CPT Coding in Oral Medicine

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1 CPT Coding in Oral Medicine

2

3 CPT - Current Procedural Terminology Medical Code Set ( ) Established as an indexing/coding system to standardize terminology among physicians and other providers Used with other codes to report healthcare services performed in the United States Copyrighted and maintained by the American Medical Association through the CPT Editorial Panel The current version is the CPT 2015

4 CPT Categories The CPT code set includes three categories of medical nomenclature with descriptors Five digit numerical code Over 7,000 service codes, plus titles and modifiers Mandatory to report for services and reimbursement

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8 Objectives of CPT Coding Provider - To prepare a standardized bill for services given to a patient Payer - To determine the amount to be paid to the provider

9 The CPT Coding Manual CPT Sections Section Guidelines Table of Contents Notes Category II codes (0001F-7025F) Category III codes (0019T-0318T) Appendices A-O Alphabetical Index

10 CPT Codes Examples: physical exam (E/M code) excision of mouth lesion trigger point injection orthopantomogram trigeminal diagnostic nerve block Service reimbursement will vary according to medical provider and insurance company

11 Minor surgical procedure with problem oriented E/M service The CPT codes for minor surgical procedures include preoperative evaluation services such as assessing the site or problem explaining the procedure and risks and benefits obtaining the patient s consent The Centers for Medicare & Medicaid Services (CMS) has clarified that the initial evaluation is always included in the reimbursement for a minor surgical procedure and, therefore, is not separately billable

12 Modifiers: Why use them? Modifiers can be the difference between full reimbursement and reduced reimbursement or denial While some payers differ in their use of modifiers, taking the time to learn the rules will pay off

13 Modifier 24 CPT suggests using it with an unrelated evaluation and management service by the same physician during a postoperative period So if a patient returns to the office within 10 days of the excision for an unrelated condition, you will need to append modifier 24 to the E/M service to get paid for the visit

14 Helpful Tip It is helpful to maintain an easily accessible list of the global periods for office-based procedures so you can remember whether a modifier is required

15 Modifier 59 Modifier 59 is used for distinct procedural services that wouldn't otherwise appear to be distinct that is, procedures and services that are not normally reported together, but are appropriately reported under the circumstances Medicare recognizes the modifier to indicate that two or more procedures are performed at different anatomic sites or different patient encounters

16 Modifier 59 For example, if you perform a destruction of a premalignant lesion (code 17000) on the same day you biopsy another lesion (code 11100), you will need to append modifier 59 to CPT code to indicate that the services were performed at different anatomic sites The CCI lists code combinations that are generally not reimbursed separately

17 Modifier 59 Private payers often use the CCI as a guide for their own bundling policies When reporting CPT codes with the designation separate procedure in conjunction with other procedure codes, be aware that these codes are often considered components of other services. If the procedures are distinct, then modifier 59 is required

18 Modifier 25 Modifier 25 is used to report a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service In some cases when an injection or drug administration code is reported, modifier 25 is required to distinguish the E/M service from the actual injection Remember, the modifier must be appended to the E/M code and the services must be clearly documented

19 Using the 25 modifier When you perform an Oh, by the way E/M service at the same visit as a procedure and the E/M service requires physician work above and beyond the physician work usually associated with the procedure, the E/M service may be billed in addition to the procedure, with modifier 25 attached to signal to the payer that both services should be paid

20 Helpful Tip You should consider including the most common modifiers on your superbill or in your EHR and plan to conduct periodic quality checks to make certain modifiers are being reported correctly

21 Missed Charges Busy practices can easily miss capturing charges for many of the services they provide Lab and other ancillary services are the ones most often missed, simply because the order may be verbally communicated to clinical or lab personnel

22 Missed Charges Injections are another area where charge capture errors tend to occur If your practice is administering injections and providing the injectable medications, you should be reporting two codes one for the administration and one for the medication The HCPCS codes for the medications include the name and the dosage for each unit of service Be sure your staff members understand how to determine the correct number of units to report

23 Location and Use of Superbills Failure to report an encounter in the emergency department is a sure way to miss getting reimbursed for the service Be sure your superbills make it easy for clinicians to capture services based in the hospital and nursing facility, and create a system for ensuring that all superbills are returned your billing office

24 GRU Center for Oral Medicine Superbill

25 AxiUm

26 Unlisted service or procedure A service or procedure may be provided that is not listed in this edition of the CPT codebook When reporting such a service, the appropriate Unlisted Procedure code may be used to indicate the service, identifying it by Special Report

27 Unlisted service or procedure Unlisted therapeutic procedure (specify) Unlisted modality Unlisted special service, procedure or report Unlisted physical medicine/rehabilitation service or procedure Therapeutic exercises Self-care/home management training Hot or cold packs

28 Special Report A service that is rarely provided, unusual, variable, or new may require a special report Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service

29 Supplied materials Supplies and materials (e.g., trays, drug supplies, and materials) over and above those usually included with the procedure(s) rendered are reported separately using code or a specific supply code

30 CPT Code Basics Review medical documentation thoroughly and gather additional reports Reference the alphabetical index for a CPT numerical code and/or code range Condition Procedure or service Anatomic site Synonyms, eponyms and abbreviations

31 CPT Code Basics Review the numerical code and/or code range for specific descriptions Follow CPT Guidelines, Conventions, and Iconology

32 Resources

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