Transcript BLUE CROSS/BLUE SHIELD - Future Home of a New Site with

Chapter 6
CODING PROCEDURES
Part II:
Surgery, Radiology,
Pathology/Laboratory, and Medicine
Chapter 6
1
PROCEDURAL CODING
PART II
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Learning Objectives
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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
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PROCEDURAL CODING
PART II
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Learning Objectives
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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
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PROCEDURAL CODING
PART II
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Performance Objective
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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
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Key Terms
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Add-on code
Anesthesia
Bilateral Procedure
Bundled Code
Closed Fracture
Closed Treatment
Component Code
Comprehensive Code
Downcoding
Elective Surgery
Chapter 6
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Endoscopy
Fixation
Fracture Manipulation
Global Surgery Policy
Indented Code
Open Fracture
Open Treatment
Percutaneous
Treatment
Professional
Component (PC)
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Key Terms
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Qualitative
Analysis
Quantitative
Analysis
Separate
Procedures
Stand-alone Codes
Surgical Package
Technical
Component (TC)
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Chapter 6
Test Panel
Unbundling
Upcoding
6
Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Introduction to the Surgery Section
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Largest Section of the CPT Codebook
16 Subsections, divided according to Body
Systems
Guidelines are found at the beginning of the
Surgery Sections.
Subsection further divided into Categories
based on Anatomic Site
Subcategories are within each Category which
list the type of procedure or condition.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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How to Code Effectively
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You must be able to analyze a procedure
description and identify various terms that will
direct you to the correct code.
To do this you must know the main categories under
which services and procedures are listed according
to their main term in the index.
After the procedure, service, or condition is
identified in the index, search for a subterm and a
sub-subterm that further defines the procedure.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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How to Code Effectively – Cont.
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When a code range is found, turn to the correct
section and read all descriptions listed under the
code range before selecting a code.
Performance Exercise
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Table 6-2/Page 138
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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How to Code Effectively
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Identify Main Term(s) in the Procedure
Description of the Medical Record
Locate Main Term(s) in the Index & Document
Code Range
Turn to the Correct Section of the CPT & Read all
Description listed in the Code Range
Select the Correct Code
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section/(10040-69979)
PERFORMANCE EXERCISE

