Procedural Coding – CPT questions and answers 2024, Exams of Nursing

Download Procedural Coding – CPT questions and answers 2024 and more Exams Nursing in PDF only on Docsity! Procedural Coding – CPT questions and answers 2024 Procedure Code - Code identifying medical treatment or diagnostic services. When a patient sees a physician, each procedure and service performed is reported on a health care claim using a standardized procedure code. Procedure codes represent medical procedures, such as surgery and diagnostic tests, and medical services, such as an examination to evaluate a patient's condition. Code Linkage - Connection between a service and a patient's condition or illness. On correct insurance claims, each reported service is connected to a diagnosis that supports the procedure as necessary to investigate or treat the patient's condition in that health care setting. Health plans analyze this connection between the diagnostic and procedural information, called code linkage, to evaluate the medical necessity of the reported charges. Procedure codes must be verified and then used to report physician's services. Physician, a medical coder, clearinghouse coder, or a medical administrative assistant may be responsible for the selection of procedure codes. Note that it is the physician's responsibility to report the correct CPT code. To be sure that the procedure codes, and the diagnosis codes, are correctly linked and valid, a medical administrative assistant, coder, or clearinghouse would review the documentation in the patient's medical record to be sure it supports the codes. A query may be communicated to the physician to resolve outstanding questions. By verifying all information and following the rules of correct coding, medical administrative Procedural Coding – CPT questions and answers 2024 assistants ensure that the provider receives the maximum appropriate reimbursement for procedures and services. Current Procedural Terminology (CPT) - Contains the standardized classification system for reporting medical procedures and services. The HIPAA-required set of procedure codes is the CPT, published by the American Medical Association (AMA) and is called the CPT. An updated edition of the CPT is available every year to reflect changes in medical practice. Newly developed procedures are added, some are changed, and old ones that have become obsolete are deleted. These changes are available in print and in an electronic file for medical offices that use a computer-based version of the CPT. New CPT codes are released on October 1 of each year and must be used for services dated the following January 1 or later. The CPT codes as of the date of service -- not the date of claim preparation -- are required by HIPAA. Encounter forms, the PMP, and any other computer systems that store CPT codes must also be updated. Category I Codes - Procedure codes found in the main body of the CPT. Category I codes -- which are most of the codes in the CPT -- are five-digit numbers with no decimals. They are organized into six sections: (1) Evaluation and Management Procedural Coding – CPT questions and answers 2024 Lightning Bolt Symbol/FDA Approval Pending - The lightning bolt symbol is used with vaccine codes that have been submitted to the Federal Drug Administration (FDA) and are expected to be approved for use soon. The codes CANNOT be used until approved, at which point this symbol is removed. Resequenced Codes (# symbol) - CPT procedure codes that have been reassigned to another sequence. As new procedures are developed and widely adopted, CPT has encountered situations where there are not enough numbers left in a particular numerical sequence of codes to handle all new items that need to be included. Also, at times codes need to be regrouped into related procedures for clarity. The AMA decided to use the idea of Resequencing rather than renumbering and moving codes. Resequencing is the practice of displaying codes outside of numerical order in favor of grouping them according to the relationships among the code descriptions. This allows out-of-sequence code numbers to be inserted under the previous key procedural terms without having to renumber and move the entire list of related codes. Codes that are Resequenced are listed two times in CPT. First, they are listed in their original numeric position with the note that the code is now out of numerical sequence and referring the user to the code range containing the Procedural Coding – CPT questions and answers 2024 Resequenced code and description. Second, the Resequenced symbol # is shown in front of the code and its descriptor where it appears in the group of codes to which it is related. Evaluation and Management (E/M) Section of CPT - These codes are for physicians' services that are performed to determine the best course for patient care. The E/M codes are organized by place and/or type of service. Guidelines for E/M codes include new/established patients, other definitions, unlisted services, special reports, and selecting an E/M service level. Anesthesia Section of CPT - These codes are for anesthesia services by or supervised by a physician; and include general, regional, and local anesthesia. This section is organized by body site. Guidelines include time-based, services covered (bundled) in codes, unlisted services/special reports, and qualifying circumstances codes. Surgery Section of CPT - These codes are for surgical procedures performed by physicians. The surgery section is organized by body system, then by body site, followed by procedural groups. Guidelines include surgical package definition, follow-up care definition, add-on codes, separate procedures, subsection notes, and unlisted services/special reports. Procedural Coding – CPT questions and answers 2024 Radiology Section of CPT - These codes are for radiology services by or supervised by a physician. This section is organized by type of procedure followed by body site. Guidelines include unlisted services/special reports and supervision and interpretation (professional and technical components). Pathology and Laboratory Section of CPT - These codes are for pathology and laboratory services by physicians or by