CODING BLOCK 1/CPT BOOK
3. Advanced practice nurses and physician assistants independently report professional services.
Advanced practice nurses and physician assistants work with physicians but are independent practitioners who may separately report the procedures or services they provide. Advanced practice nurses and physician assistants are considered as working in the exact same specialty and sub-specialty as the physician they are working with. These professionals are distinct from clinical staff who work under the supervision of a physician or other qualified healthcare provider, but do not individually report professional services.
2. Codes are not strictly classified as surgical or non surgical based on the section of the book where they appear.
Advances in medicine such as minimally invasive surgery and traditionally open procedures now being performed endovascularly, endoscopically or percutaneously have challenged the distinction between surgical vs medical procedures. The listing of a service or procedure in a specific section of the book should not be strictly interpreted as classifying the service or procedure as surgical vs non surgical for insurance or other purposes.
Appendix A - Modifiers
Appendix A contains a list of all of the modifiers. Modifiers are used to provide additional information about a procedure or service. A detailed description of when to use each modifier is listed in this appendix. A list of all of the modifiers is also included on the inside cover of the CPT codebook. Each of these modifiers will be discussed in detail in the next unit. Read the introductory text in Appendix A.
Appendix B - Summary of Additions, Deletions, and Revisions
Appendix B is a summary of codes that have been added to, deleted from, or revised in the CPT codebook from previous editions. Read the introductory paragraph for Appendix B. Code added = red circle Revised code = blue triangle Strikethrough indicates deleted text Underlined indicates new text
Appendix C - Clinical Examples
Appendix C contains coding examples to assist in the selection of the Evaluation and Management codes. Examples are provided for the following subsections: Office or Other Outpatient Services, Hospital Inpatient Services, Subsequent Hospital Care, Consultations, Emergency Department Services, Critical Care Services, Prolonged Services, and Care Plan Oversight Services. Read the introductory paragraphs for Appendix C. You will work through and learn to apply some of these examples when you study Evaluation and Management codes.
Appendix D - Summary of CPT® Add-on Codes
Appendix D contains a complete listing of the add-on codes. As previously discussed, the add-on codes are identified with a + symbol next to the code. Add-on codes can never be primary or first-listed codes.
Appendix G - Summary of CPT® Codes that Include Moderate (Conscious) Sedation
Appendix G is a list of codes that include conscious sedation as an inherent part of the procedure. In some cases conscious sedation is an inherent part of a procedure and in other cases conscious sedation is an added service not routinely associated with the procedure. Coding for these two situations differs. Appendix G is the summary of codes where conscious sedation is included in the procedure code. Read the introductory paragraphs for Appendix G. You will have the opportunity to apply codes with conscious sedation in upcoming units.
Appendix H - Alphabetic Index of Performance Measures by Clinical Condition or Topic
Appendix H is used in conjunction with Category II codes. Please note that Appendix H has been removed from the CPT Codebook and in order to review it you must access it on the AMA website at http://www.ama-assn.org/go/cpt.
Appendix I - Genetic Testing Code Modifiers
Appendix I contains a list of modifiers reported with molecular laboratory procedures related to genetic testing. From that description, you can imagine Appendix I is not used in your everyday, run-of-the-mill outpatient encounter. Appendix I will be used in CPT® and HCPCS coding when specific genetic information needs to be reported. Read the introductory paragraphs for Appendix I. You will cover Genetic Testing Code Modifiers in more detail in your study of Modifiers.
Appendix J - Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves
Appendix J is a helpful reference for identifying what nerves belong to what nerve system. Notice the appendix is organized in an outline format under main headings: Motor Nerves Assigned to Codes 95900 and 95907-95913 Upper extremity, cervical plexus, and brachial plexus motor nerves Lower extremity motor nerves Cranial nerves and trunk Nerve roots Sensory and Mixed Nerves Assigned to Code 95907-95913 Upper extremity sensory and mixed nerves Lower extremity sensory and mixed nerves Head and trunk sensory nerves If you have documentation in a medical report a patient had a procedure performed on the peroneal nerve to the extensor digitorum brevis, Appendix J helps you identify that the peroneal nerve to the extensor digitorum brevis is part of the peroneal (fiber) nerve system in the lower extremity motor nerve system. Once you identify the nerve system to which a nerve belongs, you can assign it to the correct reporting code, 95907—95913. Find the deep peroneal sensory nerve. What nerve system does it belong to? What code category would it be assigned to? You will learn more about coding electrodiagnostic medicine procedures in a future unit.