Excision of tendon, finger, flexor, single
(separate procedure), each
26180
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How to Code Effectively
 Identify Main Term(s) in the Procedure Description of
the Medical Record
 Locate Main Term(s) in the Index & Document Code
Range
 Turn to the Correct Section of the CPT & Read all
Description listed in the Code Range
 Select the Correct Code
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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How to Code Effectively – Cont.
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Stand-alone Codes – are procedure codes
that have a full description.
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Comes before the (;)
Terminology after the (;) has a Dependent
Status as the Subsequent Indented Entries
Performance Exercise
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Figure 6-3/Page 138
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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How to Code Effectively – Cont.
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Indented 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
before the semicolon (;) and,
then continue with the indented
description listed by the subsequent code
(indented code).
Performance Exercise
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Figure 6-3/Page 138
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Integral Code Description
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One Code is part of another based on
language used in the description
Example 6-2/Page139
Parentheses ( ) further define & tell where
other services are located
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Figure 6-4/Page 139
Chapter 6
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Coding Steps
Step 1
Step 2
Step 3
Step 4
Step 5
Become familiar with CPT codes
Find the services listed on patient
encounter form
Look up codes in index, then look up
actual code
Determine appropriate modifiers
Record the procedure code on the
insurance claim; PROOFREAD
numbers
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Coding from the Operative Report
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Read the Operative report thoroughly & code
on documented operations
Determine Bundled or Unbundled
Procedures
Never Code Verbal Procedures
Coding Rule: “Not Documented, Not Done”!
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(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
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Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Decision for Surgery  Criteria to Evaluate
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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 Exercise
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Figure 6-4/Page 141
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Decision for Surgery
 -57 (Modifier) – An E/M service that resulted in
the initial decision to perform the surgery.
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-25 (Modifier) - Significant, separately
identifiable evaluation and management service
by the same physician on the same day of the
procedure or other service.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Surgical 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.
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The period of time that is covered for follow-up care is
referred to as the Global Period.
For Example, the Global Period for repairing a
Tendon might be set at 15 days.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Surgical Package – Cont.
A Global Period for Major Surgery such as
Appendectomy may be set at 100 days.
After the Global Period ends additional services that
are provided can be reported separately for additional
payment.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Surgical Package – Cont.
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Surgical Package Includes
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Combination of Services
Global Period
Surgical Procedures
Anesthesia
Related E/M Encounter
Postoperative Care
Private Carriers
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May have an individual policy on what is included in the
package.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Medicare Global Package - Included
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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
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Medicare Global Package - Excluded
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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)
Related Procedures for postoperative complications that requires
a return trip to the operating room (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.
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Follow-Up Days
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Vary 0-day or 10-day for Minor Surgeries
45-day or 90-day for Major Surgeries
Most States use Relative Value Studies fee schedule
for Worker’s Compensation cases
 List the follow-up days allowed for most surgical
procedures
Federal Register
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Published annually
List follow-up days for Medicare Services
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Multiple Procedure Modifier –51
 Report the primary service or procedure (identified by
the highest dollar value listed)
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Identify all additional services or Procedures by
appending code(s) with modifier –51 or use the separate
five-digit modifier 09951
Appendix E – Summary of CPT Codes Exempt from
Modifier 51
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10040-69979)
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Add-on Code
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Add-on-Code Description start with:
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Noted by a Cross (+) Symbol represents additional Procedure
done with Primary Procedure
Found in Appendix D of CPT
Can not billed without the primary procedure
“in addition”
“list separately
Or “second lesion”
Performance Exercise
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Example 6-5/Example 6-6/Page 143
Chapter 6
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Coding Procedures & Services

