CHAPTER 13

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1

CHAPTER 13INTRODUCTION TO THE CPT AND LEVEL

II NATIONAL CODES (HCPCS)


Medical Coding

• Transforms services/procedures/ supplies/drugs into CPT/HCPCS codes

• Transforms diagnosis and procedures into diagnosis codes


Levels of Service Codes

• Level I CPT—(Category 1: 99201-99607, Category III: 0017T-0259T)

• Level II HCPCS, National Codes—(A0021-V5364)

• Level III Local Codes—phased out due to HIPAA


Diagnosis Codes

• ICD-10-CM/ICD-9-CM

• International Classification of Diseases, 10th revision, Clinical Modification

• International Classification of Diseases, 9th revision, Clinical Modification


Why Codes?

• Computers understand numbers

• Specific descriptions attached to each code


CPT

• Developed by the AMA in 1966

• Updated in November for use January 1

• Divided into Category I, II, and III codes


Examples of Types of CPT Codes

• Medical

• Surgical

• Diagnostic services

• Anesthesia, etc.

• Category II and Category III codes—alpha numeric

– Category II = performance measuring

– Category III = emerging technology


CPT Codes Allow For

• Communication that is both effective and efficient

• A mechanism to report a service not described by a specific CPT or Level II code


Consider

• Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent)

• OR 50575


Codes Are

• Used to tell third-party payers about services/procedures provided

• Often used as basis of payment


Incorrect Coding

• Results in providers being paid inappropriately

– Either over or underpayment

– Decreases cash flow

– Liability risk


Codes Are Used By

• Clinics

• Hospitals

• Rehabilitation units

• Ambulance services

• Long-term care

• Wherever health care services are provided


Outpatient Services for Physicians

• Reported on insurance form

• CMS-1500 = universal form


CMS-1500

Figure: 13.1(Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.)


CPT Format

• Symbols in CPT

• Used to convey information

• Bullseye, moderate (conscious) sedation included (full list in Appendix G, CPT)

• Lightning bolt, pending FDA approval (Appendix K, CPT)


• Pound Symbol (#) = resequenced code

• Bullet = New Code

Figure: 13.2

Figure: 13.9


▲Triangle = Revised Code

Figure: 13.3


►◄ Right and Left Triangles = Beginning and Ending of Text Change

Figure: 13.4


+ Plus = Add-On Code

Figure: 13.7


Add-On Code

(…Cont’d)

• Full list in Appendix D of CPT

• Can only be used with another specific code

• Never used alone


=Circle With Line,-51 Cannot BeUsed With these Codes

• CPT Appendix E contains a listing of -51 exempt codes

• Services typically exempt from multiple procedure reductions

Figure: 13.8


Circle = Recycled or Reinstated Code

• Circle symbol identifies codes previously published in CPT


Appendices of CPT

• Appendix A: Modifiers

• Appendix B: Additions, Deletions, Revisions

• Appendix C: Clinical Examples, E/M Codes

• Appendix D: Add-On Codes

• Appendix E: -51 Exempt Codes

• Appendix F: -63 Exempt Codes

• Appendix G: Include Moderate (Conscious) Sedation

(Cont’d…)


(…Cont’d)

• Appendix H: Performance Measures, Category II Codes, on website

• Appendix I: Genetic Testing Modifiers

• Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves

• Appendix K: Product Pending FDA Approval

• Appendix L: Vascular Families

• Appendix M: Crosswalk to Deleted CPT Codes

• Appendix N: Summary of Resequenced CPT Codes

Appendices of CPT


Six CPT Sections (like chapters)

1. Evaluation & Management (E/M)

2. Anesthesia

3. Surgery

4. Radiology

5. Pathology & Laboratory

6. Medicine• Category II Codes• Category III Codes• Appendices A-M• Index


Categorized By

• Sections

• Subsections

• Subheadings

• Categories

(Cont’d…)


Categorized By

(…Cont’d)

• Anatomy

– Knee or Shoulder

• Procedure

– Incision or Excision

• Condition

– Fracture or Dislocation

• Description

– Cast or Strap

• Surgical Approach

– Anterior Cranial Fossa or Middle Cranial Fossa

(Cont’d…)


Categorized By, Example

Figure: 13.6

(…Cont’d)


Guidelines

• Section-specific information begins each section

Figure: 13.10


Notes

• Must-reading located throughout the CPT

Figure: 13.12


Two Types of Codes

• Stand-alone: Full description

• Indented: Dependent on preceding stand-alone

– Verbiage before the semicolon applies to all indented codes that follow


Types of Codes, Example

Figure: 13.14


Semicolon

• Indicates full description in preceding code

• You must return to the stand-alone for full description


Modifiers Add Information

• CPT Modifier

• Two digits

– 62 Two surgeons performed a surgical procedure

– Each surgeon applies his/her individual skill

– Each surgeon bills the procedure with modifier -62


Level II HCPCS Modifiers

• “-AS” Physician’s Assistant

• “-F1” Left hand, second digit

• All modifiers used on CPT or HCPCS


Example of Modifier

• 43820 Gastrojejunostomy

-62 two surgeons

-43820-62 two surgeons performed a gastrojejunostomy

-62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity


• Modifiers are placed in 24D on CMS-1500 or 837

Modifier on the CMS-1500


Unlisted Services

• Codes ending in “99” = “no specific Category I or III code”

