chapter 61 surgery, radiology, pathology/laboratory, and medicine chapter 6 part ii: coding...

Chapter 6 1

Surgery, Radiology, Surgery, Radiology, Pathology/Laboratory, and MedicinePathology/Laboratory, and Medicine

Chapter 6

CODING PROCEDURES Part II:Part II:

Chapter 6 2

PROCEDURAL CODING PART IIPART II

Learning Objectives Define procedure code terminology. Explain the purpose of coding for

professional services. List all subsections of Surgery section. Compare comprehensive codes and

component codes.

Chapter 6 3

PROCEDURAL CODING PART IIPART II

Learning Objectives Distinguish between surgical package and

Medicare global package rules. Describe two ways to code for multiple

procedures. Demonstrate an understanding of surgical

terminology. Explain situations in which modifiers are

applied to surgical codes.

Chapter 6 4

PROCEDURAL CODINGPART IIPART II

Performance Objective Locate a code in the Surgery section by using the

index. Code scenarios presented in the worktext from all

of CPT. Apply CPT and HCPCS Level II modifiers when

appropriate.

Chapter 6 5

Key Terms Add-on code Anesthesia Bilateral Procedure Bundled Code Closed Fracture Closed Treatment Component Code Comprehensive Code Downcoding Elective Surgery

Endoscopy Fixation Fracture Manipulation Global Surgery Policy Indented Code Open Fracture Open Treatment Percutaneous

Treatment Professional

Component (PC)

Chapter 6 6

Key Terms Qualitative Analysis Quantitative

Analysis Separate

Procedures Stand-alone Codes Surgical Package Technical

Component (TC)

Test Panel Unbundling Upcoding

Chapter 6 7

Introduction to the Surgery Section Largest SectionLargest Section of the CPT Codebook 16 Subsections,16 Subsections, divided according to Body

Systems GuidelinesGuidelines are found at the beginning of the

Surgery Sections. SubsectionSubsection further divided into Categories Categories

based on Anatomic SiteAnatomic Site SubcategoriesSubcategories are within each Category which

list the type of procedure or condition.

Coding Procedures & Services Introduction to theIntroduction to the Surgery SectionSurgery Section

(10040-69979)(10040-69979)

Chapter 6 8

How to Code EffectivelyHow to Code Effectively You must be able to analyze a procedureprocedure

descriptiondescription and identify various termsidentify various terms that will direct you to the correct code.

To do this you must know the main categoriesmain categories under which servicesservices and proceduresprocedures are listed according to their main termmain term in the index.index.

After the procedure,procedure, service,service, or conditioncondition is identified in the index,index, search for a subtermsubterm and a sub-subtermsub-subterm that further defines the procedure.


(10040-69979)(10040-69979)

Chapter 6 9

How to Code Effectively – How to Code Effectively – Cont. When a code range is found, turn to the correct correct

section and read all descriptionssection and read all descriptions listed under the code range before selecting a code.

Performance ExercisePerformance Exercise Table 6-2/Page 138


(10040-69979)(10040-69979)

Chapter 6 10

How to Code EffectivelyHow to Code Effectively IdentifyIdentify Main Term(s) Main Term(s) in the Procedure

Description of the Medical Record LocateLocate Main Term(s)Main Term(s) in the Index & Document

Code Range TurnTurn to the Correct Section of the CPT & Read Read all

Description listed in the Code Range Select Select the Correct Code


(10040-69979)(10040-69979)

Chapter 6 11

Coding Procedures & Services Introduction to theIntroduction to the Surgery Section/Surgery Section/(10040-69979)(10040-69979)

PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Excision of tendon, finger, flexor, single (separate procedure), each

26180

How to Code EffectivelyHow to Code Effectively IdentifyIdentify Main Term(s) Main Term(s) in the Procedure Description of

the Medical Record LocateLocate Main Term(s)Main Term(s) in the Index & Document Code

Range TurnTurn to the Correct Section of the CPT & Read Read all

Description listed in the Code Range Select Select the Correct Code

Chapter 6 12

How to Code Effectively How to Code Effectively – Cont. Stand-aloneStand-alone Codes – are procedure

codes that have a full description. Comes before the (;)(;) Terminology after the (;) has a Dependent

Status as the Subsequent Indented Entries Performance ExercisePerformance Exercise

Figure 6-3/Page 138


(10040-69979)(10040-69979)

Chapter 6 13

How to Code Effectively How to Code Effectively – Cont. IndentedIndented Codes – are listed after stand-alone

codes whose descriptions have a dependent status.

