CONTENTS FOREWORD... iii DISCLAIMER... iv THE AUTHOR...v INTRODUCTION...1 TERMINOLOGY...3 CPT & HCPCS FUNDAMENTALS...33 What is CPT?...33 What is HCPCS?...34 Key points regarding CPT & HCPCS... 34 Structure of the CPT Coding System...35 Structure of the HCPCS Coding System...35 How to Use the CPT Coding System...37 Format and conventions...37 Guidelines...38 Modifiers...38 Appendices...38 CPT Index...40 How to Use the HCPCS Coding System...42 Format and conventions...43 Guidelines...43 HCPCS Level II Modifiers...43 Coding rules for HCPCS...43 Medical and surgical supplies...44 HCPCS code overlap...44 Format of HCPCS codes...44 EXERCISE 1: CPT & HCPCS FUNDAMENTALS...44 GENERAL CODING & BILLING ISSUES...47 Supporting Documentation...47 Special Medicare Considerations...48 Bilateral Modifier Usage...48 Unlisted Procedures Or Services...48 CPT Changes, Additions And Deletions...49 vii
MEDICAL PROCEDURE CODING MADE EASY! HCPCS Changes, Additions And Deletions...50 Starred Procedures...52 Definition of New Versus Established Patient...52 Place (Location) Of Service...53 Hospital Care...53 Hospital Discharge...54 EXERCISE 2: CODING & BILLING ISSUES, PART 1...54 Referral...55 Separate Or Multiple Procedures...55 Multiple Surgical Procedures...56 Consultations...56 Emergency Services...56 Supplies And Materials Provided by the Physician...57 Procedure Down-Coding...59 Purchased Diagnostic Services...60 CPT Modifiers...61 HCPCS Modifiers...67 EXERCISE 3: CODING & BILLING ISSUES, PART 2...81 ANATOMICAL ILLUSTRATIONS...83 Plate 1 Skin And Subcutaneous Tissue Male...87 Plate 2 Skin And Subcutaneous Tissue Female...89 Plate 3 Skin And Subcutaneous Tissue Female Breast...91 Plate 4 Muscular System Anterior View...93 Plate 5 Muscular System Posterior View...95 Plate 6 Shoulder And Elbow Anterior View...97 Plate 7 Hand And Wrist...99 Plate 8 Hip And Knee...101 Plate 9 Foot And Ankle...103 Plate 10 Skeletal System Anterior View...105 Plate 11 Skeletal System Posterior View...107 Plate 12 Vertebral Column Lateral View...109 Plate 13 Respiratory System...111 Plate 14 Heart External And Internal Views...113 Plate 15 Vascular System...115 Plate 16 Digestive System...117 Plate 17 Urinary System...119 Plate 18 Male Reproductive System...121 Plate 19 Female Reproductive System...123 viii
CONTENTS Plate 20 Female Reproductive System Pregnancy, Lateral View...125 Plate 21 Brain, Base View...127 Plate 22 Nervous System...129 Plate 23 Right Eye Horizontal Section...131 Plate 24 The Ear...133 EVALUATION AND MANAGEMENT SERVICES...135 Classification Of Evaluation And Management Services...135 Subsection Information...136 Materials Supplied By The Physician...136 Definitions Of Commonly Used Terms...136 New And Established Patients...137 Chief Complaint...137 Concurrent Care...137 Counseling...138 History...138 System Review...139 Levels Of Evaluation And Management Services...139 Key Components...140 Contributory Components...143 Time...145 Diagnostic Testing Or Studies...146 Unlisted Services...146 Special Report...146 Clinical Examples...146 Modifiers...147 Choosing Evaluation And Management Codes...147 Office And Other Outpatient Services...150 Hospital Observation Services...152 Hospital Inpatient Services...153 Consultations...153 Emergency Services...154 Critical Care Services...155 Inpatient Neonatal and Pediatric Intensive Care...156 Nursing Facility Service...157 Domiciliary, Rest Home or Custodial Services...158 Home Medical Services...158 Prolonged Services...158 Case Management Services...159 Care Plan Oversight Services...159 Preventive Medicine Services...160 Newborn Care...160 ix
MEDICAL PROCEDURE CODING MADE EASY! Special Services And Reports...161 EXERCISE 4: EVALUATION & MANAGEMENT SERVICES...162 DOCUMENTATION GUIDELINES...165 What Is Documentation And Why Is It Important?...165 What Do Payers Want And Why?...166 General Principles Of Medical Record Documentation...166 Documentation Of E/M Services...167 Documentation Of History...168 Review Of Systems...171 Documentation Of Examination...173 General Multi-System Examination...177 Cardiovascular Examination...182 Ear, Nose And Throat Examination...185 Eye Examination...188 Genitourinary Examination...190 Hematologic, Lymphatic And/Or Immunologic Examination...194 Musculoskeletal Examination...197 Neurological Examination...200 Psychiatric Examination...203 Respiratory Examination...206 Skin Examination...209 Documentation Of The Complexity Of Medical Decision Making...212 Number Of Diagnosis Or Management Options...213 Amount And/Or Complexity of Data to be Reviewed...214 Risk Of Significant Complications, Morbidity Or Mortality...215 Documentation Of Encounter Dominated By Counseling Or Coordination Of Care...216 Table of Risk...217 EXERCISE 5: E/M DOCUMENTATION GUIDELINES...219 NATIONAL CORRECT CODING POLICY...221 History...221 Purpose...221 What Is Correct Coding?...222 General Correct Coding Policies...224 Coding Based Upon Standard Of Medical/Surgical Practice...225 Medical/Surgical Package...228 Evaluation & Management Services...232 x
