Introduction to CPT Coding for Physician Practices

Gretchen L. Segado, MS, CPCDirector of Reimbursement ComplianceNYU School of Medicine316 East 30th StreetNew York, NY 10016(212) 263-2446(212) 263-6445 faxGretchen.Segado@med.nyu.edu

NYU School of MedicineCoding and Reimbursement Seminar Series

Presented by the Office of Reimbursement Compliance

What Is CPT-4?

Systematic listing of procedures & services performed by physicians

Five-digit codes for procedures or services Used to describe the physician’s services to a patient

for diagnosis and treatment of the medical condition(s) Codes and descriptive terminology developed and

copyrighted by AMA CPT Editorial Panel

Linkage Between ICD-9 & CPT

CPT-4 represents the “WHAT” was done to the patient

Procedure------------------- 93010 (EKG)

ICD-9 represents the “WHY” it was done

Medical Necessity--------- 786.50

(Chest Pain)

Organization of CPT ManualText organized in 6 major sections

Evaluation and Management (99201 - 99499) Anesthesiology (00100 - 01999,

99100 - 99140)

Surgery (10040 - 69990) Radiology (70010 - 79999) Pathology and Laboratory (80049 - 89399) Medicine (90281 - 99199)

Guidelines

Presented at the beginning of each of the six sections Provide information necessary to appropriately

interpret and report the procedures and services contained in that section

In addition to guidelines, several subheadings or subsections also have special instructions unique to that section

Reading the guidelines and notes are critical to using CPT correctly

CPT Symbols

Revised CPT Code-Description has been substantially altered

New CPT Code

Codes that never stand alone

Appears during the 1st year that the text is revised or added

Codes exempt from the 51 modifier, but that do not have

designated add-on procedures or services

Format of the CPT-4

Developed as a stand-alone descriptions of the procedures To conserve space, some are not printed in their entirety but

refer back to a common portion listed in a preceding entry**Example:

25100 arthrotomy, wrist joint; for biopsy25105 for synovectomy

25105 arthrotomy, wrist joint; for synovectomy

**Commonly referred to as “Indented Codes”

Who can tell me what CPT Code reads?

The book says

24102 with synovectomy

What is the full description of each of these codes?

20600* arthrocentesis, aspiration &/or injection; small joint, bursa or ganglion cyst (e.g., Fingers, toes)

20605* intermediate joint, bursa or ganglion cyst (e.g., Temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa

20610* major joint or bursa (e.g., Shoulder, hip, knee joint, subacromial bursa

Example 2

20661 application of halo, including removal; cranial

20662 pelvic

20663 femoral

The Index-The Starting Point

Listed procedures in alphabetical order at the back of the manual

Index is organized by main terms There are 4 primary classes of main entries:

– Procedure or service– Organ or anatomic site– Condition– Synonyms, eponyms or common abbreviation

CPT Index

Procedure or service– Appendectomy

Organ or anatomic site– Knee

Condition– Renal Abscess

Synonyms, eponyms or common abbreviation– Bucca (cheek)– BAER (Brainstem Auditory Evoked Potential)– Whipple Procedure

Use of CPT-4 Manual

Select the name of the procedure or service that most accurately identifies the service performed:

– Example:

Surgery: operations and minor proceduresMedicine: diagnostic or therapeutic

procedure

Radiology: radiographic study

Any physician can use any code in the CPT book.

Important!!!!!

The alphabetical index is NOT a substitute for the

main text of the CPT Manual. Even if only one code

appears, the user must refer to the main text to

ensure that the code selection is accurate

In short…NEVER CODE FROM THE INDEX@!@!

10 Steps to Basic CPT Coding

1. Read the source document. Never assume!

2. Using information in the record, analyze procedure statement provided by physician. Identify main term and modifying terms

3. Locate main term in the CPT index

4. Look for subterms indented below the main term

5. Jot down the tentative code range for each procedure.

10 Steps to Basic CPT Coding

6. Locate each tentative code in the book7. Read any instructional notes and watch for

diagnoses or specific procedures within code descriptions

8. Verify that the code matches the procedure statement provided in the record

9. Assign a modifier if necessary10. Assign the code

Now it’s your turn to use what you’ve learned…….

Identify the service or procedure performed

Identify the organ involved

Identify the condition or key word

Procedure/Organ/Key Word

What is the code for a Whipple Procedure?

48150

Procedure/Organ/Key Word

What is the code for an upper gastrointestinal endoscopy with biopsy?

43239 You can find the same code looking under

any of the terms “gastrointestinal” “endoscopy” or “biopsy”

Procedure/Organ/Key Word

What is the code for a synovectomy of the

metacarpophalangeal joint?

26135

Common mistakes made: carpometacarpal

joint vs metacarpophlangeal joint

Procedure/Organ/Key Word

What is the code for removal of a foreign

body in the nose?

Need more information, was this done under

anesthetic? Did they have to cut into nose?

Procedure/Organ/Key Word

How would you bill for a removal of a pylenoidal cyst?

Do I need more information to code it correctly? If so, where do I get the info?

Is it simple? extensive? complicated?

