The learning objectives for this chapter include: List the sections of the CPT manual, giving the code range for each, describe briefly each of the CPT’s general guidelines, list the types of EM Codes within the CPT, list the areas included in the Surgical Coding Section,...
CHAPTER 19 Procedure Coding 19-2 Learning Outcomes (cont.) 19.1 List the sections of the CPT manual, giving the code range for each 19.2 Describe briefly each of the CPT’s general guidelines 19.3 List the types of E/M Codes within the CPT 19.4 List the areas included in the Surgical Coding Section 19-3 Learning Outcomes (cont.) 19.5 Locate a CPT code using the CPT manual 19.6 Explain how to locate a HCPCS code using the HCPCS coding manual 19.7 Explain the importance of code linkage in avoiding coding fraud 19-4 Introduction • Procedural coding – Translate medical procedures and services into codes – Explains what services were provided • Code “linkage” with diagnostic codes • Maximum reimbursement 19-5 The CPT Manual • Procedure code • • Medical procedures and services Based on encounter form or patient record • Current Procedural Terminology (CPT) – HIPAA-required code set – Published by the AMA – Updated annually – Use the appropriate CPT based on date of service 19-6 Organization of the CPT Manual Section Range of Codes Evaluation and Management 99201 – 99499 Anesthesiology 00100 – 01999 99100 – 99140 Surgery 10021 – 69990 Radiology 70010 – 79999 Pathology and Laboratory 80048 – 89356 Medicine 90281 – 99602 99500 – 99602 19-7 Organization of the CPT Manual (cont.) • Manual Introduction – General instructions – Information about common • Prefixes • Suffixes • Word roots • Guidelines for each section 19-8 Organization of the CPT Manual (cont.) • Sections – Guidelines at beginning – Categories headings • Page – Section name – Subsection name – Subheading – Category 19-9 Apply Your Knowledge Match CPT section to number range Evaluation and management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine (except for Anesthesia) ANSWER: 70010-79999 00100-01999 99100-99140 99201-99499 90281-99199 99500-99602 80048-89356 10021-69990 19-10 General CPT Guidelines • Code format – 5-digit numeric code – Stand-alone unless description contains a semicolon • Add-on codes – Additional procedures – Indicated by plus sign (+) – Indented codes 25500 Closed treatment of radial shaft fracture; without manipulation 25505 with manipulation 19-41 The HCPCS Coding Manual (cont.) • HCPCS Level II codes – National codes for supplies and DME – Cover services and procedures not in CPT – characters ~ numbers, letters, or a combination of both – Modifiers 19-42 The HCPCS Coding Manual (cont.) • Coding procedures – Locate service in the Alphabetic Index – Verify description in the alphanumeric Index – Choose code that matches service, procedure, or item supplied – Enter on CMS-1505 form or into the billing program 19-43 Apply Your Knowledge What are HCPCS Level II codes and who issues them? ANSWER: HCPCS Level II codes are national codes used for supplies, DME, and services not included in the CPT They are issued by Centers for Medicare and Medicaid Services (CMS) 19-44 Coding Compliance • Physician – ultimate responsibility • Medical assistants – Submit correct claims – Help ensure maximum appropriate reimbursement • Claims must comply with – Federal and state law – Payer requirements 19-45 Code Linkage • Analysis of the connection between diagnostic and procedural information to evaluate medical necessity Diagnostic Codes Procedural Codes 19-46 Code Linkage (cont.) • Codes are checked against the medical documentation • Coding audit: – Are codes appropriate and is each coded service billable? – Is code linkage correct? – Have rules ben followed? – Does documentation support services? – Do reported services comply with regulations? 19-47 Insurance Fraud • Investigators look for patterns such as – Reporting services that were not performed – Reporting services at a higher level – Performing and billing for procedures not related to the patient’s condition and therefore not medically necessary 19-48 Insurance Fraud (cont.) • Patterns (cont.) – Unbundling – Reporting the same service twice • Copayments – Waiver may violate payer policies – Ensure policies are consistent with law and requirements of payers 19-49 Compliance Plans • Process for finding, correcting, and preventing illegal medical practices • Goals of compliance plan – Prevent fraud and abuse – Ensure compliance with applicable laws – Help defend physicians if investigation occurs 19-50 Compliance Plans (cont.) • Developed by a compliance officer and committee who also: – Audit and monitor compliance with government regulations – Develop consistent written policies and procedures – Provide ongoing staff training and communication – Respond to and correct errors 19-51 Apply Your Knowledge Why is code linkage important? ANSWER: Code linkage will ensure clean claims in which each reported service is connected to a supporting diagnosis 19-52 In Summary 19.1 The sections for the CPT manual are Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology and Laboratory, and Medicine with code ranges from 00100-99602 19.2 A CPT code is a 5-digit code representing the service provided to the patient The CPT manual general guidelines include symbols which represents important information about the code being described Always begin coding by looking up the description in the Alphabetic Index and verifying in the Tabular (numeric) List Carefully read all guidelines and information surrounding the codes 19-53 In Summary (cont.) 19.3 The E/M code types include: office and other outpatient services as well as other E/M services 19.4 Surgical Coding sections include major body systems, radiology, pathology and lab, and medicine 19.5 Students should be able to select an accurate code using the CPT manual for simple, straightforward coding scenarios 19-54 In Summary (cont.) 19.6 Students should be able to select an accurate code using the HCPCS manual for simple, straightforward coding scenarios 19.7 Code linkage demonstrates the medical necessity of services provided to the patient by accurately linking each procedure code to its appropriate diagnosis All procedures, services, and diagnoses must be documented in the patient’s medical record to be used on any health insurance claim form 19-55 End of Chapter 19 Screen captures of SpringCharts™ Electronic Health Records software are reprinted with permission from Spring Medical Systems, Inc All rights reserved Things gained through unjust fraud are never secure ~ Sophocles ... code using the HCPCS coding manual 19. 7 Explain the importance of code linkage in avoiding coding fraud 19- 4 Introduction • Procedural coding – Translate medical procedures and services into codes... – Complexity of medical decision-making 19- 29 Surgical Coding • The surgical package – All procedures normally a part of an operation • Preoperative exam and testing • Surgical procedure • Routine... provided • Code “linkage” with diagnostic codes • Maximum reimbursement 19- 5 The CPT Manual • Procedure code • • Medical procedures and services Based on encounter form or patient record • Current Procedural