Appendix K - Product Pending FDA Approval
Appendix K is a list of vaccine products assigned a CPT® code that are waiting for approval by the Food and Drug Administration (FDA). As you can imagine, the fact that a vaccine or drug has not been approved but is used is an important piece of information to report. Pharmacy/drug coding will be the topic of a future unit.
Appendix L - Vascular Families
Appendix L, like Appendix J, is a helpful reference to assist the medical coder in deciding where a piece of information fits for coding purposes. In Appendix J it was nerves; in Appendix L it is veins and the vascular system. When the medical coder has documented information for a procedure on a vessel, Appendix L helps the coder determine where the vessel fits in the vascular tree and to what main branch it belongs. This information is necessary to apply the proper code. Find the left ulnar vessel on the chart. Knowing only the name of the vessel—left ulnar—you can determine the left ulnar is a third order branch off the left deep brachial in the left subclavian and axillary vascular family. The introductory paragraph and footnotes provide additional important information on the use of the Vascular Families chart.
Modifiers
At times, the CPT code may not fully describe the procedure or service provided. Append a modifier needs to the CPT code when necessary to accurately describe the procedure or service. The complete list of modifiers and the circumstances for their use can be located in Appendix A of the CPT codebook.
Special Report Certain services are rare or infrequently provided, unusual, variable, or new. A special report must be submitted with the claim form to determine medical appropriateness of the service. The following information should be included in this report:
Description of nature, extent, and need for the procedure Time, effort, and equipment Complexity of symptoms Final diagnosis Pertinent physical findings Diagnostic and therapeutic procedures Concurrent problems Follow-up care When an unlisted procedure code is reported, the provider of the service must furnish supporting documentation (e.g., procedure report) along with the claim and a cover letter to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.
Some services and procedures performed by physicians are not found in the CPT® codebook. When you cannot find a code accurately describing a service or procedure performed and documented by the physician, you should report an unlisted code.
Example: Transurethral lysis of intraluminal bladder adhesions. Turn in the index to the main term lysis. Under the main term lysis, look for the sub-term bladder. There is no sub-term of bladder listed. Since there is no code listed for the lysis of bladder adhesions, you need to report an unlisted procedure code. To locate the unlisted procedure code, turn to the main term bladder and the sub-term unlisted services and procedures. The code listed is 53899. Turn to the "Numeric Section" to read the description of this code. The description is unlisted procedure, urinary system.
Modifiers
Modifiers provide additional information to the third-party payer about the services provided to a patient. There are times when the 5-digit CPT code may not totally reflect the service or procedure provided. In these instances a modifier is appended to the CPT code to provide further specificity. The inside cover of the CPT book and Appendix A provide a complete list of the modifiers. Modifiers will be discussed in detail in the next unit of this module. For the time being, think of modifiers as being similar to 4th - 7th characters in ICD-10-CM coding. Modifiers provide additional information to describe exactly what's happening with the patient.
The Place of Service and Facility Reporting instruction includes two important definitions.
Nonfacility: Describes services where no facility reporting may occur. Facility: Facilities are entities that may report services in addition to the physician or qualified healthcare professional.
4. Read and apply all instructional notes.
Notes and instructions are inserted for a reason. They provide guideposts and warning signs and additional information to help you make the best code selections as quickly and efficiently as possible. Take the habits you developed in ICD-10-CM coding and apply them as you work through CPT coding. Read ALL pertinent information; this practice will save you time in the long run and help you be a quality coder. The rest of the headings in the Introduction are subheadings under the Instructions for Use of the CPT Codebook. Each of the subheadings (in red) contains instructional material—a guide to CPT coding. You will work through these in the next several lessons, but should refer to them often as you begin the practical application of CPT codes.
