the extent of history and examination performed as well as the complexity of medical decision making.

Qualifying circumstances codes include:

-99100 (Anesthesia for patient of extreme age, younger than one year and older than 70) -99116 (Anesthesia complicated by utilization of total body hypothermia); -99135 (Anesthesia complicated by utilization of controlled hypotension); -99140 (Anesthesia complicated by emergency conditions [specify]) (An emergency condition results when a delay in treatment of the patient would lead to a significant increase in threat to life or body part.).

HCPCS Level II Anesthesia Modifiers

-AA (anesthesia services performed personally by anesthesiologist); -AD (medically supervised by a physician for more than four concurrent procedures); -G8 (monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure) (Report modifier -G8 with CPT codes 00100, 00400, 00160, 00300, 00532, 00920 only. Do not report modifier -G8 with modifier -QS.) -G9 (monitored anesthesia care [MAC] for patient who has a history of severe cardiopulmonary condition) -QK (medical direction of two, three, or four concurrent anesthetic procedures involving qualified individuals) -QS (monitored anesthesia care service) (Do not report modifier -G8 with modifier -QS.) -QX (CRNA service, with medical direction by physician) -QY (medical direction of one Certified Registered Nurse Anesthetist [CRNA] by an anesthesiologist) -QZ (CRNA service, without medical direction by physician)

When an unlisted service code is reported, a special report must be submitted with the insurance claim to demonstrate medical appropriateness. The provider should document the following elements in the special report:

-Complexity of patient's symptoms; -Description of, nature of, extent of, and need for service; -Diagnostic and therapeutic procedures performed Follow-up care; -Patient's final diagnosis and concurrent problems; -Pertinent physical findings; -Time, effort, and equipment required to provide the service.

steps for coding Procedures and Services

-Step 1: Read the introduction in the CPT coding manual. -Step 2: Review guidelines at the beginning of each section. -Step 3: Review the procedure or service listed in the source document (e.g., charge slip, progress note, operative report, laboratory report, or pathology report). Code only what is documented in the source document; do not make assumptions about conditions, procedures, or services not stated. If necessary, obtain clarification from the provider. -Step 4: Refer to the CPT index, and locate the main term for the procedure or service documented. Main terms can be located by referring to the: a. Procedure or service documented. b. Organ or anatomic site. c. Condition documented in the record. d. Substance being tested. e. Synonym (terms with similar meanings). f. Eponym (procedures and diagnoses named for an individual). g. Abbreviation. - Step 5: Locate subterms and follow cross-references. - Step 6: Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements. -Step 7: Assign the applicable code number and any add-on (+) or additional codes needed to accurately classify the statement being coded. *** note: 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 to find the main term in the index.

Types of medical decision making

-Straightforward -Low complexity -Moderate complexity -High complexity

Relative value units (RVUs)

-assigned by the CMS to each CPT and HCPCS level II code; -representing the cost of providing a service, and include payment components: physician work (physician's time and intensity in providing the service), practice expense (overhead costs involved in providing a service), and malpractice expense (malpractice expenses)

global period

-includes all services related to a procedure during a period of time (e.g., 10 days, 30 days, 90 days, depending on payer guidelines). -The following designations are also associated with the surgical package: MMM (global period policy does not apply) XXX (global period policy does not apply) YYY (payer-determined global period) ZZZ (procedure/service is related to another service; falls within the global period of another service)

which symbol identifies a code description that has been revised?

A triangle ▲ located to the left of a code number

separate procedure

follows a CPT code description to identify procedures that are an integral part of another procedure or service. (reported if the procedure or service is performed independently of the comprehensive procedure or service or is unrelated to or distinct from another procedure or service performed at the same time. Not reported if the procedure or service performed is included in the description of another reported code).

Comprehensive examination

general multisystem examination or a complete examination of a single organ system.

CPT codes

have five characters in length; code descriptions reflect health care services and procedures performed in modern medical practice.

boldface type

highlights main terms in the CPT index and categories, subcategories, headings, and code numbers in the CPT manual.

