Introduction to CPT Coding for

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					                          NYU School of Medicine
                 Coding and Reimbursement Seminar Series

        Introduction to CPT Coding for
              Physician Practices

Gretchen L. Segado, MS, CPC
Director of Reimbursement Compliance
NYU School of Medicine
316 East 30th Street
New York, NY 10016
(212) 263-2446
                                   Presented by the Office of Reimbursement Compliance
(212) 263-6445 fax
What Is CPT-4?

    Systematic listing of procedures & services performed
     by physicians
    Five-digit codes for procedures or services
    Used to describe the physician’s services to a patient
     for diagnosis and treatment of the medical condition(s)
    Codes and descriptive terminology developed and
     copyrighted by AMA CPT Editorial Panel
Linkage Between ICD-9 & CPT

    CPT-4 represents the “WHAT” was done to the patient
         Procedure------------------- 93010 (EKG)

    ICD-9 represents the “WHY” it was done
         Medical Necessity--------- 786.50
                                      (Chest Pain)
Organization of CPT Manual
Text organized in 6 major sections
        Evaluation and Management   (99201 - 99499)
        Anesthesiology                      (00100 - 01999,
                                             99100 - 99140)
        Surgery                             (10040 - 69990)
        Radiology                           (70010 - 79999)
        Pathology and Laboratory            (80049 - 89399)
        Medicine                            (90281 - 99199)

   Presented at the beginning of each of the six
   Provide information necessary to appropriately
    interpret and report the procedures and services
    contained in that section
   In addition to guidelines, several subheadings or
    subsections also have special instructions unique to
    that section
   Reading the guidelines and notes are critical to
    using CPT correctly
CPT Symbols

    Revised CPT Code-Description has been substantially altered

    New CPT Code

    Codes that never stand alone

    Appears during the 1st year that the text is revised or added

    Codes exempt from the 51 modifier, but that do not have

       designated add-on procedures or services
Format of the CPT-4

   Developed as a stand-alone descriptions of the procedures
   To conserve space, some are not printed in their entirety but
    refer back to a common portion listed in a preceding entry**
    25100               arthrotomy, wrist joint; for biopsy
    25105                       for synovectomy

    25105               arthrotomy, wrist joint; for

            **Commonly referred to as “Indented Codes”
   Who can tell me what CPT Code reads?

   The book says
    24102             with synovectomy
What is the full description of each of
these codes?

   20600* arthrocentesis, aspiration &/or
    injection; small joint, bursa or ganglion cyst
    (e.g., Fingers, toes)
   20605*          intermediate joint, bursa or
    ganglion cyst (e.g., Temporomandibular,
    acromioclavicular, wrist, elbow or ankle,
    olecranon bursa
   20610*          major joint or bursa (e.g.,
    Shoulder, hip, knee joint, subacromial bursa
Example 2

   20661 application of halo, including
    removal; cranial

   20662         pelvic

   20663         femoral
The Index-The Starting Point

   Listed procedures in alphabetical order at
    the back of the manual
   Index is organized by main terms
   There are 4 primary classes of main entries:
    –   Procedure or service
    –   Organ or anatomic site
    –   Condition
    –   Synonyms, eponyms or common abbreviation
CPT Index

   Procedure or service
    –   Appendectomy
   Organ or anatomic site
    –   Knee
   Condition
    –   Renal Abscess
   Synonyms, eponyms or common abbreviation
    –   Bucca (cheek)
    –   BAER (Brainstem Auditory Evoked Potential)
    –   Whipple Procedure
Use of CPT-4 Manual

   Select the name of the procedure or service that
    most accurately identifies the service performed:
    –   Example:
          Surgery:    operations and minor procedures
          Medicine:   diagnostic or therapeutic
          Radiology:   radiographic study
   Any physician can use any code in the CPT book.

