L6615. Coding CPCS. what Every. Professional Should Know 90.1

Transcription

1 CPT S8092 D6212 ICD-9-CM L6615 Coding and You CPCS what Every Healthcare Professional Should Know D L6615

2 Coding and You what Every healthcare Professional Should Know

3 is published by HCPro, Inc. Copyright 2011 HCPro, Inc. All rights reserved. Printed in the United States of America ISBN: No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center (978/ ). Please notify us immediately if you have received an unauthorized copy. HCPro provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Current Procedural Terminology (CPT) is Copyright 2010 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Hugh Aaron, MHA, JD, CPC, CPC-H, Contributing Author Cindy Basham, MHA, RN, CPC, CCS, Reviewer Kimberly Hoy, JD, Reviewer Shannon McCall, RHIA, CPC, CCS, Reviewer Ilene MacDonald, CPC, Executive Editor Lauren McLeod, Group Publisher Jean St. Pierre, Senior Director of Operations Genevieve d Entremont, Copyeditor Mike Mirabello, Senior Graphic Artist Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA Telephone: 800/ or 781/ Fax: 800/ customerservice@hcpro.com Visit HCPro online at: 03/

4 Contents Chapter 1: Overview of the coding profession Definition of medical coding Professional associations Chapter 2: Breakdown of the ICD-9-CM system Background Maintenance and application of ICD-9-CM Organization of ICD-9-CM Anatomy of an ICD-9-CM code Assigning an ICD-9-CM code How to research an ICD-9-CM coding question HIPAA and the future of ICD-9-CM Chapter 3: Breakdown of the HCPCS system Background Application of HCPCS Organization of HCPCS Appropriate modifiers HIPAA and the HCPCS system hcpro, Inc. iii

5 iv SAMPLE Chapter 4: Breakdown of the CPT system Background Maintenance and application of CPT Organization of CPT Anatomy of a CPT code Assigning a CPT code Appropriate modifiers How to research a CPT coding question HIPAA and CPT Appendix Quick reference guide for commonly used medical code sets hcpro, Inc.

6 Chapter 1: Overview of the coding profession Definition of medical coding Medical coding is the process of applying codes to represent clinical information. Providers can use codes to describe the following: Diagnostic information that is related to a patient s clinical condition Services and supplies The U.S. uses the following two primary coding systems for billing purposes: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Healthcare Common Procedure Coding System (HCPCS) In general, codes are used for billing purposes to describe: Why the patient received the service (generally using codes from Volume 1 of ICD-9-CM) What services the patient received (generally using codes from Current Procedural Terminology [CPT ], HCPCS Level II, or Volume 3 of ICD-9-CM) 2011 hcpro, Inc. 1

7 2 SAMPLE Figure 1 outlines the differences between diagnostic and procedural codes, including which setting uses each. Figure 1 Diagnosis Codes (Used to report why the patient received services) ICD-9-CM Volume 1 (Used for most admissions/encounters, both outpatient and inpatient) CPT Category I (Codes for services/items commonly accepted in clinical practice) Coding systems flow chart HCPCS (Used for most services/ items other than hospital inpatient facility services) HCPCS Level I (CPT codes maintained by the American Medical Association) CPT Category II (Codes used for tracking performance measures) Procedure Codes (Used to report what services/items were furnished to the patient) ICD-9-CM Volume 3 (Used for hospital inpatient facility services) HCPCS Level II (Non-CPT codes jointly maintained by AHIP, BCBSA, and CMS) CPT Category III (Codes for new and emerging technologies) 2011 hcpro, Inc.

8 Professional associations Although clinical knowledge can be extremely helpful to a coder, the medical coding profession does not involve the practice of medicine. Rather, it is the application of coding rules to a set of clinical facts. In recent years, coding has become a recognized profession in its own right. The following two national organizations certify individuals as having expertise in coding: American Academy of Professional Coders (AAPC) ( American Health Information Management Association (AHIMA) ( Both organizations generally require some practical coding experience and successful completion of an examination before an individual can become certified. The AAPC offers the following three coding certifications (in addition to a separate apprentice certification 1 ): Certified Professional Coder (CPC) awarded to individuals who have demonstrated competence in ICD-9-CM diagnosis coding and HCPCS/CPT procedure coding 2011 hcpro, Inc. 3

9 4 SAMPLE Certified Professional Coder-Hospital (CPC-H) awarded to individuals who have demonstrated competence in coding hospital outpatient services Certified Professional Coder-Payer (CPC-P) awarded to individuals who have demonstrated competence in the application of ICD-9-CM diagnosis coding and HCPCS/CPT as it pertains to the adjudication of provider claims AHIMA offers the following two coding certifications (in addition to a separate apprentice certification): REFEREnCE Certified Coding Specialist-Physician-based (CCS-P) awarded to individuals who have demonstrated competence in coding physician services Certified Coding Specialist (CCS) awarded to individuals who have demonstrated competence in coding hospital inpatient and outpatient services 1. Both the aapc and ahima currently offer apprentice credentials (e.g., CPC-A, cca) for those individuals with limited coding experience hcpro, Inc.

