AH 1006 Ch 1 CPT Textbook 2021

) CPT Category I The CPT code book includes a general introduction followed by six main ions that together make up the list of Category I CPT codes: Current Procedural Terminology (CPT) 3 sect Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine Specific coding guidelines are provided for each of the main sections. ; The Category I codes in each of the main sections are further broken down The AMA does not publish into subsections and subcategories according to the type of service provided and | a separate document or the body system or disorder involved. For example, code 76641 (Ultrasound, = book of guidelines; the breast, unilateral, real time with image documentation, including axilla when * quidelines are embedded erformed; complete) appears in the Radiology section under the subsection . within the code book itself. Diagnostic Ultrasound and the subcategory Chest. 1 Subcategory Chest 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Similar procedures are grouped to form ranges of codes. For example, the range of codes from 19300 through 19307 represents the various types of mastectomy procedures in the subsection covering the integumentary system in the Surgery section. The codes in each of the six main sections (or Category I) of the CPT code book are composed of five digits and are typically arranged in numerical order within each section. However, several coding sections are not in numerical order (for example, 23071). This type of formatting is explained in chapter 2. CPT Supplementary Codes 7 CPT also provides three types of supplementary codes: Category II codes, ' Category III codes, and modifiers. Each of these code sets is listed and explained in a separate section. The Category II and Category III sections are located after the Medicine codes in the code book. The list of modifiers and the coding guidelines for modifiers are included in appendix A of CPT 2021. CPT Category Il Codes Category II provides supplementary tracking codes that are designed for use in performance assessment and quality improvement activities. CPT Category II codes are composed of five characters: four numbers and an | codes are located after the alphabetic fifth character, the capital letter F. For example, code 1000F | Medicine section of CPT. describes a specific aspect of patient history: assessments of patient tobacco - | use. The following is an example of a Category II code’under the Physical Examination subsection: Category Il and Category lll

6 Chapter 1Introduction to Clinical Coding EXQIMIPI@: oo Professional Services versus Hospital Services If a 10-year-old patient was seen in the hospital outpatient surgery department for a tonsillectomy, the hospital would report CPT code 42825 to the payer. Reimbursement to the hospital would be based on costs associated with that procedure being performed at the facility, such as charges for the use of the operating room, equipment, drugs, and hospital staff (nursing and surgical assistants). In addition, the surgeon would also report the same code (42825) to the payer for reimbursement of the surgical services performed. HCPCS Level Il (National Codes) The Centers for Medicare and Medicaid Services (CMS) developed HCPCS Level II codes for use in reporting medical services not covered in CPT. Medicare, Medicaid, and private health insurers use HCPCS codes and modifiers for claims processing. Level II codes are provided for injectable drugs, ambulance services, prosthetic devices, and selected provider services. Level II codes are made up of five characters: The first character is a capital alphabetic letter, and the following four characters are numbers. Examples of HCPCS Level II codes include the following;: A4550 Surgical trays E1625 Water softening system, for hemodialysis J0475 Injection, baclofen, 10 mg EXQIMPI@:- i If a patient required an intramuscular injection of an antibiotic, the correct CPT code would be 96372, Therapeutic; prophylactic, or diagnostic injection. The CPT code identifies the service (injection) but does not identify the substance (drug) in the injection. An additional HCPCS code would identify the actual drug, such as J0561, Penicillin g benzathine, 100,000 units. HCPCS Level II codes are updated for use starting on January 1. Level Il code files are available for free on the CMS website and contain updates or errata for the code set. Several commercial publishing companies distribute the HCPCS Level II (National) codes in book form, adding enhancements such as indexes and cross-references to make them more user-friendly than the government- issued lists. (HCPCS Level II codes are discussed in more detail in chapter 11.) Table 1.2 highlights the differences between Level I and Level II codes. An overview of the HCPCS system is provided in figure 1.2. | Pevelopment and | Maintained By Common Uses American Medical Association Identification of surgical procedures, office visits, and laboratory services Il HEPES Centers for Medicare and Identification of injectable drugs, Medicaid Services devices, supplies, and equipment

