CPT Notes

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Sinclair Community College *

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2110

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Mechanical Engineering

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Dec 6, 2023

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CPT Coding in the Ambulatory Setting CPT Coding for use in the Facility Your previous classroom experience with CPT has been geared toward coding for the physician office setting. This course will provide guidance in CPT coding for the facility, which includes hospital ambulatory/outpatient surgical settings, emergency departments, free-standing surgery centers, clinics, etc. Remember that the CPT coding system is owned and operated by the American Medical Association (AMA). This organization looks out for the best interests of physicians. So, in essence, CPT coding is written by physicians, for physicians. CPT coding is mandated by the federal government to be used under the HIPAA Transactions and Code Sets law. In order to accommodate this mandate, the CPT coding system has to be interpreted somewhat differently for facility coding. We look to the Center of Medicare and Medicaid Services (CMS), as well as the AMA through publications such as CPT Assistant, for guidance. CPT Coding Review If it has been a while since you have taken CPT coding, you will want to review your book to familiarize yourself with it once again. As a reminder, the CPT code book is set up in sections based on the services provided. The sections include: Category I Codes - ● Evaluation and Management (E & M) - code numbers 99201 - 99499 ● Anesthesia - code numbers 00100 - 01999 and 99100 - 99150 ● Surgery - code numbers 10004 - 69990 ● Radiology - code numbers 70010 - 79999 ● Pathology and Laboratory - code numbers 80047 - 89398 ● Medicine - code numbers 90281 - 99607 Category II Codes - code numbers 0001F - 9007F Although the use of Category II codes is not required, many facilities use these codes for performance measures as these codes facilitate data collection regarding the quality of care rendered by coding certain services. These codes are not to be used to replace or be substituted for Category I codes. Category III Codes - code numbers 0042T - 0770T Category III contains temporary codes for emerging services, technology, and procedures. This allows data collection for these services/procedures. Unlisted

Category I codes do not offer the opportunity to collect specific data, therefore when a Category III code is available it is to be reported instead of the unlisted Category I code. The code set for Molecular Pathology is developed for the purpose of reporting "molecular diagnostics" or genetic testing. The codes are incorporated into the Pathology and Laboratory section. The code set for Proprietary Laboratory Services. These codes describe proprietary clinical laboratory analyses and can be either provided by a single laboratory or licensed or marketed to multiple providing labs approved by the FDA. Most of the CPT codes, with the exception of E & M, are sequenced in numeric order within their sections. However, you will see in Appendix N that there are some CPT codes that have been re-sequenced within their respective sections and are out of numeric order. These codes are in the tabular in red text with a notation of "Code is out of numerical sequence. See range of codes". You will then find your code within the range given and prefaced with a # hashtag. Evaluation and Management codes changed to a time-based element and a medical decision making (MDM) element to determine some E/M codes. This is only in specific E/M codes and must be watched for when assigning for the physician's billing. In this course, we will be coding for the facility where this does not apply (more to come on this topic in another module!) Within each section of Category I, there are subsections. The largest section is Surgery, with subsections organized by body sites. The subsections are further divided by type of procedure, such as debridement, excision, biopsy, removal, repair, etc. The CPT code books Index is at the back of the book, and entries are listed alphabetically. The CPT code book is rather forgiving in its approach to locating codes. A service can be found under a number of alphabetic entries. There are four primary ways CPT uses the word "main term" for looking up the a procedure. This is done by: ● Procedure or Service - ex. Endoscopy; Anastomosis; Splint ● Organ or other anatomical sites - ex. Tibia; Colon; Salivary gland ● Condition - ex. Abscess; Entropion;, Tetralogy of Fallot ● Syndromes, Eponyms, and Abbreviations - ex. EEG; Brock Operation; Clagett Procedure HCPCS Codes In addition to CPT codes, we will also utilize HCPCS (Healthcare Common Procedure Coding System) codes as they apply to ambulatory facilities. HCPCS codes, or CPT Level II codes (not to be confused with Category II codes), were developed by CMS to allow coding and billing for services not included in CPT such as those for new technology, for drugs, supplies, ambulance services, and other services for which there was no CPT code. The code format for HCPCS codes consist of 5 characters that are