Introduction to the Surgery Section
(10040-69979)
Add-on Code – Cont.
 Bilateral Procedures - is one procedure performed
on two sides.
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Two ways to Bill
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List the Code Once with Modifier –50 & double
the fee
List the Code Twice using a single fee & add the
second listing with Modifier –50
Performance Exercise
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Example 6-7/Page 143
Chapter 6
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Coding Procedures & Services
Introduction to the Surgery Section
(10000-19999)
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Assistant At Surgery
 Modifiers
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-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
allowed fee of the primary Surgeon.
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Performance Exercise
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Example 6-8/Page
144
Chapter 6
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Coding Procedures & Services
Surgery: Integumentary System
(10000-19999)
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Integumentary System
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First Subsection listed in the Surgery Section
Contains Procedures performed on the Skin
Benign versus Malignant
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Neoplasm – must indicate benign or malignant
Claim Form – should be delayed until the Pathology report can confirm
or deny Benign vs Malignant
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Lesion – is any discontinuity of the skin
Biopsy – 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
procedure code, and not reported separately.
Chapter 6
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Coding Procedures & Services
Surgery: Integumentary System
(10000-19999)
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Lesion –when coding removal of lesions note the:
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Anatomic Site
Size, measured in centimeters
Number of lesions removed
Process used to remove the lesion (excision,
destruction, paring, shaving)
Morphology (appearance of specimen’s shape and
structure used to determine benign or malignant status)
Chapter 6
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Coding Procedures & Services
Surgery: Integumentary System
(10000-19999)
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Repair of Lacerations
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Simple Closure – Superficial; involving the epidermis,
dermis, or subcutaneous tissue.
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Intermediate Closure – Requires layered closure of
deeper subcutaneous tissue in addition to the simple
closure.
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Complex Closure – Requires more than one layered
closure; debridement, scar revision, extensive
undermining, stents, or retention sutures
Chapter 6
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Coding Procedures & Services
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Surgery: Integumentary System
(10000-19999)
Multiple Lesions
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Modifier –51 (Multiple Procedures)
Read description & look for terms such as
complicated, complex, more than, etc
Watch for Add-on-codes (+) VS Codes eligible for
Modifier –51 & indented Codes
Surgical Supplies
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Bundled into Surgical Code (99070) or HCPCS Level
II Codes
Chapter 6
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Coding Procedures & Services
Surgery: Integumentary System
(10000-19999)
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Breast Category
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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
(bilateral)
Performance Exercise
 Example 6-9, 6-10 & 6-11/Page 145-46
Chapter 6
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Coding Procedures & Services
Surgery: Integumentary System
(10000-19999)
PERFORMANCE EXERCISE
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Breast reconstruction with free flap
19364
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Preoperative placement of needle localization
wire, breast:
19290
Chapter 6
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Coding Procedures & Services
Surgery: Musculoskeletal System
(20000-29999)
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Musculoskeletal System
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Arranged according to Anatomic Site
“General” first Category Contain Procedures &
Subcategories for different Anatomic Sites.
Remaining Categories Start from the “Head” to the
“Toe”
Subcategories Under Each Anatomic Category
Include:
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Incision
Excision
Introduction/Removal
Chapter 6
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Coding Procedures & Services
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Surgery: Musculoskeletal System
(20000-29999)
Subcategories Under Each Anatomic Category
Include:
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Fracture/Dislocation
Arthrodesis
Amputation
Unlisted Procedures
Fractures are:
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Open/skin broken by the fragmented bone (Compound
Fracture)
Closed/skin is not broken
Percutaneous/neither Opened or Closed
Chapter 6
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Coding Procedures & Services
Surgery: Musculoskeletal System
(20000-29999)
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Coding Treatment of a Fracture
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Locate the Anatomic Site
Find Subcategory “Fracture and/or Dislocation”
Then find the appropriate code
Description of Fractures are either:
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“With Manipulation” or
“Without Manipulation”
Chapter 6
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Coding Procedures & Services
Surgery: Musculoskeletal System
(20000-29999)
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Other Descriptive Terms Are:
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“Internal Fixation”
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“External Fixation”
Chapter 6
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Coding Procedures & Services
Surgery: Musculoskeletal System
(20000-29999)
 Fracture Manipulation is:
• The manual stretching or applying pressure or traction
to realign the broken (fractured) bone.
• Referred to as “reduction”.
 Fixation – is the use of hardware (instrumentation) to
keep a bone in place.
It can be applied internally (e.g., plates, rod, pin) or
Externally (e.g., pins that comes thru the skin to the
outside to keep the fractured bone from moving).
Chapter 6
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Coding Procedures & Services
Surgery: Musculoskeletal System
(20000-29999)
 Fracture Follow-up Period:
The surgical package rule applies.
 All fracture code carry a 90-day follow-up
period.
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Performance Exercise
Example 6-12/Page 147
Example 6-13/Page 147
Chapter 6
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Coding Procedures & Services
Surgery: Musculoskeletal System
(20000-29999)
PERFORMANCE EXERCISE
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Closed treatment of mandibular fracture;
without manipulation
21450
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Closed treatment of metacarpal fracture, with
manipulation, with external fixation, each bone.
26607
Chapter 6
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Coding Procedures & Services
Surgery: Respiratory, Cardiovascular, Hemic &
Lymphatic Systems - (30000-39999)
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Respiratory System
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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)
Chapter 6
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Coding Procedures & Services
Surgery: Respiratory, Cardiovascular, Hemic &
Lymphatic Systems - (30000-39999)
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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.
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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
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Coding Procedures & Services
Surgery: Respiratory, Cardiovascular, Hemic &
Lymphatic Systems - (30000-39999)
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Endoscopy Procedures
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Diagnostic Endoscopy
Surgical Endoscopy
Endoscopies
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Named for body area being explored
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e.g., brochial tube/bronchoscopy
Performance Exercise
Example 6-14/Page 149
Chapter 6
46
Coding Procedures & Services
Surgery: Respiratory, Cardiovascular, Hemic &
Lymphatic Systems - (30000-39999)
PERFORMANCE EXERCISE
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Nasal endoscopy, diagnostic, unilateral or
bilateral (separate procedure)
31231
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Bronchoscopy, rigid or flexible, with or without
fluoroscopic guidance; diagnostic, with or without
cell washing (separate procedure)
31622
Chapter 6
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Coding Procedures & Services
Surgery: Respiratory, Cardiovascular, Hemic &
Lymphatic Systems - (30000-39999)
 Cardiovascular System
Organized by Anatomic Site
 Then by Type of Procedure
Procedures Include:
 Heart & Blood Vessels, including Pacemaker
Implantation and Coronary Artery Bypass Graft
(CABG)
For Additional Studies Refer to: Medicine Sections
Under:
 Cardiovascular/Therapeutic Services for:
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Cardiography, Echocardiography, Cardiac Catheterization &
Other Vascular Studies
Chapter 6
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Coding Procedures & Services
Surgery: Respiratory, Cardiovascular, Hemic &
Lymphatic Systems - (30000-39999)
PERFORMANCE EXERCISE
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Repair of left ventricular outflow tract
obstruction by patch enlargement of the outflow
tract
33414
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Thrombolysis, coronary; by intracoronary
infusion, including selective coronary
angiography
92975
Chapter 6
49
Coding Procedures & Services
Surgery: Digestive System
(40000-49999)
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Digestive System
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Organized by Anatomic Site
Start with Lip & Mouth
Then continues thru the Rectum and Anus
Major Organs of the digestive system include:

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Stomach
Intestines/small/large
Liver, Pancreas & Gallbladder
Chapter 6
50
Coding Procedures & Services
Surgery: Digestive System
(40000-49999)
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Digestive System
Endoscopic Procedures used through-out
subsection (i.e. Laparoscopy Incision)
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
Endoscopic procedures are coded according to the
anatomic site examined
Notes defining proctosigmoidoscopy, sigmoidoscopy &
colonoscopy are included under Rectum: Endoscopy
Chapter 6
51
Coding Procedures & Services
Surgery: Digestive System
(40000-49999)
PERFORMANCE EXERCISE
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Repair of palate; up to 2 cm
42180
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Laparoscopy, surgical, appendectomy
44970
Chapter 6
52
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital Systems
(50000-58999)
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Urinary System
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Endoscopies include:
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Renal Endoscopy, Ureteral endoscopy, Cystoscopy,
Urethroscopy & Cystourethroscopy
Urodynamics


Organized by Anatomic Site & Type of Procedure
Include organs such as Kidney, Ureter & Bladder
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 Chapter
of the
bladder
6
53
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital Systems
(50000-58999)

Male Genital System
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
Divided by Anatomic Categories of Penis, Testis,
Spermatic Cord, Prostate, etc
Lesions
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May have specific code assigned
Chapter 6
54
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital Systems
(50000-58999)
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Male Genital System – Cont.

Interset Surgery


Is a Subsection following “Male Genital System”
Consist of only 2 Codes
55970 – Intersex survey; male to female
 55980 – Female to male
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Performance Exercise
Example 6-15/Page 150
Chapter 6
55
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital Systems
(50000-58999)

Female Genital System/Maternity 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
Chapter 6
56
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital Systems
(50000-58999)

Incision & Drainage (I&D)

Codes in the subsection with notes directing you to the
Integumentary System for specific I&D procedures

Read 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 Exercise

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
Figure 6-17/Page 150
Table 6-3/Page 151
Chapter 6
57
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital Systems
(50000-58999)

Maternity Care & Delivery


Delivery After Previous Cesarean Delivery



Category following Cesarean Delivery
Referred to as VBAC, or vaginal birth after cesarean
Abortion


Subsection following the Female Genital System Includes:
 Antepartum, Vaginal Delivery & Cesarean Delivery
Last Category within the subsection
Performance Exercise

Example 6-17/Page 150 & Table 6-3/Page 151
Chapter 6
58
Coding Procedures & Services
Surgery: Urinary, Male Genital & Female Genital
Systems/ (50000-58999)
PERFORMANCE 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
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Coding Procedures & Services
Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory
Systems (60000-69999)