To read the description, you must first read the description of the stand-alone code that comes beforebefore the semicolon (;) and,

then continue with the indented description listed by the subsequent code (indented code).

Performance ExercisePerformance Exercise Figure 6-3/8


(10040-69979)(10040-69979)

Chapter 6 14

Integral Code Description One Code is part of another based on

language used in the description Example 6-2/Page139Example 6-2/Page139

Parentheses ( )( ) further definedefine & telltell where other services are locatedlocated

Figure 6-4/Page 139Figure 6-4/Page 139


(10040-69979)(10040-69979)

Chapter 6 15

Coding Steps

Step 1 Become familiar with CPT codesStep 2 Find the services listed on patient

encounter formStep 3 Look up codes in index, then look up

actual codeStep 4 Determine appropriate modifiersStep 5 Record the procedure code on the

insurance claim; PROOFREAD numbers

Chapter 6 16

Coding from the Operative Report ReadRead the Operative report thoroughly & code

on documented operations DetermineDetermine Bundled or Unbundled

Procedures NeverNever Code Verbal Procedures Coding Rule:Coding Rule: “Not Documented, “Not Documented, Not Done”!Not Done”!


(10040-69979)(10040-69979)

Chapter 6 17


(10040-69979)(10040-69979)

Operative Report

Date of Service: 5/17/03

Surgeon: Jeffrey Thompson, MD

Assistant Surgeon: None

Preoperative Diagnosis: RLQ pain, probable appendicitis

Postoperative Diagnosis: Acute appendicitis

Procedures Performed: Exploratory laparotomy, appendectomy

Anesthesia: General Endotracheal

Chapter 6 18

Chapter 6 19

Decision for Surgery - Criteria to Evaluate

Is patient new or established? Is the E/M service significant and separately identifiable

from the procedure? What is the time lapse from the time the decision is made

for surgery to the time when the procedure is performed? Performance ExercisePerformance Exercise

Figure 6-4/Page 141


(10040-69979)(10040-69979)

Chapter 6 20

Decision for Surgery -57 (Modifier) – An E/M service that resulted in

the initial decision to perform the surgery.

-25 (Modifier) - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.


(10040-69979)(10040-69979)

Chapter 6 21

Surgical PackageSurgical Package is a combination of services included in a single procedure code for some surgical procedures in the CPT.

Governmental Programs & Insurance Companies assign fees to surgical package codes that reimburse all services provided under them.

The period of time that is covered for follow-up care is referred to as the Global Period.

For ExampleFor Example, the Global PeriodGlobal Period for repairing a Tendon might be set at 15 days.


(10040-69979)(10040-69979)

Chapter 6 22

Surgical PackageSurgical Package – Cont. A Global PeriodGlobal Period for Major Surgery such as

Appendectomy may be set at 100 days.

After the Global PeriodGlobal Period ends additional services that are provided can be reported separately for additional payment.


(10040-69979)(10040-69979)

Chapter 6 23

Surgical PackageSurgical Package – Cont. Surgical Surgical Package Includes

Combination of Services Global Period Surgical Procedures Anesthesia Related E/M Encounter Postoperative Care

Private Carriers May have an individual policy on what is included in the

package.


(10040-69979)(10040-69979)

Chapter 6 24

MedicareMedicare Global Package - IncludedIncluded Preoperative E/M Services Intraoperative Services Postoperative Visits Complications after surgery without addition trips to the

operating room Anesthesia Supplies necessary for performance of the procedure


(10040-69979)(10040-69979)

Chapter 6 25

Medicare Medicare Global Package - - ExcludedExcluded Initial Consultation or Evaluation Diagnostic Tests & Procedures Treatment required to stabilize a seriously ill patient before

surgery Postoperative visits unrelated to the diagnosis for which the

surgical procedure was performed (modifier –24)(modifier –24) Related Procedures for postoperative complications that requires

a return trip to the operating room (modifier –78)(modifier –78) Immunosuppressive Therapy after transplant surgery For services performed in a physician’s office, separate payment

may be made for splints and casting supplies, and a surgical tray.


