Y khoa - Dược - Chapter 19: Procedure coding

19Procedure CodingLearning 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.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 manual19.7 Explain the importance of code linkage in avoiding coding fraud Introduction Procedural codingTranslate medical procedures and services into codesExplains what services were provided Code “linkage” with diagnostic codesMaximum reimbursementThe CPT ManualProcedure codeMedical procedures and servicesBased on encounter form or patient recordCurrent Procedural Terminology (CPT) HIPAA-required code set Published by the AMAUpdated annuallyUse the appropriate CPT based on date of serviceOrganization of the CPT ManualSectionRange of CodesEvaluation and Management99201 – 99499Anesthesiology00100 – 0199999100 – 99140Surgery10021 – 69990Radiology70010 – 79999Pathology and Laboratory80048 – 89356Medicine90281 – 9960299500 – 99602Organization of the CPT Manual (cont.)Manual Introduction General instructionsInformation about commonPrefixesSuffixesWord rootsGuidelines for each sectionOrganization of the CPT Manual (cont.)SectionsGuidelines at beginningCategories  headingsPageSection nameSubsection nameSubheadingCategoryApply Your KnowledgeMatch CPT section to number rangeANSWER:Evaluation and managementAnesthesiologySurgeryRadiology Pathology and LaboratoryMedicine (except for Anesthesia)70010-7999900100-0199999100-9914090281-9919999500-9960280048-8935699201-9949910021-69990General CPT GuidelinesCode format5-digit numeric codeStand-alone unless description contains a semicolonAdd-on codesAdditional proceduresIndicated by plus sign (+)Indented codes Closed treatment of radial shaft  fracture; without manipulation25505 with manipulationSymbols Used in CPT Code description has been revised A new code Codes are out of numeric sequence New or revised text informationSymbols Used in CPT (cont.) Does not require modifier of 51 FDA approval pending Moderate (conscious) sedation is included in the procedureOrganization of the CPT Manual (cont.)ModifiersUp to three per procedureIndicate that special circumstance applies Appendix A Section guidelinesCategory II, III, And Unlisted Procedure CodesCategory II – supplemental tracking codes Category III – temporary codes Unlisted codes code not yet assignedInclude a description of service or procedureCheck with payers regarding useCoding TerminologyConcurrent careMore than one physicianIf different specialties, not considered duplicationCoding Terminology (cont.)ConsultationsMust have request, record of findings and recommendations, and reportVerify if payer is accepting these codesCounseling – use codes if history or physical is not doneCoding Terminology (cont.)Downcoding Reimbursement on a lower code level than submittedLack of documentation most common causeUnbundling UpcodingThe insurance representative has questioned the codes listed on three patient forms that were submitted last year. When re-checking these forms the office medical assistant should:Use the current book to validate accuracy of the codesUse last year’s book to validate accuracy of the codesUse next year’s book to validate accuracy of the codesApply Your KnowledgeANSWER:Evaluation and Management ServicesE/M codes Used by all physiciansNew patient vs. established patientNew patients – require more timeEstablished patient – seen within 3 yearsEvaluation and Management Services (cont.)Key factors that help determine level of serviceExtent of patient history takenExtent of examination conductedComplexity of medical decision makingEvaluation and Management Services (cont.)ElementsChief complaint (CC)History of present illness (HPI)Review of systems (ROS)Past, family and/of social history (PFSH)Coding descriptionsProblem-focusedExpanded problem-focusedDetailedComprehensivePatient HistoryEvaluation and Management Services (cont.)Elements Constitutional examBody areas (BA)Organ systems (OA)Coding descriptionProblem-focusedExpanded problem-focusedDetailedComprehensivePhysical ExamEvaluation and Management Services (cont.)Elements for documentationNumber of diagnoses and management optionsAmount or complexity of data to be reviewedRisk of complication or death if untreatedMedical Decision-MakingEvaluation and Management Services (cont.)Complexity level Straightforward MDMLow-complexity MDMModerate-complexity MDMHigh-complexity MDMEvaluation and Management Services (cont.)Contributory factors in assigning codesCounselingReason for encounter50% or more of timeCoordination of careEvaluation and Management Services (cont.)Nature of presenting problemMinimal complaintSelf-limited complaintLow severity complaintModerate severity complaintHigh severity complaintEvaluation and Management Services (cont.)Additional considerationsTimeAverage timesNot critical unless code choice is based on timeLocation where services occurredApply Your KnowledgeANSWER: Extent of patient history takenExtent of the examination conductedComplexity of medical decision-makingWhat are the 3 factors in determining how select E/M codes for different levels of service?Good Job!Surgical CodingThe surgical packageAll procedures normally a part of