10 Chapter 2: Breakdown of the ICD-9-CM system Background The World Health Organization first published the Inter national Classification of Diseases (ICD) in The original ICD was designed for statistical tracking purposes. The 9th Revision to ICD (ICD-9) was first published in ICD-9-CM is a modified version of the ICD-9. The U.S. National Center for Health Statistics (NCHS) is responsible for making revisions. The Clinical Modification (CM) enhances ICD-9 so that it can be used to classify morbidity data for indexing of medical records, medical case review, and ambulatory and other medical programs, as well as for basic health statistics. (Source: Medicode International Classification of Diseases, 9th Revision, Clinical Modification at 1) Maintenance and application of ICD-9-CM The NCHS and Centers for Medicare & Medicaid Services (CMS) jointly maintain ICD-9-CM. Historically, ICD-9-CM has been updated annually on October 1st of each year. ICD-9-CM is used primarily to report a patient s diagnosis or condition. In addition, hospitals use Volume 3 of ICD-9-CM to report 2011 hcpro, Inc. 5

11 6 SAMPLE certain procedural services, such as surgeries. Many third-party payers, including Medicare, use ICD-9-CM to determine medical necessity (i.e., whether the services provided were necessary based on the patient s diagnosis or condition). Organization of ICD-9-CM ICD-9-CM is organized into the following three volumes: Volume 1 Tabular List Volume 1 lists the diagnostic (as opposed to procedural) ICD-9-CM codes in numeric order. Volume 1 codes are generally used to describe the patient s clinical condition. They are used for most admissions/encounters, both outpatient and inpatient. The tabular list includes the following 17 chapters: 1. Infectious and Parasitic Diseases 2. Neoplasms 3. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders 4. Diseases of the Blood and Blood-Forming Organs 5. Mental Disorders 6. Diseases of the Nervous System and Sense Organs 7. Diseases of the Circulatory System 2011 hcpro, Inc.

12 8. Diseases of the Respiratory System 9. Diseases of the Digestive System 10. Diseases of the Genitourinary System 11. Complications of Pregnancy, Childbirth, and the Puerperium 12. Diseases of the Skin and Subcutaneous Tissue 13. Diseases of the Musculoskeletal System and Connective Tissue 14. Congenital Anomalies 15. Certain Conditions Originating in the Perinatal Period 16. Symptoms, Signs, and Ill-Defined Conditions 17. Injury and Poisoning Volume 2 Alphabetic Index to Diseases Volume 2 provides an alphabetic index to Volume 1. The alphabetic index includes the following three sections: 1. Section 1 Index to Diseases 2. Section 2 Table of Drugs and Chemicals 3. Section 3 Index to External Causes Volume 3 Procedures Volume 3 lists the procedural ICD-9-CM codes hcpro, Inc. 7

13 8 SAMPLE Anatomy of an ICD-9-CM code Diagnostic codes are located in Volume 1 of the ICD-9-CM Manual. All Volume 1 codes often referred to as category codes consist of at least three digits. For example, ICD-9-CM code 042 indicates HIV. Most category codes also have either one or two levels of subcategories. The first subcategory level is indicated by the addition of a decimal point and a fourth digit after the category code. The second subcategory level is indicated by the addition of a fifth digit. For example, category code 054 (herpes simplex) contains the following subcategory codes: Procedure codes are located in Volume 3 of the ICD-9-CM Manual. These codes are generally used for hospital inpatient facility services only. The procedure code format is similar to the diagnostic code format, except that the category codes are only two digits (eczema herpeticum) (genital herpes) (genital herpes, unspecified) (herpetic vulvovaginitis) (herpetic ulceration of vulva) (herpetic infection of penis) (other) 2011 hcpro, Inc.

