Master Core CurriculumPart B Basic

Module 2

Current Procedural Terminology (CPT)/ HCPCS

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Current Procedural Terminology (CPT) is copyright 2006 American Medical

Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the

data contained herein. Applicable FARS/DFARS restrictions apply to

government use.

CPT® is a trademark of the American Medical Association.

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Learning Outcomes

At the end of this module, participants willbe able to:

identify which CPT manuals and tools will be most beneficial to their practice

effectively navigate the CPT manuals/tools to quickly locate codes of choice

effectively utilize the CCI tools to understand correct coding methodologies

select CPT code ranges by service description

describe E/M codes documentation requirements

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Current Procedural Terminology (CPT)

Descriptive terms and identifying codesFor reporting medical services and

procedures Performed by physicians, non-physician

practitioners, and suppliers

Provides uniform language to describe medical, surgical, and diagnostic services

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CPT Manual Developed and maintained by AMA Listing of 5-digit procedure codes Divided into 6 sections

Evaluation and Management (99201-99499)

Anesthesiology (00100-01999; 99100-99140)

Surgery (10040-69979)

Radiology (70010-79999)

Pathology & Laboratory (80049-89399)

Medicine (90701-99199)

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Instructions for Use of CPT

Select code that most accurately identifies service performed

If no procedure code exists, report appropriate “unlisted” code

Medical record documentation must support service billed

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Add-on Codes

Describe additional intra-service work associated with primary procedure

Codes must be reported with primary procedure Never reported as a stand-alone code

Add-on codes apply only to services performed by same physician

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Add-On Code Example

26860: Arthrodesis, interphaleangeal joint, with or without internal fixation Represents the primary code

26861: Each additional interphalangeal joint Represents add-on code List separately in addition to code for

primary procedure

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Unlisted Procedure Codes

Used to report services or procedures not found in CPT manual

Service represented by unlisted procedure code must be described on claim Paper claim, in Item 19 Electronic claim, in narrative or free-form

fieldThere is an unlisted code for each

section of the CPT Manual

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Elimination of Grace Periods for CPT/ HCPCS Codes

Effective January 1, 2005, 90-day grace period for billing discontinued HCPCS codes was eliminated.

Providers must bill using HCPCS code that is valid for date of service

Purchase AMA CPT-4 coding book (available in October)

Level II codes posted at the end of October at: http://www.cms.hhs.gov/HCPCSReleaseCodeSets/

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HCPCS Procedure Coding System

Codes are added, deleted, and changed each January 1 Level I codes are copyrighted by the

American Medical Association’s Current Procedural Terminology, Fourth Edition (CPT-4)

Level II codes are 5-position alpha-numeric codes maintained by the Health Insurance Association of American and BCBS Association

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Additional Procedure Coding Resources

The CPT Manual (Level I) may be ordered through:

American Medical AssociationP. O. Box 10946Chicago, IL 60618-0946Telephone: 1.800.621.8335Online: www.amapress.org

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Additional Procedure Coding Resources

The HCPCS Manual (Level II) may be ordered from:Superintendent of DocumentsU. S. Government Printing OfficeWashington, D.C. 20402Telephone: 1.202.783.3238  

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Correct Coding Initiative (CCI)

Comprehensive policy and guidelines for appropriate use of CPT coding

Developed by AdminaStar Federal under contract with CMS based upon review of CPT code

descriptors, CPT coding instructions, existing local and national coding edits, and Medicare billing history

 

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Correct Coding Combinations

Column I/Column II codes Services or procedures that are included

as part of a more extensive procedure

Mutually Exclusive codes Services or procedures that would not or

could not be performed at the same time based on the CPT code description or standard of medical practice

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Correct Coding Combinations

Column I/ Column II ExampleWhen a radical mastectomy is

performed Bill CPT code 19240, modified radical

mastectomy which includes removal of all breast tissue

Procedure code 19120, excision of breast lesions such as cysts, etc., should not be billed as this service is included in 19240

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Mutually Exclusive Example

Upper GI radiological examination with high density barium and air contrast and a small bowel follow-through, bill 74249.

If the follow-through was not performed, bill 74246 or 74247.

Never report CPT code 74249 and 74246 (or 74247) together as it is not possible to perform the exam with and without the follow-through

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Use of Modifier 59

Defined as “Distinct procedural service”Use to indicate service was distinct or

separate from other services performed on the same day

Use modifier 59 to report a: Different session Different procedure or surgery Different site Separate lesion Separate injury

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Obtaining CCI Information

 CMS has published CCI edits on Internet: http://www.cms.hhs.gov/NationalCorrectCodInitEd/

For concerns about CCI policy, write:National Correct Coding InitiativeCorrect Coding SolutionsP. O. Box 907Carmel, IN 46082-0907

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Evaluation and Management (E/M) Services

Seven components that define E/M services: History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time

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Key Components of E/M Code Selection

The three key components in selecting levels of E/M services are: History Examination Medical Decision Making

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E/M Coding Guidelines

Finally, E/M codes should be selected using the following criteria: Medical necessity Individual requirements of CPT code Documentation must support level of

service billed

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Chapter Review Slide

Review question…. What procedure coding tools are available to Medicare providers to assist in choosing and billing appropriate procedure codes?

Review question…. In which section of the CPT manual (e.g. Evaluation & Management, Surgery, etc.) would you find the CPT code 72010?

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Chapter References/Citations

Current Procedural Terminology (CPT) 2005 Professional Edition

CMSManual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 23, Section 20, Healthcare Common Procedure Coding System (HCPCS)

CMSManual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 30, Correct Coding Policy

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Chapter References/Citations

CMS Manual System, Pub 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5, Section 20, Correct Coding Initiative

CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 30.6, Evaluation and Management Service Codes