Answer: 11770-11772

Procedure/Organ/Key Word

Endoscopic biopsy of the urethra– This is a tricky one….beware

Answer: 52204

Procedure/Organ/Key Word

Exploration of a penetrating wound of the abdomen

Answer: 20102

Procedure/Organ/Key Word

Exploration of nasolacrimal duct with tube insertion

Answer: 68815

Procedure/Organ/Key Word

Exploration of the knee with removal of a nail

Answer: 27310

Appendices

Appendix AModifiers Appendix BSummary of additions,

deletions and revisions Appendix C Update to short descriptor Appendix D Clinical examples

supplement Appendix ESummary of add on codes Appendix FSummary of CPT codes

exempt from modifier -51

Global Surgery Components

Preoperative visits - beginning with the day before the day of surgery for major procedures and the day of the surgery for minor procedures

– Document pre-op evaluation/exam in medical record

– Document pre-op evaluation in op report

What is the “Global” Period?

Also known as the global surgical package No one standard definition Per CPT guidelines,

The following services are always included in addition to the operation per se:

local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;

What is in the Global Period?

subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical);

immediate postoperative care, including dictating operative notes, talking with the family and other physicians;

writing orders; evaluating the patient in the post-anesthesia

recovery area; typical postoperative follow-up care.

Examples of Services Included in the Global Period

Removal of staples 10 days after a surgical procedure

A visit with a patient prior to surgery to answer any last minute questions

A post-operative visit in the office to check on wound healing

Examples of Services NOT Included in the Global Package

The visit where the decision to perform a procedure or surgery was made, even if on the same day as the procedure

A visit during the post-op period for a problem unrelated to the surgery

Example of Global Payment

CPT code 33512 - coronary artery bypass, vein

Only; 3 coronary venous grafts

Allowed payment (80%) = $2,001.40

Pre-op

Intra-op

Post-op

9%

84%

7%

$180.00

$1,681.00

$140.00

National Correct Coding Initiative

Commonly known as CCI Purpose:

– Develop a correct coding methodologies– Control improper coding that leads to

inappropriate increased in payment in Part B– Promote correct coding nationwide– Assist physicians in correctly coding their services

for payment

Definitions in the Correct Coding Initiative

Correct Coding means the reporting of a group of procedures with the appropriate comprehensive codes.

Unbundling is the billing of multiple procedure codes for a group of procedures that are covered by a single comprehensive code.

Mutually Exclusive Codes are those codes that represent services that cannot reasonably be performed in the same session

Types of Unbundling

Fragmenting one service into component parts and coding each as a separate service.

Reporting separate codes for related services when one comprehensive code includes all related services.

Breaking out bilateral procedures when one code is appropriate.

Types of Unbundling

Down coding a service in order to use an additional code when one higher code level, more comprehensive code is appropriate.

Separating a surgical approach from a major surgical service.

Examples of Bundled ServicesComponent Codes

52005- Cystourethroscopy, with urethral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiological service.– Bundled services:

51700- Bladder irrigation, simple, lavage &/or instillation

52000- Cystoeruthroscopy (separate procedure) 53670- Catheterization, urethra, simple

Examples of Bundled ServicesMutually Exclusive Codes

63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; cervical

63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical

First code would be paid and the second denied without use of an appropriate modifier

Separate Procedures

– Services “should not be reported in addition to code for total procedure or service of which it is considered an integral component”

– If the service is performed independently, unrelated or distinct from other procedures provided at the time, it may be reported by itself or in addition to other services by attaching modifier -59 (indicates service is distinct, independent procedure)

Example of Separate Procedures

Example: 44005 - Enterolysis (freeing intestinal adhesion) (separate procedure)

(Do not report 44005 in addition to 45136)

is included in 45136 Excision of ileoanal reservoir

with ileostomy

Add-on Codes

– Carried out in addition to a primary procedure Exempt from -51 modifierCPT descriptors - “list separately in

addition to primary procedure” or “each additional”

Must never be reported as a stand-alone code

Examples of Add-on Codes

64831 Suture of digital nerve, hand or foot; one nerve

+ 64832 each additional digital nerve (list separately in addition to code for primary procedure)

22325 Open tmt and/or reduction of vertebral fx and/or dislocation(s), posterior approach, one fx vertebrae or dislocated segment; lumbar

+ 22328 each additional fractured vertebrae or dislocated segment (list separately in addition to code for primary procedure)

In Summary

Learned CPT Nomenclature (how to read the book)– Reading the guidelines– Use of Symbols, Appendices, Indexes

Learned never to code from the index Learned the importance of linking CPT with

an appropriate diagnosis (ICD-9) code Learned about Correct Coding Initiative

Coming soon..

An Advanced E&M/Chart Auditing Workshop Seminar Series Classes on

– ICD-9 Coding– Billing for Non-physician Practitioners– How to Use Modifiers– Evaluation and Management Coding

A Special Session on Advance Beneficiary Notices

Sign up for classes via the School of Medicine Calendar at http://calendar.med.nyu.edu

– Select Department Calendars, Find Compliance Office under “miscellanous” category