International Classification of Diseases, Tenth Revision, Procedural Classification System (ICD-10-PCS) 9 E Xample ............................................................................................................ F11.9 Type 2 diabetes mellitus without complications Correct E11 Type 2 diabetes mellitus (This three-character code Incorrect introduces the category for Type 2 diabetes, but a more specific code must be selected based on documentation.) E11.0 Type 2 diabetes mellitus with hyperosmolarity (This code Incorrect is incomplete and requires a fifth character of either E11.00 or E11.01 based on the patient’s diagnosis.) Basic ICD-10-CM and ICD-10-PCS Coding, 2021 edition, by Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA, and Brooke N. Palkie, EdD, RHIA, provides a more detailed discussion of the basics of ICD-10-CM and ICD- 10-PCS coding. International Classification of Diseases, Tenth Revision, Procedural Classification System (ICD-10-PCS) ICD-10-PCS is the system developed to report inpatient procedures according to the principles of a classification. The seven-character alphanumeric code systematically classifies characteristics of procedures such as body part and surgical approach. The following table provides a side-by-side comparison of CPT and ICD-10-PCS codes for a laparoscopic cholecystectomy (gallbladder removal). (o 1 o (o ToL=To [T] =W ofL T, ) { [od o 38, (o B 2 J0d - oo Tol=Te (1] =N odu Te [] 47562 Laparoscopy, surgical; cholecystectomy 0OFT44ZZ Resection of gallbladder, percutaneous endoscopic approach Documentation for Reimbursement Health record documentation continues to play a pivotal role in the accurate and complete collection of health services data. The documentation records pertinent facts, findings, and observations about an individual’s health history, including past and current illnesses, examinations, tests, treatments, and outcomes. By chronologically documenting the patient’s care, the health record becomes an important element in the provision of high-quality healthcare and serves as the source document for code assignment. The following general principles of health record documentation, developed jointly by the AMA and CMS, apply to the records maintained for all types of medical and surgical services: * The health record should be complete and legible. * The documentation of each patient encounter should include o The reason for the encounter and the patient’s relevant history, physical examination findings, and prior diagnostic test results; o A patient assessment, clinical impression, or diagnosis; o A plan for care; and o The date of the encounter and the identity of the observer. CPT is a nomenclature (naming) system, and | ICD10-PCSis " classification system (systematic arrangement).