physician-supervised technicians. This section is organized by type of procedure. Guidelines include complete procedure, panels, and unlisted services/special reports. Medicine Section of CPT - These codes are for evaluation, therapeutic, and diagnostic procedures by or supervised by a physician. This section is organized by type of service or procedure. Guidelines include subsection notes, multiple procedures reported separately, add-on codes, separate procedures, and unlisted services/special report. CPT Format/Parent Code and Indented Codes - Some descriptions in CPT are indented to show that they include a common entry from above them. The parent code begins with a capital letter. Indented codes beneath the parent code begin with a lowercase letter. The indented codes refer to the parent code above them. The words in the description of the parent code that come before the semicolon are common to all the indented codes below it. Procedural Coding – CPT questions and answers 2024 Modifiers - Number that is appended to a code to report particular facts. One or more two-digit CPT modifiers may be assigned to a five-digit main number. Modifiers are written with a space before the two-digit number. The use of a modifier shows that some special circumstance applies to the service or procedure the physician performed. There are more than 30 CPT modifiers. Appendix A of the CPT explains the proper use of each modifier. Some section guidelines also discuss the use of modifiers with the section's codes. Main Number - A five-digit number to which one or more two-digit CPT modifiers may be assigned. Modifier 62 (Surgery Section) - Modifier 62 indicates that two surgeons worked together, each performing part of a surgical procedure, during an operation. Each physician will be paid part of the amount normally reimbursed for that procedure code. Modifier 80 - Indicates that the services of a surgical assistant were used, and this person's fee are a part of the claim. Procedural Coding – CPT questions and answers 2024 Modifier (Technical Component) - If a procedure has two parts, a technical component modifier (TC) is appended to show the work performed by a technician, such as a radiologist. Modifier (Professional Component) - A professional component modifier (PC) is added to show the work that the physician performs, usually the interpretation and reporting of the results. CPT Coding Steps (6 Steps for CPT Coding) - The correct process for assigning accurate procedure codes has six steps: (1) review complete medical documentation; (2) abstract the medical procedures from the visit documentation; (3) identify the main term for each procedure; (4) locate the main terms in the CPT Index; (5) Verify the code in the CPT main text; and (6) determine the need for modifiers. Step 1 (Review Complete Medical Documentation) - Review the documentation in the patient's medical record of the patient's visit and decide which procedures and/or services were performed and where the service took place (the place of service, which may be an office, a facility, or another health care setting. There are over 50 place of service codes. Procedural Coding – CPT questions and answers 2024 Step 2 (Abstract Medical Procedures from the Visit Documentation) - After reviewing complete medical documentation, and based on knowledge of CPT and of each individual insurance payer's policies, a decision is made about which services can be charged and are to be reported on the insurance claim form. Step 3 (Identify the Main Term for Each Procedure) - Identify the main term for EACH procedure. Main terms may be based on the: (1) procedure or service (such as repair, biopsy, E/M, or extraction); (2) organ or body part (such as chest wall, prostate, or bladder); (3) condition or disease being treated; (4) common abbreviation (such as ECG or CT) or synonym; (5) eponym (the name of a person or place for which a procedure is named, such as Cotte operation); and (6) symptom (for example, fracture). Step 4 (Locate the Main Terms in the CPT Index) - Locate the procedures using the main term in the index at the back of CPT. For each term a listing of a code or a code range identifies the appropriate heading and procedure code(s) in CPT. Some entries have a "See" cross-reference or a "See also" to point to another index entry. First, pick out a specific procedure or service, organ, or condition. find the procedure code in the CPT Index. Remember, the number in the index is the five- Procedural Coding – CPT questions and answers 2024 Place of Service (POS) - Administrative code indicating where medical services were provided. The place-of-service is also important to know, because different E/M codes apply to services performed in a physician's office, a hospital inpatient room, a hospital emergency room, a nursing facility, an extended-care facility, and a patient's home. Remember there are over 50 place of service codes. E/M -- Consultation - A consultation occurs when a second physician, at the request of the patient's physician, examines the patient. The second physician usually focuses on a particular issue and reports a written opinion to the first physician. The physician providing a consultation ("consult") may perform a service for the patient but does not independently start a full course of treatment (although the consulting physician may recommend one) or take charge of the patient's care. Consultations require the use of the E/M CONSULTATION CODES (the range from 99241 to 99245). Consultation requests and reports must be written documents that are stored in the medical records. If the sending provider requests a consultation, this is asking for the opinion of another physician regarding the patient's care. The patient will be returned to the care of the original provider with the specialist's written consultation report containing an evaluation of the patient's condition and/or care. Procedural Coding – CPT questions and answers 2024 Coders remember the three R's of consults: request opinion, render service, and report back. Because of fraudulent use of consult codes by some physicians -- billing consults for what are new visits -- in 2010 Medicare announced it would stop paying