Accurate assignment of E/M codes depends on:

(1) identifying the place of service (POS) and/or type of service (TOS) provided to the patient, (2) determining whether the patient is new or established to the practice, (3) reviewing the patient's record for documentation of level of service components, (4) applying CMS's Documentation Guidelines for Evaluation and Management Services, (5) determining whether E/M guidelines (e.g., unlisted service) apply.

Evaluation and Management (E/M) section

(codes 99201-99499) located at the beginning of CPT because these codes describe services (e.g., office visits) that are most frequently provided by physicians and other health care practitioners (e.g., nurse practitioner, physician assistant).

special report

(e.g., copy of procedure report) must accompany the claim when a CPT unlisted procedure or service code is reported to describe the nature, extent, and need for the procedure or service.

To code surgeries properly, three questions must be asked:

1. What body system was involved? 2. What anatomic site was involved? 3. What type of procedure was performed?

which symbol identifies new codes for procedures and services added to CPT?

A bullet (•) located to the left of a code number

qualifying circumstances

CPT Medicine Section codes reported in addition to Anesthesia Section codes when situations or circumstances make anesthesia administration more difficult (e.g., patient of extreme age, such as under one year or over 70).

stand-alone codes

CPT code that includes a complete description of the procedure or service.

resequenced codes

CPT codes that appear out of numerical order and are preceded by the # symbol (so as to provide direction to the out-of-sequence code).

CPT

Current Procedural Terminology; a listing of descriptive terms and identifying codes for reporting medical services and procedures

Parenthetical statements beginning with "eg" provide examples of terms that must be included in the health care provider's documentation of services/procedures performed (T/F)?

False. Do not have to be included in the health care provider's documentation.

types of presenting problems are recognized:

Five types: 1. Minimal (problem may not require the presence of the physician, but service is provided under the physician's supervision, such as a patient who comes to the office once a week to have blood pressure taken and recorded) 2. Self-limited or minor (problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status or that has a good prognosis with management/compliance, such as a patient diagnosed with adult-onset diabetes mellitus controlled by diet and exercise) 3. Low severity (problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected, such as a patient who is diagnosed with eczema and who does not respond to over-the-counter [OTC] medications) Moderate severity (problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis; increased probability of prolonged functional impairment, such as a 35-year-old male patient diagnosed with chest pain on exertion) 4. High severity (problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment; high probability of severe, prolonged functional impairment, such as an infant hospitalized with a diagnosis of respiratory syncytial virus)

The levels of E/M services code descriptions include seven components, six of which determine the level of E/M service code to be assigned:

History Examination Medical decision making Counseling Coordination of care Nature of presenting problem Time

Physical status modifiers are represented by __________________

Letter "P" followed by a single digit, from 1 to 6, as indicated below: -P1 (normal healthy patient; e.g., no biochemical, organic, physiologic, psychiatric disturbance) -P2 (patient with mild systemic disease; e.g., anemia, chronic asthma, chronic bronchitis, diabetes mellitus, essential hypertension, heart disease that only slightly limits physical activity, obesity) -P3 (patient with moderate systemic disease; e.g., angina pectoris, chronic pulmonary disease that limits activity, history of prior myocardial infarction, heart disease that limits activity, poorly controlled essential hypertension, morbid obesity, diabetes mellitus, type I and/or with vascular complications) -P4 (patient with severe systemic disease that is a constant threat to life; e.g., advanced pulmonary/renal/hepatic dysfunction, congestive heart failure, persistent angina pectoris, unstable/rest angina) -P5 (moribund patient who is not expected to survive without the operation; e.g., abdominal aortic aneurysm) -P6 (declared brain-dead patient whose organs are being removed for donor purposes).

Problem focused history

chief complaint, brief history of present illness or problem.

CPT Modifiers

The following CPT modifiers should be reviewed to determine whether they should be added to the reported Anesthesia section codes: -23 (unusual anesthesia) (When a patient's circumstances warrant the administration of general or regional anesthesia instead of the usual local anesthesia, add modifier -23 to the Anesthesia section code [e.g., extremely apprehensive patients, mentally handicapped individuals, patients who have a physical condition, such as spasticity or tremors].) -53 (discontinued procedure) -59 (distinct procedural service) -74 (discontinued outpatient hospital/ambulatory surgery center procedure after anesthesia administration) -99 (multiple modifiers)

Always report the comprehensive code rather than codes for individual components of a surgery (T/F)

True

Expanded problem focused history

chief complaint, brief history of present illness, problem-pertinent system review.

