The CPT Manual (2022/2023) 100% Correct

The CPT Manual (2022/2023) 100% Correct The Current Procedural Terminology Manual (CPT) The CPT manual is organized according to three categories of codes. Category I: Five-digit codes with descriptions arranged by sections within the tabular list of the CPT manual Category II: A set of supplemental or optional codes used to track performance measurement Category III: Temporary codes for emerging and new technology, procedures, and services that are not officially included in the tabular list of the CPT manual CPT Tabular List Sections The six sections and their code ranges in the tabular list include: Evaluation and Management () Anesthesia (00100-01999, ) Surgery () Radiology, including nuclear medicine and diagnostic ultrasound () Pathology and Laboratory () Medicine, except Anesthesiology () Each level of a section provides more specificity about the procedure or service performed and the anatomic site or organ system involved. The tabular index is organized so that each level of a section provides more specificity about the procedure or service performed and the anatomic site or organ system involved. Purpose of CPT The alphabetic index acts as a guide to finding data within the textbook. What is CPT Manual based on? The alphabetic index is based on main terms such as an anatomic site or diagnosis. Basic Steps for Coding Read, analyze, and abstract the procedure or service present in the health record. Compare it with the encounter form, operative report, or other documentation. Review the guidelines, notes, and conventions in the tabular list to ensure that the code selected is most accurate. Abstract to collect pertinent medical information to make an informed decision on assigning a correct code. This process ensures that all medical procedures or services present in the medical record are identified without any omission. Further, abstracted data has sections such as main terms and subterms (also known as modifying terms). These terms help to find the code or code ranges in the alphabetical index. Main Terms the primary procedure or procedure performed such as an excision Sub Terms further defines or adds information to the main term such as the anatomic location or the organ excised, the type of instrument used, a special technique, or whether or not other procedures were performed at the same time as the excision, such as obtaining biopsy tissue for examination Using the Alphabetical Index Abstract the procedures from the medical documentation and determine the main and modifying terms. Select the most appropriate main term. Select one or more modifying terms, if needed to narrow the search. Repeat steps 2 and 3 using a different main term, if no main or modifying term produces an appropriate code or code range. Find the code or code ranges that include the description of the procedure found in the medical record. Searching the Alphabetical Index Use one of the four primary classifications (or types) of main and modifying term entries: Procedure or service (e.g., examination, excision, scope) Organ or anatomic site (e.g., clavicle, mandible, humerus, liver) Condition, illness, or injury (e.g., cholelithiasis, ulcer, fracture, pregnancy) Eponym, synonym, abbreviation, or acronym (e.g., MRI [magnetic resonance imaging], Mosenthal test, GERD [gastroesophageal reflux disease]) The see statement points to another location in the alphabetical index to find the code or code range. The see also statement points to additional codes or code ranges in the alphabetical index that may be useful to the code found in the original search. Adding a semicolon (;) at the end of a main description indicates that it is followed by modifying terms and descriptions. Every indented description below a stand-alone code relates to that stand-alone code. If a main term has no additional modifying terms, there will be no indentation. The next entry is a stand-alone description of a different procedure positioned flush left. Stand-Alone Codes and Code Ranges A procedure or service may list a single code or a range of possible codes that may match the medical documentation. Some medical procedures and diagnostic tests are complex and may have a single (stand-alone) code or a code range. Example: The code for "Craterization, phalanges, toe" is 28124, which is a stand-alone code. However, using the same main term, "Craterization," but adding any of the phalanges (toes or fingers) generates a range of codes: . Add a hyphen for code range to indicate that all codes within that range could be possible. Some services or procedures may have a stand-alone code and a range of codes. Example: "Craterization, femur" lists both the stand-alone code 27360 and the code range . Then, the next step is to search in the tabular list and select the code that closely matches the medical documentation. As there will be no code descriptions in this list, use the tabular list to ensure that the code selection is accurate even if you assign a single code. Using Tabular List for Coding Search the main text and find the first code or code range given in the alphabetical index search. Compare the code description with the medical documentation. Verify if there is any additional element or information in the code description that is not present in the documentation. Read the guidelines and notes for the section, subsection, and code. This ensures correctness and avoids contraindications on usage of the code. Evaluate the conventions, especially add-on codes, and exemption from modifiers. Determine whether or not any special circumstances require the use of a modifier or a Special Report. Document the appropriate CPT code in the health record next to the procedure and in the appropriate block of the insurance claim form. CPT Coding for Surgery Abstract the procedures or services from the procedural statement in the surgical report. Select the most appropriate main term to search in the alphabetical index. (Determine whether or not the code must be modified.) Repeat steps 2 and 3 using a different possible main term based on the procedural statement if the main term is not available in the alphabetical index. Disregard any code or code range containing additional descriptions not found in the health record. Write down the selected code or code range in the surgical report. Turn to the tabular list and find the first code or code range from your search of the alphabetical index. Compare the description of the code with the procedural statement in the surgical report. Verify that most of the health record documentation matches the code description and that there is no additional information in the code description. Read the coding guidelines and notes for the section, subsection, and code to ensure that there are no contraindications listed, which would prohibit using that code. Determine if there is a need for modifier or for a special report, and then record the CPT code. CPT Coding for Surgery Using TruCode Abstract the procedures or services from the procedural statement in the surgical report. Type the