14 For example, 03 indicates operations on spinal cord and spinal canal structures. Subcategories for this code include the following: Note that E codes and V codes also contain categories and subcategories. E codes represent external causes of injury and are constructed as follows: 03.0 (exploration and decompression of spinal canal structures) E### or E###.# V codes can represent diagnoses assigned to healthy patients for screening exam purposes, treatment of a current illness or injury, or to identify co-existing conditions that may impact the treatment or care rendered. V codes are constructed as follows: V## or V##.# or V##.## (removal of foreign body from spinal canal) (reopening of laminectomy site) (other exploration and decompression of spinal canal) 2011 hcpro, Inc. 9

15 10 SAMPLE Assigning an ICD-9-CM code The ICD-9-CM coding system requires extensive training and experience. However, the general process for assigning an ICD-9-CM code is as follows: Review the clinical documentation and identify the term(s) that best describes the patient s diagnosis, disease, condition, or symptoms. Look up the term(s) that best describes the patient s diagnosis, disease, condition, or symptoms in Volume 2 (the alphabetic index) and identify the appropriate code(s). Look up the selected code(s) in Volume 1 (the tabular list) to make the definitive code(s) selection. Pay careful attention to any exclusion notes or other instructions in Volume 1. In many cases, proper diagnosis coding requires more than one ICD-9-CM code to describe the patient s diagnosis, disease, condition, or symptoms. When assigning multiple codes, you must follow special rules to properly sequence the codes (i.e., report them in the correct order) hcpro, Inc.

16 How to research an ICD-9-CM coding question Follow these steps when researching an ICD-9-CM coding question: Start with the ICD-9-CM Manual. You can resolve many ICD-9-CM coding questions by carefully studying the ICD-9-CM Manual itself, paying particular attention to typographical conventions and the various notes included throughout the manual. Review the official guidelines. The Public Health Service and CMS jointly publish the Official ICD-9-CM Guide lines for Coding and Reporting. You can download this information at The following organizations helped develop and approve these guidelines: American Hospital Association (AHA) AHIMA CMS NCHS Review Coding Clinic. Coding Clinic is a newsletter published by the AHA. Representatives from the four organizations listed above review and approve each issue of Coding Clinic. You can order a subscription or back issues of Coding Clinic from the AHA by calling 800/AHA hcpro, Inc. 11

17 12 SAMPLE HIPAA and the future of ICD-9-CM As part of the implementation of the Health Insurance Port ability and Accountability Act of 1996 (HIPAA) Administrative Simplification provisions, the federal Department of Health and Human Services (HHS) adopted ICD-9-CM, Volumes 1 and 2, as the standard medical data code set for reporting (i) diseases; (ii) injuries; (iii) impairments; (iv) other health problems and their manifestations; and (v) causes of injury, disease, impairment, and other health problems. (Source: 45 C.F.R [a]) HHS also adopted ICD-9-CM, Volume 3, as the standard medical data code set for hospital reporting of procedures and other actions performed on hospital inpatients for the prevention, diagnosis, treatment, or management of diseases, injuries, and impairments. (Source: 45 C.F.R [b]) HHS also adopted the ICD-9-CM Official Guidelines as part of ICD-9-CM when it adopted the coding system as one of the HIPAA standard medical data code sets. (Source: 45 C.F.R [a] and [b]) Effective October 1, 2013, ICD-10 will replace ICD-9 in the United States. ICD-10-CM will replace ICD-9-CM diagnosis codes (Volumes 1 and 2) in inpatient, outpatient, and professional services settings. ICD-10-PCS will be used in place of ICD-9-CM procedure codes (Volume 3), primarily for inpatient facility services hcpro, Inc.

18 ICD-10-CM and ICD-10-PCS will allow increased specificity and room for expansion, factors that impede ICD-9-CM s ability to remain a viable system. The United States also needs to be able to exchange clinical data with other nations. Most, including Canada, already use ICD-10. For more information about the new coding system, see hcpro, Inc. 13

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20 Chapter 3: Breakdown of the HCPCS system Background CMS developed the HCPCS in 1983 to standardize procedure coding throughout its programs. Visit for more information. Application of HCPCS The HCPCS primarily indicates services/supplies that physicians and certain outpatient providers, such as ambulance companies, render. This system is used for most services/items other than hospital inpatient facility services. Organization of HCPCS HCPCS contains the following two levels of codes: 1. Level I Level I refers to CPT codes that the American Medical Association (AMA) publishes and maintains. The AMA and CMS have entered into an agreement that permits HCFA [CMS], its agents, and other entities participating in programs administered by HCFA [CMS], to use CPT codes/ modifiers and terminology as part of HCPCS. (Source: Medicare Claims Processing Manual, Chapter ) 2011 hcpro, Inc. 15