CONTENTS Modifiers and Modifier Indicators...233 Standard Preparation/Monitoring Services...238 Anesthesia Service Included In The Surgical Procedure...239 HCPCS/CPT Procedure Code Definition...239 CPT Coding System and CMS Coding System Instructions...241 Separate Procedure...241 Family Of Codes...241 More Extensive Procedures...241 Sequential Procedures...243 Laboratory Panel...243 Misuse of Column Two Code with Column One Code...244 Mutually Exclusive Procedures...245 Gender Specific Procedures...245 Add-On Codes...245 Excluded Service...246 Unlisted Services Or Procedures...246 Modified, Deleted, and Added Code Pairs/Edits...247 Medically Unlikely Edits (MUEs)...248 EXERCISE 6: NATIONAL CORRECTING CODING POLICY...249 ANESTHESIA SERVICES...251 Guidelines...251 Subsection Information...251 Time Reporting...252 Physicians' Services...252 Materials Supplied By Physician...252 Separate Or Multiple Procedures...252 Special Report...252 Anesthesia Modifiers...252 Physical Status Modifiers...252 Other Modifiers...253 Qualifying Circumstances for Anesthesia...254 Correct Coding Guidelines...254 SURGERY SERVICES...265 Guidelines...265 Physicians' Services...265 Listed Surgical Procedures...265 Follow-Up Care...265 Materials Supplied By Physician...266 xi
MEDICAL PROCEDURE CODING MADE EASY! Multiple Surgical Procedures...266 Order Of Listing...266 Billing Full Versus Reduced Fees...266 Separate Procedure...267 Subsection Information...267 Unlisted Service Or Procedure...267 Special Report...268 Modifiers...268 Add-On Codes...269 Starred Procedures...269 Surgical Destruction...269 Integumentary System...269 Wound Repair...281 Free Skin Grafts...283 Musculoskeletal System...283 Grafts Or Implants...293 Reconstruction Oral and Facial Deformities...293 Cast Application...293 Arthroscopy...293 Respiratory & Cardiovascular System Correct Coding Guidelines...294 Respiratory System...295 Cardiovascular System...299 Vascular Injection Procedures...305 Hemic And Lymphatic Systems...305 Digestive System...308 Urinary System...319 Urodynamics...327 Cystoscopy, Urethroscopy, and Cystourethroscopy...328 Male Genital System...328 Female Genital System...329 Maternity Care And Delivery...330 Endocrine System...332 Nervous System...332 Eye And Ocular Adnexa...341 Auditory System...342 EXERCISE 6: ANESTHESIA AND SURGERY...343 RADIOLOGY SERVICES...345 Guidelines...345 Subject Listings...345 Separate Or Multiple Procedures...345 xii
CONTENTS Subsection Information...345 Complete Procedures...346 Supervision And Interpretation Only...346 Modifiers...346 Bilateral Procedure Codes...347 Correct Coding Guidelines...347 Diagnostic Ultrasound...356 Radiation Oncology...357 Nuclear Medicine...358 HCPCS Equipment Transportation Codes...359 PATHOLOGY & LABORATORY...361 Guidelines...361 Services Pathology And Laboratory...361 Subsection Information...361 Modifiers...361 Organ Or Disease Panels...362 Pathology Consultations...362 Surgical Pathology...362 Correct Coding Guidelines...363 EXERCISE 7: RADIOLOGY AND LABORATORY...373 MEDICINE SERVICES...375 Guidelines...375 Multiple Procedures...375 Separate Procedures...375 Subsection Information...375 Unlisted Service Or Procedure...376 Modifiers...376 Special Report...377 Materials Supplied By Physician...377 Correct Coding Guidelines...377 Immune Globulins...383 Immunization Administration for Vaccines/Toxoids...383 Vaccines, Toxoids...384 Therapeutic or Diagnostic Infusions...384 Therapeutic, Prophylactic, or Diagnostic Injections...384 Drugs Other Than Oral Method...389 Psychiatry...390 Biofeedback...391 xiii