   The alphabetical index is NOT a substitute for the
    main text of the CPT Manual. Even if only one code
    appears, the user must refer to the main text to
    ensure that the code selection is accurate

10 Steps to Basic CPT Coding

1.   Read the source document. Never assume!
2.   Using information in the record, analyze
     procedure statement provided by physician.
     Identify main term and modifying terms
3.   Locate main term in the CPT index
4.   Look for subterms indented below the main
5.   Jot down the tentative code range for each
10 Steps to Basic CPT Coding

6.    Locate each tentative code in the book
7.    Read any instructional notes and watch for
      diagnoses or specific procedures within
      code descriptions
8.    Verify that the code matches the procedure
      statement provided in the record
9.    Assign a modifier if necessary
10.   Assign the code
Now it’s your turn to use what you’ve

   Identify the service or procedure performed

   Identify the organ involved

   Identify the condition or key word
Procedure/Organ/Key Word

   What is the code for a Whipple Procedure?

   48150
Procedure/Organ/Key Word

   What is the code for an upper
    gastrointestinal endoscopy with biopsy?
   43239
   You can find the same code looking under
    any of the terms “gastrointestinal”
    “endoscopy” or “biopsy”
Procedure/Organ/Key Word

   What is the code for a synovectomy of the

    metacarpophalangeal joint?

   26135

   Common mistakes made: carpometacarpal

    joint vs metacarpophlangeal joint
Procedure/Organ/Key Word

   What is the code for removal of a foreign

    body in the nose?

   Need more information, was this done under

    anesthetic? Did they have to cut into nose?
Procedure/Organ/Key Word

   How would you bill for a removal of a
    pylenoidal cyst?
   Do I need more information to code it
    correctly? If so, where do I get the info?
   Is it simple? extensive? complicated?

   Answer:         11770-11772
Procedure/Organ/Key Word

   Endoscopic biopsy of the urethra
    –   This is a tricky one….beware

   Answer:           52204
Procedure/Organ/Key Word

   Exploration of a penetrating wound of the

   Answer:        20102
Procedure/Organ/Key Word

   Exploration of nasolacrimal duct with tube

   Answer:        68815
Procedure/Organ/Key Word

   Exploration of the knee with removal of a nail

   Answer:        27310

   Appendix A   Modifiers
   Appendix B   Summary of additions,
                 deletions and revisions
   Appendix C   Update to short descriptor
   Appendix D   Clinical examples
   Appendix E   Summary of add on codes
   Appendix F   Summary of CPT codes
                 exempt from modifier -51
Global Surgery Components

   Preoperative visits - beginning with the day
    before the day of surgery for major
    procedures and the day of the surgery for
    minor procedures
    –   Document pre-op evaluation/exam in
        medical record
    –   Document pre-op evaluation in op report
What is the “Global” Period?

   Also known as the global surgical package
   No one standard definition
   Per CPT guidelines,

The following services are always included in addition
  to the operation per se:
      local infiltration, metacarpal/metatarsal/digital
  block or topical anesthesia;
What is in the Global Period?

   subsequent to the decision for surgery, one
     related E/M encounter on the date immediately
     prior to or on the date of procedure (including
     history and physical);
    immediate postoperative care, including
     dictating operative notes, talking with the
     family and other physicians;
    writing orders;
    evaluating the patient in the post-anesthesia
     recovery area;
    typical postoperative follow-up care.
Examples of Services Included in the
Global Period

   Removal of staples 10 days after a surgical
   A visit with a patient prior to surgery to answer
    any last minute questions
   A post-operative visit in the office to check on
    wound healing
Examples of Services NOT Included in
the Global Package

   The visit where the decision to perform a
    procedure or surgery was made, even if on the
    same day as the procedure
   A visit during the post-op period for a problem
    unrelated to the surgery
Example of Global Payment

 CPT code 33512 - coronary artery bypass, vein
 Only; 3 coronary venous grafts
 Allowed payment (80%) = $2,001.40
    Pre-op           9%      $180.00