for both the outpatient and inpatient consult codes; providers must report these visits using regular office E/M codes. E/M -- Referral - When a patient is "referred" to another physician, either the total care or a specific portion of care is transferred to that provider. The patient becomes a new patient of that doctor for the referred condition and may not return to the care of the referring physician until the completion of a course of treatment. Referrals require use of the regular office visit E/M service codes. Under a referral, the PCP, or other provider is sending the patient to another physician for specialized care. The amount that can be charged for a referral is different than the amount that can be charged for a consultation. E/M Level of Service - Amount of work, time, and decision making involved in an encounter. CThe final item to decide in assigning the right E/M code is the level of service -- how much work, time, and decision making were involved in the patient Procedural Coding – CPT questions and answers 2024 encounter. These key components (factors documented in the patient's medical record for various levels of evaluation and management services) help determine the level of service: (1) the extent of the patient history taken; (2) the extent of the examination conducted; and (3) the complexity of the medical decision making. Steps for E/M Code Assignment (8 Steps for E/M Coding) - To select the correct E/M code, use the following eight steps: 91) determine the category and subcategory of service based on the place of service and the patient's status; (2) determine the extent of the history that is documented; (3) determine the extent of the examination that is DOCUMENTED; (4) determine the complexity of medical decision making that is DOCUMENTED; (5) analyze the requirements to report the service level; (6) verify the service level based on the nature of the presenting problem, time, counseling, and care coordination; (7) verify that the documentation is complete; and (8) assign the code. CPT E/M Coding Step 1 - Determine the category and subcategory of service based on the place of service and the patient's status. The list of E/M categories, such as office visits, hospital services, and preventive medicine services, is used to locate the appropriate place of service or type of service in the index. In the main text of the selected category, the subcategory -- such as new patient or established patient -- is then chosen. For most types of service, such as initial hospital care for an established patient, between three to five codes are listed. To select an Procedural Coding – CPT questions and answers 2024 Family History (FH) - The family history reviews the medical events in the patient's family. It includes the health status or cause of death of parents, brothers and sisters, and children; specific diseases that are related to the patient's chief complaint or the patient's diagnosis; and the presence of any known hereditary diseases. Social History (SH) - The facts gathered in the social history, which depend on the patient's age, include marital status, employment, and other factors. The histories documented after the HPI are sometimes referred to as PFSH, for past, family, and social history. Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive - The history that the physician decides to obtain is then categorized as one of four types on a scale from lesser to greater extent of amount of history obtained: (1) Problem Focused (determining the patient's chief complaint and obtaining a brief history of the present illness; (2) Expanded Problem Focused (determining the patient's chief complaint and obtaining a brief history of the present illness, plus a problem-pertinent system of review of the particular body system that is involved); (3) Detailed (determining the chief complaint; obtaining an extended history of the present illness; reviewing both the problem-pertinent system and additional systems; and taking pertinent past, family, and/or social history; and (4) Procedural Coding – CPT questions and answers 2024 Comprehensive (determining the chief complaint and taking an extended history of the present illness, a complete review of systems, and a complete past, family, and social history. CPT E/M Coding Step 3 - Determine the extent of the examination that is documented. The physician may examine a particular body area or organ system or may conduct a multisystem examination. The body areas are divided into the head and face; chest, including breasts and axilla (underarm/armpit); abdomen; genitalia, groin, and buttocks; back; and each extremity. The organ systems that may be examined are the eyes; the ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; and hematologic/lymphatic/immunologic. The examination that the physician documents is categorized as one of four types on a scale from lesser to greater extent: (1) Problem Focused (a limited examination of the affected body area or system; (2) Expanded Problem Focused (a limited examination of the affected body area or system and other areas; (3) Detailed (an extended examination of the affected body area or system and other related areas; and (4) Comprehensive (a general multisystem examination or a complete examination of a single organ system). Procedural Coding – CPT questions and answers 2024 CPT E/M Coding Step 4 - Determine the complexity of medical decision making that is documented. The complexity of the medical decisions that the physician makes involves how many possible diagnoses or treatment options were considered; how much data information (such as test results or previous records) was considered in analyzing the patient's problem; and how serious the illness is, meaning how much risk there is for significant complications, advanced illness, or death. The decision-making process that the physician documents is categorized as one of four types on a scale from lesser to greater complexity: (1) Straightforward (minimal diagnoses options, a minimal amount of data, and minimum risk); (2) Low Complexity (limited diagnoses options, a low amount of data, and low risk); (3) Moderate Complexity (multiple diagnoses options, a moderate