(10040-69979)(10040-69979)

Chapter 6 26

Follow-Up Days Vary 0-day or 0-day or 10-day10-day for Minor Surgeries 45-day or 45-day or 90-day90-day for Major Surgeries Most States use Relative Value StudiesRelative Value Studies fee schedule

for Worker’s Compensation cases List the follow-up days allowed for most surgical

procedures Federal Register

Published annually List follow-up days for Medicare Services


(10040-69979)(10040-69979)

Chapter 6 27

Multiple Procedure Modifier –51Modifier –51 Report the primary serviceprimary service or procedureprocedure (identified by

the highest dollar value listed)

Identify all additional services or Procedures by appending code(s) with modifier –51–51 or use the separate five-digit modifier 0995109951

Appendix E – Appendix E – Summary of CPT Codes Exempt from Modifier 51


(10040-69979)(10040-69979)

Chapter 6 28

Add-on Code Noted by a Cross (+)(+) Symbol represents additional Procedure additional Procedure

done with Primary Proceduredone with Primary Procedure Found in Appendix DAppendix D of CPT Can not billed without the primary procedureCan not billed without the primary procedure

Add-on-Code Description start with: “in addition” “list separately Or “second lesion”

Performance ExercisePerformance Exercise Example 6-5/Example 6-6/Page 143


(10040-69979)(10040-69979)

Chapter 6 29

Add-on Code – Cont. Bilateral Procedures - is one procedure performed

on two sides.

Two ways to Bill List the Code OnceOnce with Modifier –50–50 & doubledouble

the fee List the Code TwiceTwice using a singlesingle fee & add the

second listing with Modifier –50–50

Performance ExercisePerformance Exercise Example 6-7/Page 143Example 6-7/Page 143


(10040-69979)(10040-69979)

Chapter 6 30

Assistant At Surgery Modifiers

-80 Assistant surgeon -81 Minimum Assist Surgeon -82 Assistant surgeon (when qualified resident surgeon not available)

-62 Two Surgeons -66 Surgical Team

The Surgeon who assist is usually paid a fee of 16 to 30 percent of the The Surgeon who assist is usually paid a fee of 16 to 30 percent of the allowed fee of the primary Surgeon.allowed fee of the primary Surgeon.

Performance ExercisePerformance Exercise Example 6-8/Page 144Example 6-8/Page 144

Coding Procedures & Services Introduction to the Introduction to the Surgery SectionSurgery Section

(10000-19999)(10000-19999)

Chapter 6 31

Integumentary System First Subsection listed in the Surgery Section Contains Procedures performed on the Skin Skin

Benign versus Malignant Neoplasm – must indicate benign or malignant Claim Form – should be delayed until the Pathology report can

confirm or deny Benign vs Malignant

Lesion – is any discontinuity of the skinBiopsy – performed for the purpose of determining the morphology (shape,

form, & structure) is reported separately.

Biopsy of a lesion followed by excision would be included in the excision a lesion followed by excision would be included in the excision procedure code, and not reported separately.procedure code, and not reported separately.

Coding Procedures & Services Surgery:Surgery: Integumentary SystemIntegumentary System

(10000-19999)(10000-19999)

Chapter 6 32

Lesion –when coding removal of lesions note the: Anatomic Site Size, measured in centimeters Number of lesions removed Process used to remove the lesion (excision,excision,

destructiondestruction, paringparing, shavingshaving) Morphology (appearance of specimen’s shape and

structure used to determine benign or malignant status)


(10000-19999)(10000-19999)

Chapter 6 33

Repair of Lacerations Simple Closure – Superficial; involving the

epidermis, dermis, or subcutaneous tissue.

Intermediate Closure – Requires layered closure of deeper subcutaneous tissue in addition to the simple closure.