See

a cross-reference that directs coders to an index entry under which codes are listed. No codes are listed under the original entry.

Detailed history

chief complaint, extended history of present illness, problem-pertinent system review extended to include a limited number of additional systems, pertinent past/family/social history directly related to patient's problem.

Comprehensive history

chief complaint, extended history of present illness, review of systems directly related to the problem(s) identified in the history of the present illness, plus a review of all additional body systems and complete past/family/social history.

global surgery

also called package concept or surgical package; including: -Surgical procedure performed -Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia -One related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of the procedure (including history and physical) -Immediate postoperative care, including dictating operative notes, talking with family and other physicians, documenting postoperative orders, and evaluating the patient in the postanesthesia recovery area -Typical postoperative follow-up care, including pain management, suture removal, dressing changes, local incisional care, removal of operative packs/cutaneous sutures/staples/lines/wires/tubes/drains/casts/splints (however, casting supplies can usually be billed separately)

unlisted procedure

also called unlisted service: assigned when the provider performs a procedure or service for which there is no CPT code.

Face-to-face time

amount of time the office or outpatient care provider spends with the patient and/or family.

Unit/floor time

amount of time the provider spends at the patient's bedside and managing the patient's care on the unit or floor (e.g., writing orders for diagnostic tests or reviewing test results). => applies to inpatient hospital care, hospital observation care, initial and follow-up inpatient hospital consultations, and nursing facility services.

Instructional notes

appear throughout CPT sections to clarify the assignment of codes.

indented code

appears below a stand-alone code, requiring the coder to refer back to the common portion of the code description that is located before the semicolon. exp: Indented code description 27780 - Closed treatment of proximal fibula or shaft fracture; without manipulation 27781 - with manipulation

physical examination

assessment of the patient's body areas (e.g., extremities) and organ systems (e.g., cardiovascular).

Anesthesia time units

based on the total anesthesia time, and they are reported as one unit for each 15 minutes [or fraction thereof] of anesthesia time. For example, 45 minutes of anesthesia time equals three anesthesia time units. The number 3 is entered in Block 24G of the CMS-1500 claim.

The E/M section of CPT is organized according to: ________

categories (e.g., Hospital Inpatient Services), subcategories (e.g., Initial Hospital Care), and headings (e.g., New or Established Patient). Each category of E/M contains five-digit numeric codes ranging from 99201 to 99499.

(+) symbol

identifies add-on codes (Appendix D of CPT) for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure. Parenthetical notes, located below add-on codes, often identify the primary procedure to which add-on codes apply. exp: 22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical + 22216 each additional vertebral segment (List separately in addition to primary procedure).

🛇 The forbidden symbol:

identifies codes that are not to be used with modifier -51. These codes are reported in addition to other codes, but they are not classified as add-on codes.

Contributory components

include counseling, coordination of care, nature of presenting problem, and time; they are used to select the appropriate E/M service code when patient record documentation indicates that they were the focus of the visit.

extent of examination (CPT)

includes comprehensive, detailed, expanded problem focused, and problem focused levels, based on physician documentation.

extent of history (CPT)

includes comprehensive, detailed, expanded problem focused, and problem focused levels, based on physician documentation.

🗲 The flash symbol:

indicates codes that classify products that are pending FDA approval but have been assigned a CPT code (e.g., code 90668).

physical status modifier

indicates the patient's condition at the time anesthesia was administered

history

interview of the patient that includes the following components: history of the present illness (HPI) (including the patient's chief complaint), a review of systems (ROS), and a past/family/social history (PFSH).

★ The star symbol:

is used to identify codes that may be used to report telemedicine services when appended with modifier -95 (e.g., 90791-95).

Expanded problem focused examination

limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Problem focused examination

limited examination of the affected body area or organ system.

blocked unindented note

located below a subsection title and contains instructions that apply to all codes in the subsection.

indented parenthetical note

located below a subsection title, code description, or code description that contains an example.