alpha-numeric, the first character is alphabetic, followed by 4 numeric characters. One example of a type of service that is used in the ambulatory setting and is reported by HCPCS codes for Medicare patients is Observation. There are codes in CPT (in the Evaluation & Management section) with which to report Observation, but CMS needed observation hours reported. The existing CPT code for observation reported services for the day. Therefore, to meet the need for this type of reporting, HCPCS codes were developed specifically for Medicare patients so that correct coding and reporting could be performed. Please read the attached link for additional information (look under the History of HCPCS). Also listed below in a link is the current alphabetic list of HCPCS Codes and a list in code order. The Table of Drugs is also included. Please keep track of these links (download and save them to your computer) as you will need to use them as references for future assignments during the rest of this course. History of HCPCS Scroll down to the HCPCS Background Information. Alpha-Numeric HCPCS Within this CMS.gov link you will also find links to the current Table of Drugs and more. Choose HCPCS20XXAPRANWEB2.xls file. Then scroll to the first 5-digit alphanumeric code A0021 and review. The Table of Drugs has been pulled from the .xls file above for ease of use. Modifiers Modifiers play a large role in coding for facilities. These modifiers and their descriptions are included in Appendix A. Modifiers are 2-character additions to the CPT or HCPCS code to provide additional information to the service. The characters can be numeric, alpha-numeric, or alpha. For this course we will be using the Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use. Reimbursement With CPT Coding It is critical for outpatient facilities to submit accurate CPT coding for the services delivered. Government-sponsored health insurance programs, such as Medicare and Medicaid, make reimbursement based upon the CPT codes submitted. Many of the commercial insurance companies are following suit. Medical necessity is determined by the CPT codes submitted along with the diagnosis codes. Auditing agencies, such as the Recovery Audit Contractors (RACs), are reviewing outpatient claims for the purpose of accuracy, and they are recovering overpayments because facilities submitted incorrect CPT codes based upon documentation. It is highly encouraged that students utilize 3M as well as the CPT code book to locate CPT codes. Using these two resources side by side in this course will be very beneficial

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to developing your coding skills. While the encoder is utilized widely in the local facilities, there are times when a code book may become necessary (such as during down time, Internet interruptions, or taking a coding test for a job and more). Encoders also may contain errors, and this is when the code book becomes an essential tool for determining the appropriate code. Sequencing CPT Codes The order in which CPT codes are reported is no less important than it is for ICD-10-CM codes. As you may remember, physician office coding is reported on a CMS-1500 form, where the CPT codes must correlate with a specific diagnosis code. For hospital outpatient departments and ambulatory surgical centers, the billing form that is used is called the Uniform Bill (UB) 04 (the last year the form was significantly updated), or CMS-1450. On a UB-04, the CPT codes are reported on line items and are assigned to a Revenue Center (RC), which is basically a uniform department number. For example, a lab CPT code is assigned a RC of 300, and an emergency room CPT code is assigned a RC of 450. The RC for Operating Room is typically 360. Coders may be responsible for assigning a Revenue Center to a CPT code that is added to the account by them. This can be done in 3M or an "abstracting system" that is used by a facility to collect vital information (such as diagnosis and procedure codes, discharge disposition, correct patient name and birthdate, insurance information, etc.) that transfers to the bill. You will see Revenue Centers in 3M are listed as REV 9999 - No Rev Code. If in a facility you will see or assign the revenue code for services you enter. The UB-04 typically prints from a facility billing system with the line items in numerical order based on the Revenue Centers. Each lab that is reported under, for example, RC 300, is listed on a single line item for each date of service. Let's say that the patient had a CBC, CMP, and PT performed in an outpatient setting. The lab would process the claim and charge for each test upon completion. Each lab test would be listed separately on the UB-04 with RC 300, a brief description of the lab test, an appropriate CPT code, and the date of service. This is all done through the Chargemaster (hardcoded), and coders do not have to assign the CPT codes. But, if the patient had one of these lab tests repeated on the same date, the coder may be responsible for applying modifier 91 to indicate that it was a repeated test. APA APCs - Ambulatory Payment Classifications The APC (Ambulatory Payment Classification) is an Outpatient Prospective Payment System for certain outpatient services provided by hospitals to Medicare patients. The following link provides detailed information regarding APCs: Hospital Outpatient Prospective Payment System

When using 3M, the "grouper" will determine the APCs as well as estimated reimbursement and status indicators assigned to that APC. Please be sure to understand the terms "status indicators" and "packaging" in relation to APC reimbursement. Status Indicators The following addenda are included in the OPPS annual update - these are updated quarterly. Addendum A shows the APC payment in relation to the APC assignment. You will see the payment rate as well as the minimum coinsurance (this is the patient's responsibility) The assigned status indicator is also listed. Addendum B shows the same information but in relation to the CPT or HCPCS code assigned. Addendum E lists CPT and HCPCS codes that are considered "Inpatient Only" procedures and all have a status indicator of C. CMS has determined which procedures should always be performed in an inpatient setting. If a procedure code from this list is reported for a patient who is registered as an outpatient, Medicare will not pay for the procedure. Addendum A and Addendum B Updates Addendum E - Inpatient Only Procedures NCCI edits National Correct Coding Initiative As you use the 3M encoder to find and sequence codes, you will see some notices in red under the title of a procedure that give a little warning about the use of this code with other codes. Those belong to the National Correct Coding Initiative developed by CMS to try to avoid improper billing and then incorrect reimbursements. The 3M encoder provides much of the information you may need in the future, but the official site for the NCCI edits is the CMS website . Following are links that help explain these edits and their uses. First is an article from AHIMA. It was written in 2000, but it gives a very clear and concise explanation of these edits. National Correct Coding Initiative Affects CPT Reporting Second is a brief explanation of the purpose of these edits. "How to Use the National Correct Coding Initiative (NCCI) Tools" is a document that you will need to read to give yourself a good understanding of the many types of edits you may encounter during coding.

