Coding Basics

ASDIN Coding Committee

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CPT Codes

• CPT stands for Current Procedural Terminology• Current Procedural Terminology refers to a listing of

descriptive terms and identifying 5 digit codes for reporting medical services and procedures performed by physicians

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CPT

• CPT codes and their descriptors are created by the AMA CPT Editorial Panel assisted by the AMA CPT Advisory Committee

• The CPT codes are owned by the AMA• They have been adopted as a standard by CMS

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CPT Advisory Committee

• This committee plays a very important role in the creation and description of CPT codes

• It is made up of representatives of all of the appropriate speciality societies

• The RPA represents interventional nephrologists on this committee

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Requirements for Representation

• Representation on the CPT advisory committee is critically important

• In order to have representation on the committee, at least 50% of RPA members must be members of the AMA

• In order for RPA to represent interest of ASDIN, at least 50% of our members must be members of RPA

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RBRVS• RBRVS stands for Resource-Based Relative Value Scale • This is a schema used to determine how much medical

providers should be paid by CMS for any given code• RBRVS assigns procedures relative value units (RVU)

which are adjusted by geographic region• This value is then multiplied by a fixed conversion

factor, which changes annually, to determine the amount of payment

• RBRVS determines prices based on three separate factors: – physician work (52%)– practice expense (44%), and – malpractice expense (4%)

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• CMS is mandated to make appropriate adjustments to the RBRVS in response to the Omnibus Budget Reconciliation Act of 1989 to account for changes in medical practice coding and new data and procedures

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RUC Committee

• RUC stands for AMA/Specialty Society Relative Value Scale Update Committee (RUC)

• This committee acts as an expert panel in developing RVS update recommendations to CMS in making adjustments to the RBRVS

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Make-Up of RUC Committee

• The committee has 31 members• The AMA Board of Trustees selects the RUC chair

and also the AMA representative to the RUC• The individual RUC members are nominated by the

specialty societies and are approved by the AMA • Nephrology representation on this committee is

through an Internal Medicine representative

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CPT Codes

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CPT Codes

• Each code is unique and consists of 5 digits• The first digit of each code is determined by its

category– 3 XXXX indicates a surgical (or procedural) code– 7XXXX indicates a radiological code– 9XXXX indicates a medical code

• However, any of these codes can be used by any type of physician, they are not restricted to a speciality

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Component Coding

• This is a process by which multiple codes (a list) are used for a single patient encounter

• This list may differ somewhat from one encounter to another based upon what was actually done

• For example in performing a thrombectomy, there are a few basic codes that are always used, but in an individual case something additional might be required resulting in an additional code being added to the list

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Documentation

• Documentation is an important part of the coding of a procedure

• It is critical that what was done be documented in a manner that can be easily understood by another person who might have a reason to read the operative report

• If the documentary evidence does not support the coding, it is problematic

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Add-On Codes

• Add-on codes enable separate identification of a service that is performed in certain situations as an additional component or as a commonly performed supplemental service to the primary service/procedure that was performed

• For example if an access is cannulated, the basic code is 36147. However, at times it is necessary to cannulate a second time. This warrants a second code + 36148. In this situation the second cannulation is an add-on code

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More on Add-On Codes• CPT designates the codes that are considered add-on

codes• These codes are identified with a “+” sign (+36148) • In addition, the code descriptors contain some variation

of the phrase “List separately in addition to code for primary procedure.”

• An add-on code is not a stand-alone code, it can not be used except with the primary code

• They are exempt to the depreciated value that occurs when multiple procedures

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NCII Edits

• NCII stands for the National Correct Coding Initiative• NCII edits are published from time to time to clarify

how certain codes are to be applied• A series of NCII edits has been published dealing

with pairs of codes when used together:– Column 1/Column2 edits– Medically unlikely edits

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Column 1/Column 2 Edits

• These edits get their name from the table in which the code-pairs appear

• The CPT code appearing in Column 1 is the payable service

• The code in Column 2 is the non-payable code (unless it is qualifies for an appropriate modifier)

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• In effect, the edit bundles the Column 2 service into the Column 1 service when either:– The Column 2 procedure is an integral part of Column 1

(comprehensive), or when – The Column 1 and Column 2 procedures could not

reasonably, based on medical necessity, be provided to the same patient on the same day by the same physician

• However, in some cases the Column 2 code can be used with a modifier

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• In the printed version of these edits there are 6 columns

• Only 3 are of importance to us– Column 1 is the payable code in the edit pair – Column 2 is the non-payable code in the edit pair – Column 6 shows whether exceptions are allowed for

billing the code pair (the use of a modifier)

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• Column 6 will have either a “0” or a “1” – “0” – indicates that the two are mutually exclusive, the

column 2 code can not be used with the Column 1 code– “1” – indicates that the Column 2 code can be used with

Column 1 but only with an appropriate modifier attached

• The modifier most frequently applied is 59

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Examples

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• It should be noted that the same code can be a column 1 code when paired with one code and a column 2 code when paired with a different code