21 16 SAMPLE 2. Level II Level II codes are national non-cpt codes that CMS, the Blue Cross/Blue Shield Association, and the Health Insurance Association of America jointly maintain. Level II codes typically represent items and services that are not included in CPT (e.g., ambulance services, durable medical equipment, orthotics, etc.). Keep the following in mind regarding Level I codes: There are three categories of Level I codes: Category I, Category II, and Category III. Category I codes signify services/items commonly accepted in clinical practice. These codes consist of five numeric characters. Category II codes are used for tracking performance measures. These codes consist of four numeric characters followed by the alpha character F. Category III codes represent new and emerging technologies. These codes consist of four numeric characters followed by the alpha character T. Keep the following in mind regarding Level II codes: Level II codes consist of five digits. Digit one is alphabetic ( A through V ). Digits two through five are numeric hcpro, Inc.

22 Medicare and Medicaid require Level II codes. Some private payers also use them. For certain procedures, a HCPCS Level I (CPT) code and a HCPCS Level II code can both describe the same procedure. In these instances, the correct code selection will be based on payer-specific information. Common uses of Level II codes include the following: Injections A Level II code typically identifies the drug injected Nonroutine supplies A Level II code typically identifies a nonroutine supply that a provider furnishes in conjunction with a physician-office visit Appropriate modifiers Modifiers are used to provide additional information about the service performed (or the circumstances under which the service was performed) that goes beyond the code description. Modifiers can be either two-digit numeric or alphanumeric combinations preceded by a hyphen (e.g., -NN ). There are two levels of HCPCS modifiers: 1. Level I These are the AMA s CPT modifiers hcpro, Inc. 17

23 18 SAMPLE 2. Level II These are national non-cpt modifiers. Level II modifiers are comprised of two alphabetic digits (e.g., -AA ). The range is -AA through -VP. Level II modifiers are sometimes used with Level I codes (i.e., CPT codes) and vice versa. HIPAA and the HCPCS system As part of the implementation of the HIPAA Administrative Simplification provisions, HHS adopted HCPCS as the standard medical data code set for reporting all substances, equipment, supplies, or other items used in healthcare services that are not included within one of the other standard code sets. (Source: 45 C.F.R [f]) 2011 hcpro, Inc.

24 Chapter 4: Breakdown of the CPT system Background The AMA developed CPT and first published it in Maintenance and application of CPT The 16-member AMA CPT Editorial Panel, along with the AMA s CPT Advisory Committee (which is made up of representatives from more than 90 medical specialty societies and other healthcare professional organizations), update CPT annually. The CPT system contains more than 8,000 codes. Providers typically use CPT to describe physician/professional services, as well as the technical component of services provided in conjunction with professional services. The professional component generally refers to direct patient care services furnished by a physician or other qualified practitioner. The technical component generally refers to the nonphysician resources used during the performance of a diagnostic test. This component typically includes space, equipment, supplies, and nonphysician personnel hcpro, Inc. 19

25 20 SAMPLE CPT contains the following three categories of codes: 1. Category I Codes for services and items that are consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. (Source: CPT Assistant, February 2001) 2. Category II Codes used for performance measurement purposes. (Source: CPT Assistant, February 2001) 3. Category III Codes used for new and emerging technology. (Source: CPT Assistant, February 2001) Organization of CPT CPT lists Category I codes first, followed by Category II and Category III codes. Category I codes (which make up the bulk of CPT) are divided into six main sections, followed by various appendixes and an alphabetic index. Category I codes are listed in numeric order within sections and subsections. The main sections include the following: Evaluation and management Anesthesia Surgery 2011 hcpro, Inc.

26 Radiology Pathology and laboratory Medicine All of the main sections are further divided into subsections. For example, the surgery section is generally divided into one subsection for each major body system. Section guidelines appear at the beginning of each of the six Category I sections. In addition, subsection guidelines appear at the beginning of most of the subsections. In general, the section and subsection guidelines provide definitions and other information necessary to properly select CPT codes from the applicable section/subsection. The CPT index is organized by five general types of main terms: Procedures (i.e., patient services) Organs or anatomic sites Conditions Synonyms, eponyms, and abbreviations Modifying terms 2011 hcpro, Inc. 21