Nervous System


Code in subsections deals with both Central &
Peripheral Nervous System
Procedures
Brain, spinal cord, & all types of nerves
 Organized by Anatomic site & then Procedure

Chapter 6
60
Coding Procedures & Services
Surgery: Endocrine, Nervous, Eye & Ocular Adnexa/Auditory
Systems (60000-69999)

Eye & Ocular Adnexa/Auditory System




Includes Surgical Codes of the Eye & related visual
structures.
Modifier –50 (bilateral procedure) appended all procedures
when done on both eyes.
Extensive Notes such as “previous eye surgery” are found
through-out this subsection
Auditory System/Subsection

Divided into categories of External Ear, Middle Ear, Inner
Ear & Temporal Bone Middle Fossa Approach
Chapter 6
61
Coding Procedures & Services
Surgery: Operating Microscope
(69990)

Operating Microscope

Last subsection of the Surgical section

Has only one code (69990 - for use of a operating
microscope when the surgical code does not contain the
microscope as an inclusive component)

Code 69990 used in all Surgery Subsections where
Microscope needs to be coded (i.e. 19364- breast
reconstruction)
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Coding Procedures & Services
Surgery: Endocrine, Nervous, Eye & Ocular
Adnexa/Auditory Systems (60000-69999)
PERFORMANCE EXERCISE

Twist drill hole for subdural or ventricular puncture; for
implanting ventricular catheter or pressure recording
device
61107

Biopsy of Cornea
65410
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Coding Procedures & Services
Radiology Section
(70000-79999)

Radiology Section


Include Nuclear Medicine & Diagnostic Ultrasound
Subsections/References are:




Diagnostic Radiology/X-ray index
Diagnostic Ultrasound/Ultrasound index
Radiation Oncology/Radiation Therapy index
Nuclear Medicine/Nuclear Medicine index
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Coding Procedures & Services
Radiology Section
(70000-79999)

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 performs both the professional & technical
component there is know need to modify the Code.
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Coding Procedures & Services
Radiology Section
(70000-79999)


Professional & Technical Components – cont.
Modify Procedures



Modifier -26/professional element used when the physician performs
only the professional component
Modifier –TC/technical element used only when billing for technical
component
Performance Exercise

Example 6-18/Page 152
Chapter 6
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Coding Procedures & Services
Radiology Section
(70000-79999)

Professional & Technical Components Cont.
 Combination Coding - Is a code from one section of
the procedural code book combined with a code from
another section that is used to completely describe a
procedure performed.
 Services that maybe combined are:




Injection of contrast materials
Placement of catheters
Placement of guidewires
Placement of stents
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Coding Procedures & Services
Radiology Section
(70000-79999)

Radiology Procedure

When a radiology procedure is performed from
the required combined services:



A Code from the Radiology Section describes the
Procedure
A Code from the Surgery Section describe the
Combination Procedure
Performance Exercise

Example 6-19/Page 153
Chapter 6
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Coding Procedures & Services
Radiology Section
(70000-79999)
PERFORMANCE EXERCISE

Radiologic examination; forearm, two views
73090

Ultrasound, transvaginal
76830

Injection procedure for knee arthrography
Surgery 27370 & Radiology 73580
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Coding Procedures & Services
Pathology & Laboratory
(80000-89999)

Pathology & 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
Panels”
Single Code that groups Lab Tests which are frequently done
together.
To use a Panel Code, all test listed within the panel must be
performed
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Coding Procedures & Services
Pathology & Laboratory
(80000-89999)

Qualitative/Quantitative Analysis

Qualitative Analysis test may determines the presence of
an agent within the body

Quantitative Analysis measures how much of the agent is
within the body
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Coding Procedures & Services
Pathology & Laboratory
(80000-89999)

Surgical Pathology

Arranged according to Levels/In Alphabetical
Order

Level I/Gross Exam only (which means the way the
specimen looks to the naked eye before it is prepared
for microscopic study.)