This last link will open directly into the CMS website for the Procedure to Procedure (PTP) Coding Edits. Read this page to help you understand what you are about to open. Now that you are at the bottom of the page, you can see "Related Links". You will choose the line item that corresponds with your code/hospital and the current year. Pairs of Codes Example: This is taken from the list of procedures: 21501 64415 20021001 * 1 Code 21501 is the main procedure. Code 64415 is the secondary procedure. The number 20021001 stands for the date that this edit was added to the list. The date is year 2002, month 10 October, and day 01 the first. The asterisk marks that the edit is still valid; it has not been discontinued. Modifiers are allowed with this code if it appropriate to do so. For these 2 codes, why do you think that they should not be coded together? The descriptions of the codes are as follows: 21501 - Incision and drainage of deep abscess or hematoma, soft tissue of neck or thorax 64415 - Introduction/injection of anesthetic agent, diagnostic or therapeutic; brachial plexus, single The deep abscess or hematoma would need anesthesia, but it would be provided more locally. There would be no reason to provide a nerve block to perform the incision and drainage because the abscess/hematoma would be located in the subcutaneous or soft tissue, not in the path of the brachial nerve. But what if the patient had been in an accident and had nerve pain in the left arm, and the abscess was in the right side of the neck? The nerve block would not be for the purpose of delivering anesthesia in order to treat the abscess. Therefore, these 2 codes could be reported together as long as the appropriate modifier(s) are applied to 64415. Medical Necessity/Local Coverage Determinations

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Valid Physician Orders With a few exceptions, such as screening mammograms, scheduled diagnostic tests must be based on a valid physician order . Although verbal orders can be initially accepted under certain circumstances defined in an organization's bylaws, all orders must be formally signed by the ordering physician . An authenticated signature can be written, faxed, or digital (as part of an electronically generated order). Stamped signatures are NOT allowed by Medicare except in rare instances. According to Medicare, a physician order must include the following elements in order to be considered valid: ● Reason for ordering the test or service (diagnosis description, ICD-10-CM code, sign(s), symptoms) ● Test or service requested ● Provider's name ● Provider's signature ● Patient's complete name ● Patient's date of birth An order may be written by the physician on a prescription pad or pre-printed order that lists the tests performed most often. These orders often include the CPT code which will be billed through the charge master. Coders are not typically responsible for applying the CPT code for diagnostic testing such as laboratory, radiology, EKGs, etc. If the test is scheduled, these paper orders are usually sent via fax or scan to the scheduling department of the facility where the test will be performed. For tests that can be performed at the convenience of the patient (or where the patient must be fasting before it is performed), the paper order may be sent with the patient to be hand-carried to the facility of the patient's choice. With the implementation of electronic health records in most physician offices and outpatient facilities, paper orders are becoming rare. For orders written on prescription pads, faxed or scanned orders are difficult to read because of the watermark imbedded in the paper to avoid fraudulent use of the prescription pads. Medical Necessity Since most physician orders for diagnostic testing today are generated via electronic records, they can be sent directly to the facility where the exam or test will be performed. The patient may never see the order, as the physician's office staff often call to make arrangements on behalf of the patient. Staff from either the physician's office or the facility are also often responsible for determining whether the patient has insurance eligibility. These staff members also may call insurance companies to obtain approval for the test's performance. If the test is performed without prior approval, the facility may be liable for the financial cost. This may apply to both commercial or government- sponsored payers. So, what is medical necessity? For Medicare, CMS determines whether a test is

