Master Core Curriculum

Part B Basic Module 2 Current Procedural Terminology (CPT)/ HCPCS

Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association.
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Learning Outcomes
At the end of this module, participants will be able to:

identify which CPT manuals and tools will be most beneficial to their practice effectively navigate the CPT manuals/tools to quickly locate codes of choice effectively utilize the CCI tools to understand correct coding methodologies select CPT code ranges by service description describe E/M codes documentation requirements
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Current Procedural Terminology (CPT)

Descriptive terms and identifying codes

For reporting medical services and procedures

Performed by physicians, non-physician practitioners, and suppliers

Provides uniform language to describe medical, surgical, and diagnostic services

CPT Manual
Developed and maintained by AMA Listing of 5-digit procedure codes Divided into 6 sections

Evaluation and Management (99201-99499) Anesthesiology (00100-01999; 99100-99140) Surgery (10040-69979) Radiology (70010-79999) Pathology & Laboratory (80049-89399) Medicine (90701-99199)
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Current Procedural Terminology 2006 American Medical Association. All Rights Reserved.

Instructions for Use of CPT

Select code that most accurately

identifies service performed If no procedure code exists, report appropriate unlisted code Medical record documentation must support service billed

Add-on Codes
Describe additional intra-service work

associated with primary procedure Codes must be reported with primary procedure

Never reported as a stand-alone code

Add-on codes apply only to services performed by same physician

Add-On Code Example

26860: Arthrodesis, interphaleangeal

joint, with or without internal fixation

Represents the primary code

26861: Each additional

interphalangeal joint

Represents add-on code List separately in addition to code for primary procedure

Current Procedural Terminology 2006 American Medical Association. All Rights Reserved.

Unlisted Procedure Codes

Used to report services or procedures

not found in CPT manual Service represented by unlisted procedure code must be described on claim

Paper claim, in Item 19 Electronic claim, in narrative or free-form field

There is an unlisted code for each section of the CPT Manual

Elimination of Grace Periods for CPT/ HCPCS Codes

Effective January 1, 2005, 90-day

grace period for billing discontinued HCPCS codes was eliminated. Providers must bill using HCPCS code that is valid for date of service Purchase AMA CPT-4 coding book (available in October) Level II codes posted at the end of October at: http://www.cms.hhs.gov/HCPCSReleas eCodeSets/
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HCPCS Procedure Coding System

Codes are added, deleted, and

changed each January 1

Level I codes are copyrighted by the American Medical Associations Current Procedural Terminology, Fourth Edition (CPT-4) Level II codes are 5-position alpha-numeric codes maintained by the Health Insurance Association of American and BCBS Association

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Additional Procedure Coding Resources

The CPT Manual (Level I) may be

ordered through: American Medical Association P. O. Box 10946 Chicago, IL 60618-0946 Telephone: 1.800.621.8335 Online: www.amapress.org

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Additional Procedure Coding Resources

The HCPCS Manual (Level II) may

be ordered from: Superintendent of Documents U. S. Government Printing Office Washington, D.C. 20402 Telephone: 1.202.783.3238

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Correct Coding Initiative (CCI)

Comprehensive policy and guidelines

for appropriate use of CPT coding Developed by AdminaStar Federal under contract with CMS

based upon review of CPT code descriptors, CPT coding instructions, existing local and national coding edits, and Medicare billing history

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Correct Coding Combinations

Column I/Column II codes

Services or procedures that are included as part of a more extensive procedure Services or procedures that would not or could not be performed at the same time based on the CPT code description or standard of medical practice

Mutually Exclusive codes

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Correct Coding Combinations

Column I/ Column II Example When a radical mastectomy is performed

Bill CPT code 19240, modified radical mastectomy which includes removal of all breast tissue Procedure code 19120, excision of breast lesions such as cysts, etc., should not be billed as this service is included in 19240

Current Procedural Terminology 2006 American Medical Association. All Rights Reserved.

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Mutually Exclusive Example

Upper GI radiological examination with

high density barium and air contrast and a small bowel follow-through, bill 74249. If the follow-through was not performed, bill 74246 or 74247. Never report CPT code 74249 and 74246 (or 74247) together as it is not possible to perform the exam with and without the follow-through
Current Procedural Terminology 2006 American Medical Association. All Rights Reserved.

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Use of Modifier 59
Defined as Distinct procedural service Use to indicate service was distinct or separate from other services performed on the same day Use modifier 59 to report a:

Different session Different procedure or surgery Different site Separate lesion Separate injury

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Obtaining CCI Information

CMS has published CCI edits on

Internet:

http://www.cms.hhs.gov/NationalC orrectCodInitEd/
For concerns about CCI policy, write: National Correct Coding Initiative Correct Coding Solutions P. O. Box 907

Carmel, IN 46082-0907

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Evaluation and Management (E/M) Services

Seven components that define E/M

services:

History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time

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Key Components of E/M Code Selection

The three key components in

selecting levels of E/M services are:

History Examination Medical Decision Making

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E/M Coding Guidelines

Finally, E/M codes should be

selected using the following criteria:

Medical necessity Individual requirements of CPT code Documentation must support level of service billed

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Chapter Review Slide

Review question. What procedure

coding tools are available to Medicare providers to assist in choosing and billing appropriate procedure codes? Review question. In which section of the CPT manual (e.g. Evaluation & Management, Surgery, etc.) would you find the CPT code 72010?

Current Procedural Terminology 2006 American Medical Association. All Rights Reserved.

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Chapter References/Citations
Current Procedural Terminology (CPT)

2005 Professional Edition CMSManual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 23, Section 20, Healthcare Common Procedure Coding System (HCPCS) CMSManual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 30, Correct Coding Policy
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Chapter References/Citations
CMS Manual System, Pub 100-9,

Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5, Section 20, Correct Coding Initiative CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 30.6, Evaluation and Management Service Codes

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