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Medically Unlikely Edits (MUE)

• An MUE for a CPT code sets the maximum number of units that a physician can report under most circumstances for a single patient on a single date of service

• These are ordinarily based upon the natural anatomic limits

• If the MUE is “2,” no more than 2 units of that code can be used for a single patient on a single date of service

• It should be noted that not all CPT codes have MUEs associated with them

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Example

• 35476 (venous angioplasty) has an MUE of 2 for a dialysis access case

• This means that this code can only be used 2 times for each individual patient on a single day of service

• However, 35476 can only be used 1 time within the access (MUE of 1) and 1 time within the central veins (MUE of 1)

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Use of Dx and Tx RS&I Codes Together

• Vascular diagnostic and therapeutic procedures often are performed at the same encounter

• Each of these may be associated with a radiological supervision and interpretation code (RS&I)

• When a diagnostic RS&I code is used in association with a therapeutic RS&I code, a -59 modifier should be attached to the diagnostic RS&I code

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Example

• Procedure - embolization coil followed by a post-coil angiogram via catheter

• Codes for the coil placement - 37204 and 75894 – 75894 is a therapeutic RS&I

• Code for the angiogram - 75898-59 – 75898 is a diagnostic RS&I

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Lower Extremity Revascularization (LER) Codes

• In most instances, the coding guidelines for the upper and lower extremity are the same

• An exception to this rule occurs when arterial work is performed in the lower extremity

• In this instance the LER rules apply

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Global Period

• A number of the procedures that are performed have global periods

• This is a period of time following a procedure during which services provided by the physician related to the original procedure are considered to be included in the reimbursement and cannot be separately reported

• For our purposes, this means that if the same procedure is repeated during this period, it is not covered

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Global Period Examples

• 36870 (thrombectomy) - 90 days• 36565 (tunneled catheter placement) – 10 days• 36581 (tunneled catheter exchange) – 10 days• 36589 (tunneled catheter removal) – 10 days• 49421 (insertion of peritoneal catheter) – 90 days• 49422 (removal of peritoneal catheter) – 10 days

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Definitions

• The definition of what constitutes a repeat procedure is important

• Examine the following two scenarios:

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Scenario 1

Day 1 - A patient had a thrombectomy - flow was restoredDay 2 – At dialysis, the access was found to have thrombosed again. The patient returned to the center where it is found that a stenotic lesion had been missed and that a clot had formed distal to the lesion. A repeat thrombectomy was performed

This procedure should not be reported, it is a continuation of the original which was incomplete – it is within the global period.

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Scenario 2Day 1 - A patient had a thrombectomy - flow was restoredDay 4 –The access thrombosed again following a prolonged period of hypotension. The patient returned to the center and a thrombectomy was performed. There was no evidence of stenosis present. The only apparent cause for the event was the hypotension.

The procedure can be reported. This is not a continuation of the previous procedure, but a new event related to the hypotension. The global period would not apply.36870 should be reported with a 79 modifier to indicate that this is an unrelated procedure

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Professional and Technical Services• Some radiology services (7xxxx codes) are eligible for

the separate payment of professional and technical components– Applies only to hospital, not ASC or office site of service– Used if physician does not own or is not employed by the

facility• Modifier– 26 Physician services only– TC Technical component only

• No modifier (Global designation)– Used if the physician owns or is employed by the facility

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Place of Service

• Codes are utilized on professional claims to specify the entity where service(s) were rendered

• Applicable codes to vascular access procedures– 11 office– 22 outpatient hospital– 24 ambulatory surgery center– 21 inpatient hospital

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Physician Office Based Procedures• Paid according to the CMS Physician Fee Schedule (PFS)– Updated annually

• Facility– Includes only the physician’s professional service (work) payment

assuming that the procedure is being performed in a facility which the physician does not own (Hospital, ASC)

• Non-facility– The payment for physicians who are performing procedures in

their own office facility– This higher reimbursement is intended to reimburse both the

physician’s professional work and the facility costs related to the procedure.

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Ambulatory Surgery Center Procedures• Physician paid using CMS Physician Fee Schedule (PFS)

according to the facility rate• ASC paid using CMS Ambulatory Surgery Center

Schedule– List of reimbursable procedures published annually– Some procedures used for vascular access not reimbursable

in this place of service• e.g. Currently no reimbursement for radiologic 7xxxx codes

– Expanded number of surgical procedures reimbursed compared to office place of service• e.g. Many open surgical procedures have no “non-facility”

reimbursement

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Important Note• This document is for informational purposes only and

should serve as a guideline for appropriate coding.• The ultimate responsibility for correct coding

/documentation remains with the provider of service. • ASDIN makes no representation, warranty, or guarantee

that this compilation of information is error-free, nor that the use of this guide will prevent differences of opinion or disputes with CMS or any other carrier.

• ASDIN will bear no responsibility or liability for the results or consequences that may grow out of the use of this guidance.

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