medically necessary based upon the diagnosis or by frequency. For example, would it be medically necessary for a patient to have a chest x-ray when the chief complaint is leg pain? Or if a screening mammogram was ordered more than once per year? This is why CMS developed National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Local Coverage Determinations - LCDs LCDs are used to verify that an order provides a diagnosis that indicates the medical necessity for the test, procedure, or surgery. It is preferred that the diagnosis is written in words, rather than an ICD-10-CM code so that the diagnostic coder at the facility can determine the code. If the diagnosis provided does not meet Medicare's list or policies for a specific test or procedure, the claim will be flagged and returned to the Coding Department by Billing Services. It is preferable to determine those claims before they are sent to Medicare and denied. The scheduling department, as mentioned above, may check these LCDs for coverage prior to scheduling the test. This may also be a department where a coder's expertise is required in order to properly determine medical necessity prior to rendering services. We are now going to follow the procedure written below to access the LCDs used in OHIO and review policies for Bone Mass Measurement. 1. Log on to Medicare's website: Medicare Coverage Database (MCD) 2. In the drop-down box that then appears, select Local Coverage Final LCDs by State Report and choose Ohio choose CGS Administrators, LLC (MAC-PartB), then click on the drop down of All LCDs and choose Active then click on the submit button. 3. Scroll down to find the LCD on any of the links here that you want to review. For our example we will select the topic: Bone Mass Measurement. 4. Next a disclaimer will show and you will need to press "accept" to continue. 5. Once the LCD is accessed, you can review the LCD, but notice you can also download it as a PDF, print it, or email it. In this course you will just want to review it. Read through the LCD for Bone Mass Measurement. There is a lot of medicolegal jargon included in these documents, but they are fairly easy to follow once you become accustomed to them. At the beginning of the document, you will see the LCD number and name. There is also a section that indicates how the National Coverage Determination policy applies to the LCD. The NCDs are more generic; the LCD provides much more detail. The LCDs also include Coverage Indications and Limitations. Under the Coding Information, you will see a list of bill types, revenue centers, CPT codes that are applicable to the LCD, and diagnosis codes that are supported by medical necessity. There is also guidance on whether more than one diagnosis must be submitted in order to meet medical necessity. For example, let's say that you receive an order from a physician for a bone density screening exam for a patient who is a 68-year-old female who had undergone a total

abdominal hysterectomy and bilateral salpingo-oophorectomy when she was 40 years old, prior to entering menopause. This patient is at risk for developing osteoporosis, but she has not been diagnosed with the disease. Let's scroll down to the bottom of this document to find "Associated Documents " Click on the article "Billing and Coding: Bone Mass Measurement". Scroll again to the " Coding Informatio n" section and find your CPT code used for this test. You will see that there are many codes that can be used for screening bone density such as 77078, 76977, and G0130. These codes are set up in the Charge Description Master (CDM) and not usually applied by the coder. Let's say that G0130 is the chosen charge because this is the procedure that was performed. The results indicate that the patient has developed osteopenia (not osteoporosis). So, the coder will code the indication (she is being screened for osteoporosis because she went through artificial menopause at the age of 40). The LCD indicates that the result of the test should also be coded if the test turns out to show positive findings (her test shows osteopenia in the right shoulder). Scroll through the list of codes to Group 2 to find your CPT code G0130 and use the table for Group 2 codes to see if your codes determine medical necessity in order to bill for this service (G0130) appropriately, the diagnosis codes from the information on the order are below. If you said yes, that is correct! Z90.722 - Acquired absence of ovaries, bilateral (status post surgical removal both ovaries) Z90.79 - Absent genital organs (status post surgical removal fallopian tubes) M85.811 - Osteopenia (the result of the exam for which the patient will likely need to be monitored more closely) Advance Beneficiary Notice If it is determined, at the point of registration, that a physician-ordered service is deemed as not medically necessary, the facility shall be responsible to issue an Advance Beneficiary Notice (ABN) to a Medicare patient. This allows the patient to make an informed decision prior to undergoing the test. The patient then may choose to not have the service or to have the service and pay for it personally. Reasons for denial for medical necessity stems from frequency of test performance (for instance, screening mammograms are paid for by Medicare only once per year), or because the diagnosis does not indicate the need for the test (such as a chest x-ray for leg pain). Keep in mind that coders cannot code "rule out", "possible", "probable", etc., as definitive in an outpatient setting. So if the physician documents one of these terms in a diagnosis for an outpatient order, it may take a phone call to the physician to determine the most definitive diagnosis. This may include a symptom instead of an actual diagnosis. Coders may be responsible for adding a modifier to a CPT code that represents a service that may be considered not medically necessary. Coders may also be assigned the duties of calling physicians for additional diagnoses to explain the need for the test that was performed in case an ABN was not obtained at the time the service was

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delivered. This typically occurs when the service was delivered in the ER, because a patient in the ER is not as likely to comprehend the process of signing an ABN due to the emergent nature of the need for the service. A patient must be in a stable condition and not under duress to make an informed decision about the service. This is not as likely to be the case in the ER. The link below is a CMS booklet to help us understand the purpose and use of the ABN. Please review this document: ABN Booklet