Complex Closure – Requires more than one layered closure; debridement, scar revision, extensive undermining, stents, or retention sutures


(10000-19999)(10000-19999)

Chapter 6 34

Multiple Lesions Modifier –51 (Multiple Procedures) ReadRead description & look for terms such as

complicated, complex, more than, etc Watch Watch for Add-on-codes (+) (+) VS Codes eligible for

Modifier –51–51 & indented Codes Surgical Supplies

Bundled into Surgical Code (99070)(99070) or HCPCS Level HCPCS Level II CodesII Codes


(10000-19999)(10000-19999)

Chapter 6 35

Breast Category Included within the Integumentary system because of

the type of tissue involved. Each Breast Considered Separate If procedure occur on both sides use Modifier –50 Modifier –50

(bilateral)(bilateral)

Performance ExercisePerformance Exercise Example 6-96-9, 6-106-10 & 6-116-11/Page 145-46


(10000-19999)(10000-19999)

Chapter 6 36

Coding Procedures & Services

Surgery:Surgery: Integumentary SystemIntegumentary System (10000-19999)(10000-19999)

PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Breast reconstruction with free flap

19364

Preoperative placement of needle localization wire, breast:

19290

Chapter 6 37

Musculoskeletal System Arranged according to Anatomic Site ““General”General” first Category Contain Procedures Procedures &

SubcategoriesSubcategories for different Anatomic Sites. Remaining Categories Start from the “Head”“Head” to the

“Toe”“Toe” Subcategories Under Each Anatomic Category

Include: Incision Excision Introduction/Removal

Coding Procedures & Services Surgery:Surgery: Musculoskeletal SystemMusculoskeletal System

(20000-29999)(20000-29999)

Chapter 6 38

Subcategories Under Each Anatomic Category Include: Fracture/Dislocation Arthrodesis Amputation Unlisted Procedures

Fractures are: OpenOpen/skin broken by the fragmented bone (Compound (Compound

Fracture)Fracture) ClosedClosed/skin is not broken PercutaneousPercutaneous/neither OpenedOpened or ClosedClosed


(20000-29999)(20000-29999)

Chapter 6 39

Coding Treatment of a Fracture Locate the Anatomic Site Find Subcategory “Fracture and/or Dislocation”“Fracture and/or Dislocation” Then find the appropriate code

Description of Fractures are either: “With Manipulation” or “Without Manipulation”


(20000-29999)(20000-29999)

Chapter 6 40


(20000-29999)(20000-29999)

Other Descriptive Terms Are:

“Internal Fixation”

“External Fixation”

Chapter 6 41


(20000-29999)(20000-29999)

Fracture Manipulation is:• The manual stretching or applying pressure or traction to realign the broken (fractured) bone.• Referred to as “reduction”.“reduction”.

Fixation – is the use of hardware (instrumentation) to keep a bone in place. It can be applied internally internally (e.g., plates, rod, pin) or ExternallExternally (e.g., pins that comes thru the skin to the outside to keep the fractured bone from moving).

Chapter 6 42


(20000-29999)(20000-29999)

Fracture Follow-up Period:

The surgical package rule applies.The surgical package rule applies. All All fracture codefracture code carry a carry a 90-day90-day follow-up follow-up period.period.

Performance ExercisePerformance ExerciseExample 6-12/Page 147Example 6-136-13/Page 147

Chapter 6 43


(20000-29999)(20000-29999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Closed treatment of mandibular fracture; without manipulation

21450

Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone.

26607

Chapter 6 44

Respiratory System Respiratory System Organized by Anatomic Site Then by Type of Procedure Includes procedures of the nose, sinuses, larynx

(voice box), trachea (windpipe), bronchial tubes, lungs, and pleura (membrane that surrounds the lung)

Coding Procedures & Services Surgery:Surgery: Respiratory, Cardiovascular, Hemic & Respiratory, Cardiovascular, Hemic &

Lymphatic Systems - Lymphatic Systems - (30000-39999)(30000-39999)

Chapter 6 45

Endoscopy – is the insertion of a flexible fiber-optic tube, called scope, through a small incision into a body cavity or into a natural body opening, such as the ears, nose, mouth, vagina, etc.

Diagnostic Endoscopy – is done for the purpose of visualization and determination of the disease process.