• Used if no more specific code

• Special report must accompany submission


Special or Written Report Indicates:

• Nature

• Extent

• Need

• Time

• Effort

• Equipment Used

• Photos and medical journal articles if relevant


Category I Codes

• Category I codes (00100–99607)

– Approved by AMA and Food and Drug Administration

– Proven clinical effectiveness (efficacy)


Category II Codes—Supplemental Tracking Codes

• Used for performance measurements

• Codes collect data concerning quality of care and test(s) required

• Alphanumeric and end in the letter “F” (1006F)

• Location AMA Website


Category III Codes—New Technology• Temporary codes—up to _ years

• Identify emerging technology, services, and procedures

• Located after Medicine section

• Alphanumeric (0016T)

– May or may not receive future Category I code status

5


Category III Codes

• Category III codes have not been approved and have no proven clinical effectiveness

• Usage order

– Use Category III code instead of unlisted code

– Use unlisted code if no Category III code


The Index!

• Used to locate service/procedure terms and codes

• Speeds up code location

• Like a dictionary

• First entries and last entries


CPT Index

Figure: 13.18


Presentation of Codes in Index

• Single code: 38115

• Multiple codes: 26645, 26650

- Note comma

• Range of codes: 22305-22325

- Note hyphen


1. Service/procedure: repair, excision

2. Anatomic site: median nerve, elbow

3. Condition or disease: cleft lip, clot

4. Synonym: toe and interphalangeal joint

5. Eponym: Jones procedure, Heller operation

6. Abbreviation: ECG, PEEP (Pressure Breathing, Positive)

Location Methods with Examples


Always

• Reference index

• Locate code in main portion of CPT

• Read the entire description and any notes


“See” in Index

• Cross-reference terms

– “Look here for code”

• Index: Stem, Brain: See Brainstem


HCPCS

• Healthcare Common Procedure Coding System

• Developed by Centers for Medicare and Medicaid Services (CMS)– Formerly HCFA

• HCPCS developed in 1983

• CPT did not contain all codes necessary for Medicare services reporting


Levels of Codes

• Level I: CPT

• Level II:HCPCS, also known as national codes

• Level III: Local codes (phased out) due to HIPAA


Level III, Local Codes

• Developed by Medicare carriers for use at local level

• Varied by locale

• Discontinued December 31, 2003

– Some codes incorporated into HCPCS Level I and II


Level II: National Codes

• Codes for wide variety of providers

– Physicians

– Dentists

– Orthodontists

– Temporary codes for Medicare

(Cont’d…)


Level II: National Codes

(…Cont’d)

• Codes for wide variety of services

– Specific drugs

– Durable medical equipment (DME)

– Ambulance services


HCPCS Gains Popularity

• Many payers require

• Each year increased number of HCPCS codes

– J0585—Botox, per unit


Format

• Begins with letter, followed by four digits

– Example: E0618, apnea monitor

• Each letter represents group of codes

– Example: “J” codes used to report drugs and dosage


Temporary Codes

• Certain letters (G, K, Q, S, H, T) indicate temporary codes

– Example: K0006 heavy duty wheelchair

• Code books published every January

– But codes added, deleted, and revised throughout the year

– Notified through carrier bulletins


Coverage

• Just because item/service has HCPCS code does NOT mean service covered

– Example:

– V5130, binauralhearing aid

– Not covered under Medicare

From Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, editors: Cummings Otolaryngology-Head & Neck Surgery, ed 4, Philadelphia, 2005, Mosby.


Where HCPCS Are Used

• Outpatient settings

– Including outpatient departments in hospital

• Level I and II used to report outpatient services to certain payers


HCPCS Index

• Directs to specific codes

• Do not code directly from index

• Reference main portion text before assigning code

• See Figure 13–22 in textbook

(Cont’d…)


HCPCS Index

• Alphabetical order

(Cont’d…)

(…Cont’d)

Figure: 13.22

Modified from Buck CJ: 2012 HCPCS Level II Professional Edition, St. Louis, 2012, Saunders.


HCPCS Index

• Main text display

(…Cont’d)

Figure: 13.27



HCPCS Modifiers

• CPT and HCPCS modifiers used with both HCPCS and CPT codes

Figure: 13.25



Anatomical Modifiers

• F1 Left hand, second digit

• F2 Left hand, third digit

• F3 Left hand, fourth digit

• F4 Left hand, fifth digit

• FA Left hand, thumb

• F5 Right hand, thumb

• F6 Right hand, second digit

• F7 Right hand, third digit

• F8 Right hand, fourth digit

• F9 Right hand, fifth digit


Often Used HCPCS Modifiers

• LT Left

• RT Right

• Example:• Right kidney biopsy, 50200-RT

• Left kidney biopsy, 50200-LT


Ambulance Modifiers

• Origin and destination used in combination:

– First letter: Origin

– Second letter: Destination

– Example:

• R = Residence

• H = Hospital

• RH: origin (first letter) residence and destination (second letter) hospital


Table of Drugs

• Listed by generic name


Figure: 13.26


Durable Medical Equipment

• DME

• Used with chronic disabling condition

• Medicare and Medicaid pay for some DME items

• Physician must attest to need using Certificate of Medical Necessity


Home Oxygen Therapy

• Medicare may also pay for oxygen with certain medical conditions

• Physician must complete form (CMS-484) attesting to medical necessity


ConclusionCHAPTER 13

INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

CHAPTER 13

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