an operationPreoperative exam and testingSurgical procedureRoutine follow-up careGlobal period – time period covered for follow-up careSurgical Coding (cont.)Integumentary SystemCodes based on size and locationRead and follow instructions carefullyMusculoskeletal SystemSubheadingsgeneralHead to toeFracture codes most commonSurgical Coding (cont.)Respiratory SystemCode to furthest extent of the procedureApproach ScopeIncision Incision vs. excision codesRepair proceduresCardiovascular SystemComplicated codingRead instructions carefullySequence codes correctlySurgical Coding (cont.)Hemic/Lymphatic Systems and Mediastinum and DiaphragmDigestive SystemUpperLower Urinary SystemKidneys and renal functionDiagnostic and therapeutic proceduresLaparoscopy vs. incisionSurgical Coding (cont.)Male Genital SystemFemale Genital System/Maternity and DeliveryEndocrine SystemNervous SystemSubheadings by anatomic sitesSubdivided by procedureSpecialized guidelinesSurgical Coding (cont.)Eye and Ocular AdnexaHighly specialized proceduresRead instructions and guidelines carefullyAuditory SystemRadiologyDiagnostic and therapeutic proceduresRead all includes and excludes carefullySurgical Coding (cont.)Laboratory Procedures – panels Medicine and ImmunizationsTwo codesProcedure Vaccine or toxoidApply Your KnowledgeWhat do the terms surgical package and global period include?ANSWER: Surgical package includes preoperative exam and testing, the surgical procedure and local or regional anesthesia if used, and routine follow-up care.The global period is the time covered for follow-up care and included any care provided related to the surgical procedure.Bravo!Using the CPT ManualBecome familiar with guidelines and notes for each sectionFind the procedures and services provided by the office Determine appropriate codes E/M sectionsAlphabetic listingCheck all codes listedUsing the CPT ManualDetermine appropriate modifiersRequired if availableEnhance reimbursementEnter codes and modifiers on CMS-1500 formPrimary procedure first and match with appropriate diagnostic codeAll other procedures matched with appropriate diagnostic codeApply Your KnowledgeWhat are the steps for locating a code in the CPT manual?ANSWER: Determine if the patient is new or establishedFind procedures and services provided (encounter form)Verify information with the medical recordLocate the correct code in the CPT manual starting with the alphabetic index and verifying with the numeric index.Check for modifiers Document on CMS-1505 or in the billing programThe HCPCS Coding ManualHealth Care Common Procedure Coding SystemUse for coding services for Medicare patientHCPCS Level I codes – CPT codesThe HCPCS Coding Manual (cont.)HCPCS Level II codesNational codes for supplies and DMECover services and procedures not in CPT5 characters ~ numbers, letters, or a combination of bothModifiers The HCPCS Coding Manual (cont.)Coding procedures Locate service in the Alphabetic IndexVerify description in the alphanumeric IndexChoose code that matches service, procedure, or item suppliedEnter on CMS-1505 form or into the billing programApply Your KnowledgeWhat 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).Stellar!Coding CompliancePhysician – ultimate responsibilityMedical assistantsSubmit correct claimsHelp ensure maximum appropriate reimbursementClaims must comply withFederal and state lawPayer requirementsCode LinkageAnalysis of the connection between diagnostic and procedural information to evaluate medical necessityDiagnosticCodes Procedural CodesCode Linkage (cont.)Codes are checked against the medical documentationCoding 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?Insurance FraudInvestigators look for patterns such asReporting services that were not performedReporting services at a higher level Performing and billing for procedures not related to the patient’s condition and therefore not medically necessaryInsurance Fraud (cont.)Patterns (cont.)Unbundling Reporting the same service twiceCopaymentsWaiver may violate payer policiesEnsure policies are consistent with law and requirements of payersCompliance PlansProcess for finding, correcting, and preventing illegal medical practicesGoals of compliance planPrevent fraud and abuseEnsure compliance with applicable lawsHelp defend physicians if investigation occursCompliance Plans (cont.)Developed by a compliance officer and committee who also:Audit and monitor compliance with government regulationsDevelop consistent written policies and procedures Provide ongoing staff training and communicationRespond to and correct errorsApply Your KnowledgeWhy is code linkage important?ANSWER: Code linkage will ensure clean claims in which each reported service is connected to a supporting diagnosis.In Summary19.1 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.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.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.Things gained through unjust fraud are never secure. ~ SophoclesEnd of Chapter 19Screen captures of SpringCharts™ Electronic Health Records software are reprinted with permission from Spring Medical Systems, Inc. All rights reserved.