A sequence of events occurs as a result of a test. The four steps in this sequence are:
Testing Results Interpretation Reports Let's see how this would appear in an example: Testing: Film exposed to x-rays Results: X-ray picture Interpretation: Physician reads x-ray Report:Impression — Normal chest
Appendix E - Summary of CPT Codes Exempt from Modifier 51
The modifier 51 is used to indicate multiple procedures that are performed during the same session by the same physician. The codes listed in Appendix E are all exempt from use of modifier 51. Read the introductory paragraph for Appendix E. You will learn more about modifiers and how they work when you study modifiers in an upcoming unit.
Appendix F - Summary of CPT Codes Exempt from Modifier 63
The modifier 63 is used to indicate procedures performed on infants less than 4 kg. The codes listed in this appendix are exempt from the use of modifier 63. Codes that are exempt from modifier 63 are identified by the parenthetical instruction "(Do not report modifier 63 in conjunction with ...)." Read the introductory paragraph for Appendix F. You will learn more about modifiers as you study modifiers in an upcoming unit. You should notice the cross-check, cross-reference system used in CPT (just like it was in ICD-9). Turn to codes 30540 and 30545 and read the note in parentheses. The "Numeric Section" notes the information modifier 63 should not be used with these codes and Appendix F reiterates this instruction.
Add on codes
The plus symbol symbol has an important meaning in coding. The plus symbol symbol identifies a code that MAY be added to the primary procedure but CANNOT stand alone. Read the Add-on Codes instructional notes in the Introduction.
Appendix N - Summary of Resequenced CPT Codes
This appendix contains a list of codes that do not appear in numeric sequence in the numeric portion of the CPT codebook. These codes are identified with the symbol # to indicate that these codes are out of numeric sequence.
Appendix O - Multianalyte Assays with Algorithmic Analyses
This appendix includes a list of Multianalyte Assays with Algorithmic Analyses (MAAA). These lab procedures are typically proprietary to a specific lab or manufacturer. These codes are administrative in nature and include the names of the particular lab or manufacturer connected to the procedures.
Appendix M - Crosswalked Deleted CPT Codes
This appendix lists a summary of the deleted and renumbered codes and descriptions and crosswalks them to the current CPT codes. Crosswalk is just a fancy way of indicating that deleted codes appear in a new way in the current CPT book, under new codes, code categories, and/or with new descriptions. The process of deleting and reassigning procedures to new codes was only done from 2007-2009. This was done to try and keep codes in sequential order but that process has been discontinued.
Time
Time is measured as the face-to-face time with the patient Charting and reporting are not counted as part of the time Once time has hit 31 minutes or more it is counted as one hour If a patient is seen for 2 hours and 31 minutes it is coded as 3 hours If a patient is seen for 78 minutes it is coded as 1 hour If a continuous service lasts beyond midnight you will still add up the total time for that continuous service and assign the appropriate code. A new day does not mean you must start over with a new code and time.
1. Additional codes
Turn to code 49180 and read the code description.
TO DO:
Turn to the beginning of the Surgery section. Find the guideline called CPT® Surgical Package Definition. This guideline is applied to all the codes listed in the Surgery Section.
1. Select the name of the procedure or service that accurately identifies the service performed.
Where have we heard something like this before? With ICD-10 diagnosis coding! Just as the diagnosis codes selected should describe as accurately and thoroughly as possible the documented diagnoses, the procedure (CPT) codes should accurately and thoroughly describe the documented treatments, procedures, and services received by the patient. "Kinda close" is not close enough in CPT coding. The selected code(s) should describe the service. If a code does not exist that accurately describes the procedure/treatment, then the coder must use the appropriate unlisted code. (You will learn more about unlisted codes later.) The important thing to drum into your head now is that codes must accurately reflect what is documented in the record.