CPT Appendices

located between the Medicine section and the Index

Typically, just one E/M code is reported each day by a provider for a patient. When a separately identifiable E/M service is provided in addition to a surgical procedure, the E/M code is reported with _______

modifier 25.

Codes identified with (+) are ________

never reported as stand-alone codes; they are reported with primary codes. Also, do not append add-on codes with modifier -51.

Transfer of care

occurs when a physician who is managing some or all of a patient's problems releases the patient to the care of another physician who is not providing consultative services.

new patient

one who has not received any professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

# The number symbol:

precedes CPT resequenced codes, which appear out of numerical order (e.g., code 99224).

Category I codes

procedures/services identified by a five-digit CPT code and descriptor nomenclature; these codes are traditionally associated with CPT and organized within six sections.

modifiers

provide additional information about a procedure or service (e.g., left-sided procedure).

Parenthetical notes within a code series ________

provide information about deleted codes. Such content does not have to be included in provider documentation.

coordination of care

provider makes arrangements with other providers or agencies for services to be provided to a patient.

Monitored anesthesia care (MAC)

provision of local or regional anesthetic services with certain conscious-altering drugs when provided by a physician, anesthesiologist, or medically directed CRNA; monitored anesthesia care involves sufficiently monitoring the patient to anticipate the potential need for administration of general anesthesia, and it requires continuous evaluation of vital physiologic functions as well as recognition and treatment of adverse changes.

Telemedicine

provision of remote medical care using an interactive audio and video telecommunications system that permits real-time communication between the provider, at the distant site (e.g., physician's office), and the beneficiary/patient, at the originating site (e.g., patient's home several hours driving distance away from the provider); an alternative to in person face-to-face encounters.

Concurrent care

provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day.

organ- or disease-oriented panels

series of blood chemistry studies routinely ordered by providers at the same time to investigate a specific organ (e.g., liver panel) or disease (e.g., thyroid panel).

CPT organizes Category I procedures and services within _______:

six sections: -Evaluation and Management (E/M) (99201-99499) -Anesthesia (00100-01999, 99100-99140) -Surgery (10021-69990) -Radiology (70010-79999) -Pathology and Laboratory (80047-89398, 0001U-0138U) -Medicine (90281-99199, 99500-99607)

Main Terms

standing alone or be followed by modifying terms; can represent: -Procedure or service (e.g., endoscopy) -Organ or anatomic site (e.g., colon) -Condition (e.g., abscess) -Synonyms, eponyms, and abbreviations (e.g., Bricker Operation, Fibrinase, EEG).

radiologic views

studies taken from different angles.

Radiology section includes:

subsections for diagnostic radiology (imaging), diagnostic ultrasound, radiation oncology, and nuclear medicine

Descriptive qualifiers

terms that clarify assignment of a CPT code. They can occur in the middle of a main clause or after the semicolon and may or may not be enclosed in parentheses.

Place of service (POS)

the physical location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, nursing facilities, home health care, or emergency departments); the two-digit location code is required by Medicare.

The professional component of a radiologic examination covers _______

the supervision of the procedure and the interpretation and documentation of a report describing the examination and its findings.

The technical component of an examination covers ______

the use of the equipment, supplies provided, and employment of the radiologic technicians.

how many categories of CPT codes?

three categories

"Notes" should be applied to all codes located under a heading (T/F)

true

multiple surgical procedures

two or more surgeries performed during the same operative session. The major surgical procedure (the procedure reimbursed at the highest level) should be reported first on the claim, and the lesser surgeries listed on the claim in descending order of expense. Modifier -51 is added to the CPT number for each lesser surgical procedure that does not have the symbol (🛇> or (+) in front of the code

Italicized type

used for the cross-reference term, See, in the CPT index.

semicolon (;) symbol

used to save space in CPT, and some code descriptions are not printed in their entirety next to a code number. Instead, the entry is indented and the coder must refer back to the common portion of the code description that is located before the semicolon. The common portion begins with a capital letter, and the abbreviated (or subordinate) descriptions are indented and begin with lowercase letters.

inferred words

used to save space in the CPT index when referencing subterms.

which symbol is not used for revised code descriptions?

▸◂ Horizontal triangles surround revised guidelines and notes.