    Intra-op        84%    $1,681.00

    Post-op          7%      $140.00
National Correct Coding Initiative

   Commonly known as CCI
   Purpose:
    –   Develop a correct coding methodologies
    –   Control improper coding that leads to
        inappropriate increased in payment in Part B
    –   Promote correct coding nationwide
    –   Assist physicians in correctly coding their services
        for payment
Definitions in the Correct Coding

   Correct Coding means the reporting of a group of
    procedures with the appropriate comprehensive
   Unbundling is the billing of multiple procedure
    codes for a group of procedures that are covered by
    a single comprehensive code.
   Mutually Exclusive Codes are those codes that
    represent services that cannot reasonably be
    performed in the same session
Types of Unbundling

   Fragmenting one service into component
    parts and coding each as a separate service.
   Reporting separate codes for related
    services when one comprehensive code
    includes all related services.
   Breaking out bilateral procedures when one
    code is appropriate.
Types of Unbundling

   Down coding a service in order to use an
    additional code when one higher code level,
    more comprehensive code is appropriate.
   Separating a surgical approach from a major
    surgical service.
Examples of Bundled Services
Component Codes

   52005- Cystourethroscopy, with urethral
    catheterization, with or without irrigation,
    instillation, or ureteropyelography, exclusive
    of radiological service.
    –   Bundled services:
           51700- Bladder irrigation, simple, lavage &/or
           52000- Cystoeruthroscopy (separate procedure)
           53670- Catheterization, urethra, simple
Examples of Bundled Services
Mutually Exclusive Codes

   63045 Laminectomy, facetectomy and foraminotomy
    (unilateral or bilateral with decompression of spinal
    cord, cauda equina and/or nerve root(s), (eg, spinal or
    lateral recess stenosis)), single vertebral segment;
   63040       Laminotomy (hemilaminectomy), with
    decompression of nerve root(s), including partial
    facetectomy, foraminotomy and/or excision of
    herniated intervertebral disk, reexploration, single
    interspace; cervical
   First code would be paid and the second denied
    without use of an appropriate modifier
Separate Procedures

–   Services “should not be reported in addition to
    code for total procedure or service of which it
    is considered an integral component”
–   If the service is performed independently,
    unrelated or distinct from other procedures
    provided at the time, it may be reported by
    itself or in addition to other services by
    attaching modifier -59 (indicates service is
    distinct, independent procedure)
Example of Separate Procedures

    44005 - Enterolysis (freeing intestinal
    adhesion) (separate procedure)

   (Do not report 44005 in addition to 45136)

   is included in
   45136      Excision of ileoanal reservoir with
    Add-on Codes

–   Carried out in addition to a primary
     Exempt  from -51 modifier
     CPT descriptors - “list separately in
      addition to primary procedure” or
      “each additional”
     Must never be reported as a stand-alone
Examples of Add-on Codes

    64831 Suture of digital nerve, hand or foot; one
   + 64832        each additional digital nerve (list
    separately in addition to code for primary procedure)

   22325 Open tmt and/or reduction of vertebral fx
    and/or dislocation(s), posterior approach, one fx
    vertebrae or dislocated segment; lumbar
    + 22328       each additional fractured vertebrae or
    dislocated segment (list separately in addition to
    code for primary procedure)
In Summary

   Learned CPT Nomenclature (how to read the
    –   Reading the guidelines
    –   Use of Symbols, Appendices, Indexes
   Learned never to code from the index
   Learned the importance of linking CPT with
    an appropriate diagnosis (ICD-9) code
   Learned about Correct Coding Initiative
Coming soon..
   An Advanced E&M/Chart Auditing Workshop
   Seminar Series Classes on
    –   ICD-9 Coding
    –   Billing for Non-physician Practitioners
    –   How to Use Modifiers
    –   Evaluation and Management Coding
   A Special Session on Advance Beneficiary Notices

   Sign up for classes via the School of Medicine Calendar at
    –   Select Department Calendars, Find Compliance Office under
        “miscellanous” category

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