amount of data, and moderate risk); and (4) High Complexity (extensive diagnoses options, an extensive amount of data, and high risk). CPT E/M Coding Step 5 - Analyze the requirements to report the service level. The descriptor for each E/M code explains the standards for its selection. For office visits and most other services to new patients, and for initial care visits, all three of the key components must be documented. Procedural Coding – CPT questions and answers 2024 denied. the need for any modifiers, based on the documentation of special circumstances, is also reviewed. Reporting E/M Codes on Claims -- Documentation Guidelines for Evaluation and Management - Two sets of guidelines for documenting evaluation and management codes have been published by CMS and the AMA: the 1995 Documentation Guidelines for Evaluation and Management Services and a 1997 version. CMS and most payers permit providers to use EITHER the 1995 or the 1997 E/M guidelines. A medical practice must be clear about which set of guidelines it generally follows for E/M coding and reporting. Office and Hospital Services - Office and other outpatient services are the most often reported E/M services. When a patient is evaluated and then admitted to a health care facility, the service is reported using the codes for "initial hospital care" (99221-99223). The admitting physician uses the initial hospital care services codes. Only one provider can report these services; other physicians involved in the patient's care, such as a surgeon or radiologist, use other E/M service codes or other codes from appropriate sections. Codes for "initial hospital observation care" (99218-99220), "initial hospital care" (99221-99223), and "initial inpatient consultations" (99251- 99255) should be reported by a physician only once for a patient admission. Procedural Coding – CPT questions and answers 2024 Emergency Department Services - An emergency department is hospital based and is available to patients twenty-four hours a day. When emergency services are reported, whether the patient is new or established is not applicable. Time is NOT a factor in selecting the E/M service code. The code ranges are 99281 to 99288. Preventive Medicine Services - Preventive medicine services are used to report routine physical examinations in the absence of a patient complaint. These codes, in the range 99381-99397, are divided according to the AGE of the patient. Counseling is coded from code range 99401-99429. Immunizations and other services, such as lab tests that are normal parts of an annual physical, are reported using the appropriate codes from the Medicine and the Pathology and Laboratory sections of the CPT. Coding Surgical Procedures - Codes in the Surgery section represent groups of procedures that include all routine elements. The combination of services is called a surgical package. Procedural Coding – CPT questions and answers 2024 According to the Surgery section guidelines in the CPT, the procedure codes for surgical procedures include the following: (1) after the decision for surgery, one related E/M encounter on the date immediately before or on the date of the procedure; (2) the operation: preparing the patient for surgery, including injection of anesthesia by the surgeon (local infiltration, metacarpal/metatarsal/digital block or topical anesthesia), and performing the operation, including normal additional procedures, such as debridement; (3) immediate postoperative care, including dictating operative notes, talking with the family and other physicians; (4) writing orders; (5) evaluating the patient in the postanesthesia recovery area; and (6) typical postoperative follow-up care. A complete procedures includes the operation, the use of a local anesthetic, and post-operative care, all covered under a single code. Surgical Package - Combination of services included in a single procedure code. Services NOT Included in Surgical Package Codes - Two types of services are not included in surgical package codes. These services are reported separately and reimbursed in addition to the surgical package fee: (1) Complications or recurrences that arise after therapeutic surgical procedures; and (2) Care for the condition for which a diagnostic surgical procedure is performed. Procedural Coding – CPT questions and answers 2024 Laboratory Tests - Organ or disease-oriented panels listed in the Pathology and Laboratory section of the CPT include tests frequently ordered together. A comprehensive metabolic panel, for example, includes tests for albumin, bilirubin, calcium, carbon dioxide, chloride, glucose, and other factors. Each element of the panel has its own procedure code in the Pathology and Laboratory section. However, when the tests are performed together, the code for the panel must be used, rather than listing each test separately. Coding Immunization - Injections and infusions of immune globulins, vaccines, toxoids, and other substances require TWO codes: (1) one code for giving the injection and (2) one code for the particular vaccine or toxoid that is given. These codes are selected from the Medicine section of CPT. Note: An E/M code is NOT used along with the codes for immunizations unless a significant separate evaluation and management service is also done. HCPCS (Health Care Common Procedure Coding System) Level I and Level II Codes - Procedure codes for Medicare claims. HCPCS was developed by the Centers for Medicare and Medicaid Services (CMS) for use in coding services for Medicare patients. The HCPCS coding system has two levels: Level I codes duplicate those Procedural Coding – CPT questions and answers 2024 from the CPT and Level II codes are issued by CMS in the Medicare Carriers Manual. Level II codes are called national codes and cover many supplies, such as sterile trays, drugs, and DME (durable medical equipment). Level II codes also cover services and procedures not included in the CPT. Level II HCPCS codes have five characters. HCPCS modifiers, either two letters with a letter and a number, are also available for use. These modifiers are different from the CPT modifiers. For example, HCPCS modifiers may indicate social worker services or equipment rentals.