MEDICAL PROCEDURE CODING MADE EASY! Dialysis...391 Gastroenterology...392 Ophthalmology...393 Otorhinolaryngologic Services...395 Cardiovascular Services...397 Non-Invasive Vascular Studies...397 Pulmonary Services...402 Allergy And Immunology...404 Neurology and Neuromuscular Procedures...406 Central Nervous System Assessments/Tests...407 Chemotherapy Administration...408 Physical Medicine and Rehabilitation...410 Medical Nutrition Therapy...412 Acupuncture...412 Osteopathic Services...413 Chiropractic Services...413 Special Services And Reports...415 Home Health Procedures/Services...418 CPT Category III Codes...418 Transportation Services...418 Miscellaneous And Experimental...418 Rehabilitative Services...419 Temporary Codes...420 EXERCISE 9: MEDICINE SERVICES...420 APPENDIX A: ANSWERS TO EXERCISES...423 INDEX...433 xiv
INTRODUCTION Coding is the language of medical billing and reimbursement. Fluency in this language is required for all medical personnel involved in the processes of billing for medical services, chart abstracting, coding, medical transcription, and reimbursement management. If the insurance billing staff is not fluent in this language, the practice will not receive the reimbursement it deserves and audit liability will increase. If hospital coders and patient accounting personnel are not fluent in this language, the hospital will not be paid properly and likewise may find itself with higher audit liability. If health insurance company claims processing personnel are not fluent in this language, claims processing errors may be made which result in improper denial or low payment of claims, or improper payment or overpayment of claims. To a beginning coder, the coding and reimbursement process may appear at first to be simple and easy. Just find out what the doctor did for the patient, take a CPT book, look up the procedure and get the CPT code. Then find out what the doctor s diagnosis is, take an ICD-9-CM book, look up the diagnosis and get the ICD-9-CM code. Print out a CMS1500 health insurance claim form... mail it in...and get paid. What could be easier than that? Experienced coders know that the process of selecting the correct CPT, HCPCS and ICD-9-CM codes to report medical services and procedures is actually very complicated and complex. Not only do you have to select the correct CPT or HCPCS and ICD-9-CM codes, you have to know: How to interpret, decipher, and transfer medical acronyms, eponyms and abbreviations and terminology. When to use HCPCS procedure codes instead of CPT procedure codes. When to use CPT or HCPCS modifiers. How to sequence multiple procedure codes properly when completing health insurance claim forms. How to sequence multiple ICD-9-CM diagnosis codes. When a medical report is required to support your procedures. If a procedure is covered by Medicare. If there are special billing rules or payment policies for Medicare or other health insurance payer. And a variety of other rules, regulations, policies and procedures. Medical Procedure Coding Made Easy! is designed to answer the most common coding, compliance, coverage, reimbursement and terminology questions encountered by medical coding personnel involved in procedure coding. Selection of the proper CPT and/or HCPCS procedure codes has a tremendous 1
MEDICAL PROCEDURE CODING MADE EASY! impact on reimbursement for the medical practice. In addition, proper reporting of CPT and/or HCPCS codes helps to protect your medical practice in the event of an audit by Medicare or other health insurance carriers. The CPT coding system provides a uniform coding language that accurately describes medical, surgical and diagnostic procedures and services, and provides an effective means for reliable communication among physicians, hospitals, and health insurance companies. The CPT coding system is maintained by the American Medical Association (AMA). Each year the CPT coding system is revised and numerous codes are added, deleted or descriptions revised. HCPCS Level II coding system provides a uniform coding language for reporting durable medical equipment, orthotics, prosthetics, supplies, materials and injections to the Medicare program. HCPCS Level II also includes codes for procedures and services that are not included in the CPT coding system. Codes from either system may be reported independently or together, depending upon the status of the patient. The HCPCS coding system is maintained by the Centers for Medicare and Medicaid (CMS). Each year the HCPCS coding system is revised and codes are added, deleted or descriptions revised. You should always use the most current edition of the HCPCS coding system. Once you have chosen the correct CPT and/or HCPCS procedure codes to report medical services and procedures, you also have to choose ICD-9-CM diagnosis