Level II/Gross & Microscopic Exam (it identification of
tissue in the absence of disease)

Level III through Level VI/Gross & Microscopic Exam
(Exam of diseased tissue and each level requires
additional work of theChapter
pathologist.
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72
Coding Procedures & Services
Pathology & Laboratory
(80000-89999)
PERFORMANCE EXERCISE

Acute hepatitis panel
80074

Insulin antibodies
86337
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Coding Procedures & Services
Medicine Section
(90000-99199)

Medicine Section




List of codes used by Physician of different Specialties in
conjunction with codes from different sections of the CPT
Diagnostic & Therapeutic Services that are not surgically
invasive are listed in this section, including many specialized
testing
Notes in this section should be carefully read before coding
a subsection, category or subcategory
Documentation may be included with the claim form to
justify the use of the code
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Coding Procedures & Services
Medicine Section
(90000-99199)

Drugs & Injections


Five Codes (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 (national drug code) may be used to specify the drug, dosage,
and the manufacturer
HCPCS Level II Code may be used to specify the injected drug
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Coding Procedures & Services
Medicine Section
(90000-99199)

Special Services, Procedures, and Reports



Additional codes are found under the category
“Miscellaneous Services”
Codes provide physician with means of identifying Special
Services & Reports that are an addition to basic services
provided
Two commonly used codes are:


99000 – Handling and/or conveyance of specimen
99070 – Supplies and materials (except spectacles)
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Coding Procedures & Services
Medicine Section
(90000-99199)
PERFORMANCE EXERCISE

Lyme disease vaccine, adult dosage, for intramuscular
use
90665

Measles and rubella virus vaccine, live for
subcutaneous use
90708
Chapter 6
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Coding Procedures & Services
Coding Terminology

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” if done intentionally for increased
reimbursement (Can result in Claim Audit)
Chapter 6
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Coding Procedures & Services
Coding Terminology

Unbundling Examples are:

Fragmenting one service into component parts and coding
each component as if it were a separate service


Reporting separate codes for related services when one
Comprehensive Codes includes all related services


Example 6-20/156
Example 6-21/156
Coding Bilateral Procedures as two codes when one code is
inclusive

Example 6-22/156
Chapter 6
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Coding Procedures & Services
Coding Terminology

Unbundling Examples Cont.

Separating a Surgical Approach from a major surgical
service that includes the same approach


Example 6-23/156
Downcoding occurs when:

The Physician Coding System does not match the Coding
System of the Insurance Company receiving the Claim

Example 6-24/156
Chapter 6
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Coding Procedures & Services
Coding Terminology

Upcoding
 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
screens
Chapter 6
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Coding Procedures & Services
Coding Terminology

Code Edits (Software)
 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
programs and State Medicare programs.
Chapter 6
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Coding Procedures & Services
Coding Terminology


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:



Comprehensive/Component Edits
Separate Code Edits
Mutually Exclusive Code Edits
Chapter 6
83

Coding Procedures & Services
Coding Terminology
Type 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 indented and the basis
for its description appears before the semicolon (;)
Chapter 6
84

Coding Procedures & Services
Coding Terminology
Type of Code Edits – Cont.

Component Code




The portion of a service described before the semicolon
(;) of a CPT comprehensive code, together with the
portion of a service described by the indented (component)
code
Component Code is indented
Should be used only be used if both portions of the service
were performed
Performance Exercise

Example 6-25/157
Chapter 6
85
Coding Procedures & Services
Coding Terminology

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 Exercise
 Example 6-26/157


Chapter 6
86
Coding Procedures & Services
Coding Terminology

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 Exercise
 Example 6-27/157
Chapter 6
87
Coding Procedures & Services
Coding Terminology

Illegal or Unethical Coding


To avoid Illegal Or unethical coding: follow Coding
Guidelines & Individual Coding Policies from various
Insurance Carriers
Modifiers

Additional Modifiers:


Figure 6-6A & B - Page 160 & 161
Complete List of Modifier/in Appendix A
Chapter 6
88