Diagnostic Endoscopy is always included in a surgical endoscopy and may not be billed separately



Chapter 6 46

Endoscopy Procedures Diagnostic Endoscopy Surgical Endoscopy

Endoscopies Named for body area being explored

e.g., brochial tube/bronchoscopy



Performance ExercisePerformance ExerciseExample 6-14/Page 149

Chapter 6 47


Lymphatic Systems - Lymphatic Systems - (30000-39999)(30000-39999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)

31231

Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure)

31622

Chapter 6 48

Cardiovascular SystemCardiovascular System Organized by Anatomic Site Then by Type of Procedure

Procedures Include:Procedures Include: Heart & Blood Vessels, including Pacemaker

Implantation and Coronary Artery Bypass Graft (CABG)

For Additional Studies Refer to: For Additional Studies Refer to: Medicine Sections Medicine Sections Under:Under: Cardiovascular/Therapeutic Services for:

Cardiography, Echocardiography, Cardiac Catheterization & Other Vascular Studies



Chapter 6 49


Lymphatic Systems - Lymphatic Systems - (30000-39999)(30000-39999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract

33414

Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography

92975

Chapter 6 50

Digestive SystemDigestive System Organized by Anatomic Site Start with Lip & Mouth Then continues thru the Rectum and Anus

Major Organs of the digestive system include: Stomach Intestines/small/large Liver, Pancreas & Gallbladder

Coding Procedures & Services Surgery:Surgery: Digestive SystemDigestive System

(40000-49999)(40000-49999)

Chapter 6 51

Digestive SystemDigestive System

Endoscopic Procedures used through-out subsection (i.e. Laparoscopy Incision)

Endoscopic procedures are coded according to the anatomic site examined

NotesNotes defining proctosigmoidoscopy, sigmoidoscopy & colonoscopy are included under Rectum: Rectum: EndoscopyEndoscopy

Coding Procedures & Services Surgery:Surgery: Digestive SystemDigestive System

(40000-49999)(40000-49999)

Chapter 6 52

Coding Procedures & Services Surgery:Surgery: Digestive System Digestive System

(40000-49999)(40000-49999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Repair of palate; up to 2 cm

42180

Laparoscopy, surgical, appendectomy

44970

Chapter 6 53

Urinary System Urinary System Organized by Anatomic Site & Type of Procedure Include organs such as Kidney, Ureter & Bladder

Endoscopies include: Renal Endoscopy, Ureteral endoscopy, Cystoscopy,

Urethroscopy & Cystourethroscopy Urodynamics

Separate subcategory found under Bladder Urodynamics procedure measure how well the

bladder stores and holds urine as well as the rate at which urine moves out of the bladder

Coding Procedures & Services Surgery:Surgery: Urinary, Male Genital & Female Genital Systems Urinary, Male Genital & Female Genital Systems

(50000-58999)(50000-58999)

Chapter 6 54

Male Genital SystemMale Genital System Divided by Anatomic Categories of Penis, Testis,

Spermatic Cord, Prostate, etc

LesionsLesions May have specific code assigned


(50000-58999)(50000-58999)

Chapter 6 55

Male Genital System – Male Genital System – Cont.Cont. Interset SurgeryInterset Surgery

Is a Subsection following “Male Genital System”“Male Genital System” Consist of only 2 Codes

5597055970 – Intersex survey; male to female 5598055980 – Female to male


(50000-58999)(50000-58999)

Performance ExercisePerformance ExerciseExample 6-15/Page 150

Chapter 6 56

Female Genital System/Female Genital System/Maternity Care & DeliveryMaternity Care & Delivery Organized by Anatomic Site Subsection starts with the external genitalia Then progress upward thru the female genital system to

the uterus, fallopian & uterine tubes & conclude with the ovary

The last category is In Vitro- Fertilization


(50000-58999)(50000-58999)

Chapter 6 57

Incision & Drainage (I&D) Codes in the subsection with notes directing you to the

Integumentary SystemIntegumentary System for specific I&D procedures

Read Code DescriptionRead Code Description to determine surgical approach is Vaginal or abdominal

Many codes include bilateral descriptions as well as a variety of procedures bundled together and routinely performed at same time of the operative session.