codes that support the reason that the procedure was performed. For a comprehensive tutorial on diagnosis coding, consider our companion guide, ICD-9-CM Coding Made Easy!. Medical Procedure Coding Made Easy! begins with a comprehensive list of common terms and definitions used in the coding and billing process, followed by chapters on CPT & HCPCS coding, documentation guidelines, the national correct coding initiative, and specific chapters regarding coding for evaluation and management services, anesthesia, surgery, radiology, laboratory and medicine services. While designed specifically for beginning coders, experienced coders will also find new material of interest and value. 2
TERMINOLOGY Understanding the coding and compliance process requires a fundamental working knowledge of the words and acronyms used by medical professionals, government agencies and health insurance carriers to describe services, benefits and reimbursement policies. While many publications place the terminology section in an appendix at the back of the book, we feel that you should have an opportunity to review and learn the terminology before you encounter it within the text itself. Following is a comprehensive list of billing, coding, compliance, HIPAA and reimbursement words, terms and acronyms, including some that may not appear in the text of the book. Ablation: The removal or destruction of a body part or tissue or its function. Ablation may be performed by surgery, hormones, drugs Abortion: The premature termination of a pregnancy; may be induced or spontaneous (miscarriage) Abrasion: A surgical procedure that involves the controlled abrasion (wearing away) of the upper layers of the skin with sandpaper or other mechanical means. Abstract: The collection of information from the medical record via hard copy or electronic instrument. Access: The ability to obtain needed medical care. Accident and health insurance: Health insurance under which benefits are payable in case of disease, accidental injury or accidental death. Actual charge: One of the factors determining a physician's payment for a service under Medicare; equivalent to the billed or submitted charge. See Customary, Prevailing and Reasonable. Acupuncture: The use of special needles, with or without electrical stimulation, inserted into specific areas of the body. Acute: Refers to the condition that is the primary reason for the current encounter. ADA : American Dental Association Addenda: Official updates to ICD-9-CM published continuously since 1986 that become effective on October 1st of each year. Add-on codes: Procedures listed in the CPT coding system that are commonly carried out in addition to the primary procedure performed. 3
MEDICAL PROCEDURE CODING MADE EASY! Adjusted historical payment basis (AHPB): The average historical payment in a specific locality for a specific service. Adjustment: A chiropractic term which describes the skilled application of force to a joint or motion segment to improve intersegmental motion, decrease localized muscle tension, and restore normal motion and position. Admission date: The date the patient was admitted for inpatient care, outpatient service, or start of care. For an admission notice for hospice care, enter the effective date of election of hospice benefits. Admitting diagnosis code: Code indicating patient's diagnosis at admission. Adverse: Any response to a drug that is noxious and unintended and occurs with proper dosage. AFDC: Aid to Families with Dependent Children Aftercare: An encounter for something planned in advance, for example, cast removal. AHFS: American Hospital Formulary Service. AHPB: Adjusted Historical Payment Basis Allergy and Immunology: The section of the CPT coding system that includes codes for allergy testing and the preparation and administration of antigens. Allograft: A transplant process wherein a tissue or organ is taken from one individual (donor) and placed into another (recipient) Allowed charge: Payment for a physician service under the customary, prevailing and reasonable system; includes the payment from Medicare and the beneficiary's coinsurance, but not any balance bill. See Balance Bill; Coinsurance; Customary, Prevailing and Reasonable. Alphabetic index: The portion of ICD-9-CM that lists definitions and code sets in alphabetic order. Also referred to as Volume 2. AMA: American Medical Association Ambulatory Surgical Center (ASC): A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. 4