27 22 SAMPLE The main terms are often followed by modifying terms that provide greater specificity in locating CPT codes. CMS also publishes Documentation Guidelines for Evaluation & Management Services (located in the first section of the CPT Manual). Although these guidelines are technically not a part of CPT, Medicare carriers generally use them when reviewing Medicare Part B claims. There are currently two versions of the guidelines: a 1995 version and a 1997 version. Copies of the 1995 and 1997 versions of the guidelines are available at 25_EMDOC.asp. Currently, Medicare carriers permit physicians to use either the 1995 or 1997 version (see 1998 letter from HCFA to the AMA, reprinted at CCH 46,327). Anatomy of a CPT code Category I CPT codes consist of five numeric characters. Cate - gory II and III CPT codes consist of a combination of five alphanumeric characters. Assigning a CPT code As with the ICD-9-CM coding system, using CPT requires extensive training and experience. However, the general process for assigning a CPT code is as follows: 2011 hcpro, Inc.

28 Review the clinical documentation and identify the term(s) that best describe the service(s) provided. Look up the term(s) that best describes the service(s) provided in the CPT index to identify the code(s) that appears to apply. Look up the selected code(s) in the main body of CPT to make the definitive code selection. Pay careful attention to the applicable section and subsection guidelines and to any other notes contained in the manual. Also, pay careful attention to the use of indentations and semicolons. In some cases, a related code is indented and printed below another code. Treat only the portion of the description of the first code up to the semicolon (referred to as the common portion) as a part of the indented code. Determine whether any modifier(s) are required. If so, select the appropriate modifier(s) from Appendix A of the CPT Manual. Note that third-party payers sometimes implement their own coding rules that are, in some cases, inconsistent with those of the AMA. Assuming the payer has the right to implement such rules (either by law in the case of governmental payers, or by contract in the case of private payers), the payer-specific rules generally take precedence over the AMA rules hcpro, Inc. 23

29 SAMPLE Appropriate modifiers A modifier might be used with a CPT code to indicate: Unusual circumstances (e.g., that general anesthesia was necessary, even though the particular procedure is typically performed without anesthesia or with local anesthesia) That the provider performed only the professional or technical component of a procedure, even though the procedure typically includes both a professional and a technical component That the provider did not complete a service as described by the CPT code (e.g., the physician discontinued a pro - cedure that had already begun based on a change in the patient s condition) How to research a CPT coding question Follow these steps when researching a CPT coding question: Start with the CPT Manual. You can resolve many CPT coding questions by carefully studying the CPT Manual itself, paying particular attention to typographical conventions and the various guidelines and other notes included throughout the manual. Review CPT Assistant and CPT Changes. CPT Assistant is a monthly newsletter published by the AMA that is designed to clarify CPT coding issues. CPT Changes is 2011 hcpro, Inc.

30 3 a book that the AMA republishes each November. CPT Changes provides background information on the annual changes to CPT for the upcoming year. Locate any applicable specialty-society guidelines. For example, the Society of Interventional Radiology has published an Interventional Radiology Coding Users Guide that attempts to provide guidance on the proper way to code interventional radiology procedures (a particularly difficult coding area). In cases when the CPT Manual does not provide clear guidance with regard to CPT coding for a particular service, third-party payers will often give substantial weight to such specialty-society guidelines. HIPAA and CPT As part of the implementation of the HIPAA Administrative Simplification provisions, HHS adopted the combination of CPT and HCPCS as the standard medical data code sets for reporting physician services and other health care services including, but not limited to, the following: Physician services Physical and occupational therapy services Radiologic procedures Clinical laboratory tests 2011 hcpro, Inc. 25

31 26 SAMPLE Other medical diagnostic procedures Hearing and vision services Transportation services, including ambulance (Source: 45 C.F.R [e]) 2011 hcpro, Inc.

32 Appendix Quick reference guide for commonly used medical code sets Diagnosis codes ICD-9-CM Volume I, other than E codes and V codes E codes ( External causes of injury and poisoning ) V codes ( Factors influencing health status and contact with health services ) Procedure/supply/drug codes ### or ###.# or ###.## E### or E###.# V## or V##.# or V##.## ICD-9-CM Volume III (Inpatient) ##.# or ##.## CPT Category I (Outpatient) ##### CPT Category II (Outpatient, for tracking performance measures) CPT Category III (Outpatient, for emerging technology) HCPCS Level II (Outpatient) Note: # indicates a numeric character. ####F ####T [A-V]#### where [A-V] is a single alphabetic character between A and V inclusive 2011 hcpro, Inc. 27

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