Performance ExercisePerformance Exercise Figure 6-17/Page 150 Table 6-3/Page 151


(50000-58999)(50000-58999)

Chapter 6 58

Maternity Care & DeliveryMaternity Care & Delivery Subsection following the Female Genital System Includes:

Antepartum, Vaginal Delivery & Cesarean Delivery Delivery After Previous Cesarean DeliveryDelivery After Previous Cesarean Delivery

Category following Cesarean Delivery Referred to as VBAC, or vaginal birth after cesarean

AbortionAbortion Last Category within the subsection

Performance ExercisePerformance Exercise Example 6-17/Page 1506-17/Page 150 & Table 6-3/Page 151Table 6-3/Page 151


(50000-58999)(50000-58999)

Chapter 6 59

Coding Procedures & Services Surgery:Surgery: Urinary, Male Genital & Female Genital Urinary, Male Genital & Female Genital

Systems/ Systems/ (50000-58999)(50000-58999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Biopsy, prostate; needle or punch, single or multiple, any approach

55700

Biopsy of ovary, unilateral or bilateral (separate procedure)

58900

Aspiration of bladder by needle

51000

Chapter 6 60

Nervous SystemNervous System Code in subsections deals with both Central Central &

Peripheral Peripheral Nervous System ProceduresProcedures

Brain, spinal cord, & all types of nerves Organized by Anatomic site & then Procedure

Coding Procedures & Services Surgery:Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Endocrine, Nervous, Eye & Ocular Adnexa/Auditory

Systems Systems (60000-69999)(60000-69999)

Chapter 6 61

Eye & Ocular Adnexa/Auditory SystemEye & Ocular Adnexa/Auditory System Includes Surgical Codes of the Eye & related visual

structures. Modifier –50Modifier –50 (bilateral procedure) appended all procedures

when done on both eyes. Extensive Notes such as “previous eye surgery”“previous eye surgery” are found

through-out this subsection Auditory System/SubsectionAuditory System/Subsection

Divided into categories of External Ear, Middle Ear, Inner Ear & Temporal Bone Middle Fossa Approach

Coding Procedures & Services Surgery:Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory Endocrine, Nervous, Eye & Ocular Adnexa/Auditory

Systems Systems (60000-69999)(60000-69999)

Chapter 6 62

Operating MicroscopeOperating Microscope Last subsection of the Surgical section

Has only one code (69990 69990 - for use of a operating for use of a operating microscope when the surgical code microscope when the surgical code does notdoes not contain the contain the microscope as an inclusive component)microscope as an inclusive component)

Code Code 6999069990 used in all Surgery Subsections where used in all Surgery Subsections where Microscope needs to be coded Microscope needs to be coded (i.e. 19364- breast reconstruction)

Coding Procedures & Services Surgery:Surgery: Operating MicroscopeOperating Microscope

(69990)(69990)

Chapter 6 63

Coding Procedures & Services Surgery:Surgery: Endocrine, Nervous, Eye & Ocular Endocrine, Nervous, Eye & Ocular

Adnexa/Auditory Systems Adnexa/Auditory Systems (60000-69999) (60000-69999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device

61107

Biopsy of Cornea

65410

Chapter 6 64

Radiology SectionRadiology Section Include Nuclear Medicine & Diagnostic Ultrasound

Subsections/References are:Subsections/References are: Diagnostic Radiology/X-ray indexX-ray index Diagnostic Ultrasound/Ultrasound indexUltrasound index Radiation Oncology/RadiationRadiation Therapy indexTherapy index Nuclear Medicine/Nuclear Medicine indexNuclear Medicine index

Coding Procedures & Services Radiology SectionRadiology Section

(70000-79999)(70000-79999)

Chapter 6 65

Professional & Technical Components Professional Components

Tests/Procedures performs by Physician such as interpreting an Electrocardiogram (ECG), reading an X-ray, or making an observation and determination using a microscope.

Technical Component The use of equipment and its operators that perform the test or

procedure, that is, the ECG machine and technician, radiography machine and technician and microscope technician.

When the physician physician performs both the professionalprofessional & technical technical component there is know need to modify the Code.

Coding Procedures & Services Radiology Section Radiology Section

(70000-79999)(70000-79999)

Chapter 6 66

Professional & Technical Components – cont. Modify Procedures

Modifier -Modifier -2626/professional element used when the physician performs only the professional component

Modifier –TCModifier –TC/technical element used only when billing for technical component

Performance ExercisePerformance Exercise Example Example 6-18/Page 1526-18/Page 152


(70000-79999)(70000-79999)

Chapter 6 67

Professional & Technical Components Cont. Combination CodingCombination Coding - Is a code from one section of

the procedural code bookprocedural code book combined with a code from another section that is used to completely describe a that is used to completely describe a procedure performed. procedure performed.