main term into the encoder search box and select the CPT. Then click "Show all Results." Repeat steps 2 and 3 using a different possible main term based on the procedural statement, if the main term is unavailable in the alphabetical index. Choose the procedure description that is closest to the procedural statement in the surgical report to prevent upcoding or downcoding errors. Record the CPT code that matches the procedural statement in the patient's health record to prevent repeated reference to the alphabetical index. Evaluation and Management List 01 Pharmacy 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 17 Walk-In Retail Health Clinic 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room-Hospital 24 Ambulatory Surgery Center 31 Skilled Nursing Facility 34 Hospice 51 Inpatient Psychiatric Facility 60 Mass Immunization Center 65 End-Stage Renal Disease Treatment Facility 71 Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory The E/M section is divided into subsections, and the subsections are further divided into subcategories. The subsections include office visit, emergency room visit, hospital visit, and consultation. The subcategories include place of service and the patient status. Choosing E/M coding Identify the POS: the MA should identify the place of service where the patient receives medical service from the provider to determine the most accurate CPT E/M code. Identify the patient status: the MA should identify the patient status as "new" or "established."Identify the subsection, category, or subcategory of service. Determine the level of service by determining the extent of the history obtained, the extent of examination performed, and the amount of complexity involved in making the medical decision. Ensure the selection of appropriate service by comparing the medical documentation with the examples in Appendix C of the CPT manual. History, examination, and medical decision-making are the key components while determining the level of service for E/M procedure coding. Patient History Types History relates to the clinical information obtained by the provider by asking specific questions to the patient. The levels of history include the following: Problem-focused history: focuses on the chief complaint, symptoms, severity, and duration of the problem. Expanded problem-focused history: involves the review of systems pertinent to the chief complaint. Detailed history: includes extended history of present illness and past, family and social histories related to the patient's problem. Comprehensive history: includes the chief complaint, an ROS that is directly related to the problem, review of other body systems, and complete past, family and social histories. Medical Examination Types During examination, the provider obtains measurable findings and documents it. The levels of examination include the following: Problem-focused examination: limited to the single body area or single system mentioned in the chief complaint. Expanded problem-focused examination: the examination of organs or body areas that are related to the organ or body area of the chief complaint. Detailed examination: includes performing an extended examination on the body areas and related organ systems. Comprehensive examination: includes a complete multisystem examination or complete examination of a single organ system. Elements of Medical Decision Making Elements that comprise a medical decision-making process are: The number of diagnoses and/or management options The amount and/or complexity of data obtained, reviewed, and analyzed The risk of significant complications and/or morbidity and/or mortality Contributing complexity factors (Counseling) This involves interacting with a patient and the family members regarding the diagnostic results, treatment options, and the follow-up. A degree of counseling is involved in every E/M service and it is factored into the E/M code. If this factor exceeds 50%, then counseling is considered a contributing factor to E/M complexity. Contributing complexity factors (Nature of the Presenting the Problem) This may range from something as simple as a common cold to a life-threatening illness. If the nature of the presenting problem exceeds more than half of the patient encounter, then it is considered a factor in selecting the level of service. Contributing complexity factors (Coordination of Care) A patient may be in need of care even after the visit or hospitalization. Coordination of care determines the level of service when it exceeds 50% of the patient encounter. Key factors of Determining the Level of Service Using E/M Coding History Examination Decision Making Anesthesia Codes (CPT-4 Codes) The codes used in the anesthesia section of the tabular list are also known as CPT-4 codes. Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) generally use these codes. These codes are used for conscious sedation and general anesthesia (which renders the patient unconscious during the procedure). Anesthesia coding is essentially different from any other form of coding in the way the anesthesia services are billed. Codes for conscious sedation are found in the medical section. CPT-4 codes start with a zero and are used to identify the anatomic location of surgery performed. Anesthesia CPT Code Formula To bill anesthesia services, the following standard formula is used: Basic unit values (B) + Time units (T) + Modifying units (M) Basic unit value (B) The numeric value assigned to each anesthesia service based on the level of complexity using the Relative Value Guide (RVG). Time Units (T) The time (in hours and minutes) of how long anesthesia services were administered to the patient. Generally, one time unit is equal to 15 minutes. The time starts when the anesthetist prepares the patient and ends when the patient is no longer under anesthetist care. The time is documented in the patient's health record. Modifying Units (M) A condition or circumstance that changes the environment in which the anesthesia service was provided. Modifying units are based on the qualifying circumstances and physical status modifiers, which are the modifying features of anesthesia services. The physical status modifiers include: P1 for a normal healthy patient P2 for a patient with mild systemic disease P3 for a patient with severe systemic disease P4 for a person with systemic disease that is threat to life P5 for a moribund patient who is not expected to survive without the procedure P6 for a declared brain-dead patient whose organs are being removed for donor purposes. Anesthesia Conversion Factor Formula The dollar value of each basic unit is called the conversion factor. Each third-party payer issues a list of conversion factors. The conversion factor assigned to a specific location is multiplied with each basic unit value. Calculation of the payment of anesthesia service involves basic unit value (B), modifying unit (M), time unit (T), physical status modifier, if applicable (PS), and the conversion factor. The formula used for anesthesia billing is: (B + M + T + PS) × Conversion factor