42 Chapter 1 Introduction to Clinical Coding Figure 1.4. Sample CMS 1500 form b SO G A~ W N Elt;:“[é] s HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 ]PICA PICA { 1. MEDICARE MEDICAID TRIGARE ”] (Medicare) L J(Medicaid#) t T (ID#/DoD#) CHAMPVA GROUP OTHER HEALTH PLAN pmy BLK LUNG L [ ] Member ID#) [j (iD#) D) E(ID#) 1a. INSURED'S 1.D. NUMBER {For Program in item 1} 2. PATIENT'S NAME (Last Name, First Name, Middle initiat) 3. PATIENT'S BIRTH DATE SEX MM DD YY ][] 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED Selfm SpouseD Childm Otherm 7. INSURED'S ADDRESS (No., Street) - [ CARRIER ctry STATE | 8. RESERVED FOR NUCC USE 2iP CODE ( ) TELEPHONE (Include Area Code) CITY STATE ZIP CODE TELEPHONE (Include Area Code) ( ) 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initialy 10. 1S PATIENT'S CONDITION RELATED TO: a. OTHER INSURED’S POLICY OR GROUF NUMBER a. EMPLOYMENT? (Current or Previous) YES m NO b. RESERVED FOR NUCC USE SENT? b. AUTO ACCIDENT? PLACE (State) [les [, ¢. RESERVED FOR NUCC USE ¢. OTHER ACCIDENT? [_no [Jves 11, INSURED'S POLICY GROUP OR FECA NUMBER a. INSURED'S DATE OF BIRTH SEX MM, DD ; Yy ul] FL] b. OT!HER CLAIM ID (Designated by NUCC) i ¢. INSURANCGE PLAN NAME OR PROGRAM NAME d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. 18 THERE ANOTHER HEALTH BENEFIT PLAN? [Tres [ Jno If yes, complete items 9, 9a, and 9d. PATIENT AND INSURED INFORMATION READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize the release of any medical or other information necessary to process this claim. 1 also request payment of government benefits either to myself or to the party who accepts assignment 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE | authorize services described below. payment of medical benefits to the undersigned physician or supplier for below. SIGNED DATE Y SIGNED __. 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) | 15. OTHER DATE MM . DD v 16. DATES PATIENT UNABLE JO WORKIN CURF&NT OCCUPAT[\%I{\I A | I i i ! QUAL.| QUAL. ! 1 FROM : TO ! i 17. NAME OF REFERHING PROVIDEH OR OTHER SOURCE 17a. 18. HOSPIT{V}HZATION DATES RELATED T0 CUMRRENT SERVICES I ' 17b.| NP FROM i TO 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES D YES D NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service fino below (248) 0 " 22, RESUBMISSION nd. | CODE ORIGINAL REF. NO, B. f.. . D. | , A 23. PRIOR AUTHORIZATION NUMBER Fol. G. 1 H. i . JoLo Kol L. 34 A, DATE(S) OF SERVICE B, .7 b, PROGEDURES, SERVICES, OF SUPPLIES E. F. G, H 1 I J. 2z From PLAGE OF (Explain Unusual Circumstances) DIAGNOSIS O =y RENDERING o MM DD YY MM DD YY_|SERVICE] EMG | CPT/HCPCS | MODIFIER POINTER $ CHARGES UNITS | Pin’ | QuaL, PROVIDER ID. # : A = H H H i - 1ot | | | | NPI o ,,,,, ! [ = | i ; | ] ] I I | | ! : l | ] NPI x 7 3 i I ] H H | L] L 1 i B L 5 ) . . Y | - . ] L1 | S 2 } i < { } H i ! ] (3] ! ‘ 1 i : ; | i I I NPl ] > ; , ; ; ) . , . XL : I Lo | Lo [ [ * 25, FEDERAL TAX 1.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27, @CQEVE’I.A}&SL%L% NT? | 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use " - i i L] vES NO $ 5 $ | 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33, BILLING PROVIDER INFO & PH # ( ) INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE & P & ib‘ Y NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)

re part of the fields for electronic claim submission for Medicare Part Further information on UB-04 can be found on the National Uniform ttee website. for completing the UB-04 can be found in the Medicare Claims Manual. The form has been revised to accommodate ICD-10-CM/ elemeflts a A gervices. Ittt pilling Com™! Instructions Processir\g PCS codes. Answers 0 odd-numbered questions can be found in appendix C of this textbook. Answers to even-numbered questions are located in the instructor materials and are available to approved instructors. Review each of the following questions and write the appropriate answers in the spaces provided. 1. What organization(s) are responsible for updating CPT codes? 2. What organization is responsible for maintaining HCPCS Level II codes? 3. What code set describes the diagnosis codes to support medical necessity? 4. On December 3, 2020, Dr. Smith saw a Medicare patient with a diagnosis of rectal abscess in Central Hospital. She performed an incision and drainage in the outpatient surgery department. a. Which coding system would be used to capture the diagnosis of rectal abscess? b. Which coding system would Central Hospital use to bill for the surgical services? ¢. Which coding system would Dr. Smith use to report her surgical services? 5. Place a check mark in front of all of the following diagnoses that would logically support medical necessity for CPT code 92550, Tympanometry and reflex threshold measurements. D333 Benign neoplasm of cranial nerves G10 Huntington’s disease G83.84 Todd’s paralysis (postepileptic) H82.3 Vertiginoussyndromes in diseases classified elsewhere, bilateral H83.12 Labyrinthine fistula, left ear 2 H65.06 Acute serous otitis media, recurrent, bilateral Chapter 1 Review 15