Services that maybe combined are: Injection of contrast materials Placement of catheters Placement of guidewires Placement of stents


(70000-79999)(70000-79999)

Chapter 6 68

Radiology ProcedureRadiology Procedure When a radiology procedure is performed from

the required combined services: A Code from the Radiology SectionRadiology Section describes the

Procedure A Code from the Surgery SectionSurgery Section describe the

Combination Procedure Performance ExercisePerformance Exercise

Example Example 6-19/Page 1536-19/Page 153


(70000-79999)(70000-79999)

Chapter 6 69


(70000-79999) (70000-79999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Radiologic examination; forearm, two views

73090

Ultrasound, transvaginal

76830

Injection procedure for knee arthrography

Surgery 27370Surgery 27370 && Radiology 73580Radiology 73580

Chapter 6 70

Pathology & LaboratoryPathology & Laboratory Codes listed according to type of Test performed (i.e.,

Hematology Tests, Urinalysis, etc.) Test Panels

Listed under first subsection “Organ or Disease Oriented “Organ or Disease Oriented Panels”Panels”

Single CodeSingle Code that groups Lab Tests which are frequently done together.

To use a Panel Code, all test listed within the panel must be performed

Coding Procedures & Services Pathology & Laboratory Pathology & Laboratory

(80000-89999)(80000-89999)

Chapter 6 71

Qualitative/Quantitative Analysis Qualitative AnalysisQualitative Analysis test may determines the presence presence of

an agent within the body

Quantitative AnalysisQuantitative Analysis measures how muchhow much of the agent is within the body


(80000-89999)(80000-89999)

Chapter 6 72

Surgical Pathology Arranged according to Levels/In Alphabetical Alphabetical

OrderOrder Level I/Level I/Gross Exam only ((which means the way the which means the way the

specimen looks to the naked eye before it is specimen looks to the naked eye before it is prepared for microscopic study.)prepared for microscopic study.)

Level II/Level II/Gross & Microscopic Exam (it (it identification identification of tissue in the absence of disease)of tissue in the absence of disease)

Level IIILevel III through through Level VILevel VI//Gross & Microscopic Exam ((Exam of diseased tissue and Exam of diseased tissue and each level requires each level requires additional work of the pathologist.additional work of the pathologist.


(80000-89999)(80000-89999)

Chapter 6 73


(80000-89999)(80000-89999)PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Acute hepatitis panel

80074

Insulin antibodies

86337

Chapter 6 74

Medicine SectionMedicine Section List of codes used by PhysicianPhysician of different Specialties Specialties in

conjunction with codes from different sections of the CPT Diagnostic Diagnostic && Therapeutic ServicesTherapeutic Services that are not surgically

invasive are listed in this section, including many specialized testing

NotesNotes in this section should be carefully read before coding carefully read before coding a subsection, category or subcategorya subsection, category or subcategory

DocumentationDocumentation may be included with the claim form to justify the use of the code

Coding Procedures & Services Medicine Section Medicine Section

(90000-99199)(90000-99199)

Chapter 6 75

Drugs & Injections Five Codes (90782, 90783, 90784, 90788 & 90799)(90782, 90783, 90784, 90788 & 90799) in the subsection:

“Therapeutic, Prophylactic or Diagnostic Injections”, which: Represents all subcutaneous, intramuscular, intra-arterial, and

intravenous injections Insurance may require additional information on the substance being

injected and communicated by: Listing the name, amount, & strength of the medication A NDC NDC (national drug code)(national drug code) may be used to specify the drug, dosage,

and the manufacturer HCPCS Level II CodeHCPCS Level II Code may be used to specify the injected drug


(90000-99199)(90000-99199)

Chapter 6 76

Special Services, Procedures, and Reports Additional codes are found under the category

“Miscellaneous Services”“Miscellaneous Services” Codes provide physician with means of identifying Special Special

Services & ReportsServices & Reports that are an addition to basic services provided

Two commonly used codes are: 9900099000 – Handling and/or conveyance of specimen 9907099070 – Supplies and materials (except spectacles)


(90000-99199)(90000-99199)

Chapter 6 77


(90000-99199) (90000-99199) PERFORMANCE EXERCISEPERFORMANCE EXERCISE

Lyme disease vaccine, adult dosage, for intramuscular use

90665

Measles and rubella virus vaccine, live for subcutaneous use

90708

Chapter 6 78

Bundled Code Single Procedure Code used to report group of related

procedures Unbundling

The practice of using numerous CPT Codes to identify procedures normally covered by a single code

Also known as: Itemizing, Exploding, Charges, Fragmented Billing or Surgery, or A La Carte Medicine

Considered “Fraud”“Fraud” if done intentionally for increased reimbursement (Can result in Claim AuditClaim Audit)

Coding Procedures & Services Coding TerminologyCoding Terminology

Chapter 6 79

Unbundling Examples are: Fragmenting Fragmenting one service into component parts and coding

each component as if it were a separate service Example 6-20/156Example 6-20/156

Reporting separate codes for related services when one Comprehensive CodesComprehensive Codes includes all related services

Example 6-21/156Example 6-21/156 Coding Bilateral ProceduresBilateral Procedures as two codes when one code is

inclusive Example 6-22/156Example 6-22/156


Chapter 6 80

Unbundling Examples Cont. Separating a Surgical ApproachSurgical Approach from a major surgical

service that includes the same approach Example 6-23/156Example 6-23/156

Downcoding occurs when: The Physician Coding SystemCoding System does not match the Coding

System of the Insurance Company receiving the Claim Example 6-24/156Example 6-24/156


Chapter 6 81

UpcodingUpcoding Deliberate manipulation of CPT Codes for increased payment

Upcoding can be spotted in Insurance Carrier’s software screens, such as the prepayment, postpayment or stop alert prepayment, postpayment or stop alert screensscreens


Chapter 6 82

Code Edits (Software)Code Edits (Software) Correct Coding Initiative (CCI)Correct Coding Initiative (CCI) – was implemented by

Medicare on 01/01/96 Contain a code edit system consistent with Medicare policies Its function is to eliminate improper reporting of CPT Codes. When online edit is performed, the computer software

program checks: Codes on an Insurance Form Detect improper code submissions

Similar software is used by private payers, other Federal private payers, other Federal programs and State Medicare programs.programs and State Medicare programs.


Chapter 6 83


Code Edits (Software) – Cont.Code Edits (Software) – Cont. Code edits will help you obtain maximum reimbursement for

each service rendered Will also Help to avoid denials, lowered reimbursement &

possible audit Code Edit Examples are:Code Edit Examples are:

Comprehensive/Component Edits Separate Code Edits Mutually Exclusive Code Edits

Chapter 6 84


Type of Code EditsType of Code Edits Comprehensive/Component Edits

Single Procedural code that describes or covers two or more CPT component codes that are bundled together as one unit

Comprehensive Codes are never indentednever indented and the basis and the basis for its description appears before the semicolon (;)for its description appears before the semicolon (;)

Chapter 6 85


Type of Code Edits – Type of Code Edits – Cont. Component Code

The portion of a service described before before the semicolon (;) of a CPT comprehensive code, together with the portion of a service described by the indented (component) code

Component Code is indentedis indented Should be used only be used if both portions of the service

were performed Performance ExercisePerformance Exercise

Example 6-25/157Example 6-25/157

Chapter 6 86


Separate Procedure Code Edits Integral part of a large procedure and does not

need a separate code, unless performed independently and not immediately related to other service

Performance ExercisePerformance Exercise Example 6-26/157Example 6-26/157

Chapter 6 87


Mutually Exclusive Code Edits Procedures that meet any of the following criteria: Code combinations that are restricted by the guidelines outlined in CPT

Procedures that cannot be reasonably done during the same session Procedures that represent medically impossible or improbable code

combinations Procedures that represent two methods of performing the same

service

Performance ExercisePerformance Exercise Example 6-27/157Example 6-27/157

Chapter 6 88

Illegal or Unethical Coding To avoid Illegal Or unethical coding: follow Coding follow Coding

Guidelines & Individual Coding Policies from various Guidelines & Individual Coding Policies from various Insurance CarriersInsurance Carriers

Modifiers Additional Modifiers:

Figure 6-6A & B - Figure 6-6A & B - Page 160 & 161Page 160 & 161 Complete List of Modifier/in Appendix AAppendix A


chapter 61 surgery, radiology, pathology/laboratory, and medicine chapter 6 part ii: coding...

Documents

correct code

code range

procedure code terminology

code scenarios

subsections of surgery

thesurgery section

correct section

surgery sections