Presentation 29581 2013 CPC Study Guide Cy

User Manual: 29581

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CPC®

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CPT®

reserved.

Fee schedules, relative value units, conversion factors and/or related

components are not assigned by the AMA, are not part of CPT®, and

the AMA is not recommending their use. The AMA does not directly or

indirectly practice medicine or dispense medical services. The AMA

assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.

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The Business of Medicine

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Payers

•Self-pay

•Insurance

–Private (commercial) insurance

•BCBS

•Aetna

•Cigna

•Etc

–Government insurance

•Medicare

•Medicaid

•TriCare

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Medicare

•Part A –Inpatient hospital care

•Part B –Outpatient medical care

•Part C –Medicare Advantage

•Part D –Prescription drug coverage

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RBRVS

–Non-Facility Pricing Amount

[(Work RVU * Work GPCI) +

(Transitioned Non-Facility PE RVU * PE GPCI) +

(MP RVU * MP GPCI)] * Conversion Factor (CF)

–Facility Pricing Amount

[(Work RVU * Work GPCI) +

(Transitioned Facility PE RVU * PE GPCI) +

(MP RVU * MP GPCI)] * CF

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www.cms.gov/apps/glossary

Medical Necessity

Services or supplies that:

•are proper and needed for the diagnosis or treatment of your

medical condition,

•are provided for the diagnosis, direct care, and treatment of

your medical condition,

•meet the standards of good medical practice in the local

area, and

• aren’t mainly for the convenience of you or your doctor.

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National Coverage Determinations

•National Coverage Determinations (NCD) help to spell out

CMS policies on when Medicare will pay for items or

services

–Each Medicare Administrative Carrier (MAC) is then responsible

for interpreting national policies into regional policies

– LCD’s only have jurisdiction within their regional area

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Advance Beneficiary Notice

•Providers are responsible for obtaining an ABN prior to

providing the service or item to a beneficiary.

–The form must be filled out in its entirety as well as the cost to the

patient and the reason why Medicare may deny the service

–Only the approved Form CMS-R-131 is valid and the forms may not

be altered

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HIPAA

•National standards for electronic health care transactions

and code sets;

•National unique identifiers for providers, health plans, and

employers;

•Privacy and Security of health data.

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HITECH

•The Health Information Technology for Economic and Clinical

Health Act

–Promote the adoption and meaningful use of health information

technology

–Strengthened HIPAA

–Patient audit trail

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OIG Compliance Plan

1. Conduct internal monitoring and auditing.

2. Implement compliance and practice standards.

3. Designate a compliance officer or contact.

4. Conduct appropriate training and education.

5. Respond appropriately to detected offenses and develop corrective

action.

6. Develop open lines of communication with employees.

7. Enforce disciplinary standards through well-publicized guidelines.

http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp

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ICD-9-CM Coding

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NEC vs. NOS

•NEC Not elsewhere classifiable

―We know what’s wrong, but there isn’t a specific code for it.‖

•NOS Not otherwise specified

―We aren’t sure what’s wrong.‖

14 14

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Punctuation

[ ] Brackets: in tabular enclose synonyms or alternate

wording

Example:

008.0 Escherichia coli [E. coli]

[ ] Slanted brackets: in index identifies manifestations and

indicates sequence.

Example:

Diabetes, diabetic 250.0x

cataract 250.5x [366.41]

15 15

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Punctuation

( ) Parentheses: enclose supplementary words that may be

present in the description

Example:

Cyst (mucus)(retention)(serous)(simple)

16 16

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Additional Terms

599.0 Urinary tract infection, site not specified

candidiasis of urinary tract (112.2)

urinary tract infection of newborn (771.82)

280 Iron deficiency anemias

anemia

asiderotic

hypochromic-microcytic

sideropenic

Includes

Excludes

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Use Additional Code

282.42 Sickle-cell thalassemia with crisis

Sickle-cell thalassemia with vaso-occlusive pain

Thalassemia Hb-S disease with crisis

Use additional code for the type of crisis, such as:

acute chest sydrome (517.3)

splenic sequestration (289.52)

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Use Additional Code, if Applicable

416.2 Chronic pulmonary embolism

Use additional code, if applicable, for associated long-term

(current) use of anticoagulants (V58.61)

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Combination Codes

Single codes:

787.02 Nausea alone

787.03 Vomiting alone

Combination code:

787.01 Nausea with vomiting

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Steps to Look Up

a Diagnosis Code

1. Find the documented diagnosis

2. Determine the main term

3. Look up the main term in the Index to Diseases (Volume

4. Find the code in the Tabular List (Volume 1)

5. Read all notes associated with the code

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ICD-9-CM Official Guidelines for Coding and

Reporting

•Section 1

–A: Coding conventions

–B: Coding guidelines

–C: Chapter-specific guidelines

•Sections 2 & 3

–Inpatient Only

•Section 4

–UHDDS guidelines for first listed conditions for outpatient and

office visits www.cdc.gov/nchs/data/icd9/icdguide10.pdf

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ICD-9-CM Guidelines

Hierarchy of Rules

1. Always follow instructions within ICD-9-CM that are

specific to the code.

2. Follow chapter or section instructions when they do not

conflict with the individual code instructions.

3. Follow guidelines when they do not conflict with the

chapter, section, or individual code instructions.

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General Coding Guidelines:

Section I. B.

1. Use of Both Alphabetic Index and Tabular List

2. Locate each term in the Alphabetic Index and Tabular List

3. Level of Detail in Coding

4. Code or codes from 001.0 through V91.99

5. Selection of codes 001.0 through 999.9

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General Coding Guidelines:

Section I. B.

6. Signs and symptoms

7. Conditions that are an integral part of the disease

process

8. Conditions that are not an integral part of the disease

process

9. Multiple coding for a single condition

10. Acute and Chronic conditions

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General Coding Guidelines:

Section I. B.

11. Combination code

12. Late Effects

13. Impending or threatened conditions

14. Reporting same diagnosis more than once

15. Admissions/encounters for rehabilitation

16. Documentation of BMI (Body Mass Index) and pressure

ulcer stages

17. Syndromes

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Section IV: Diagnostic Coding and Reporting

Guidelines for Outpatient Services

A. Selection of first-listed condition

1. Outpatient surgery

2. Observation stay

B. Codes from 001.0 through V91.99

C. Accurate reporting of ICD-9-CM diagnosis codes

D. Selection of codes 001.0 through 999.9

E. Codes that describe symptoms and signs

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Section IV: Diagnostic Coding and Reporting

Guidelines for Outpatient Services

F. Encounters for circumstances other than a disease or

injury

G. Level of detail in coding

4th 5th

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Section IV: Diagnostic Coding and Reporting Guidelines for

Outpatient Services

H. ICD-9-CM code for the diagnosis, condition, problem, or

other reason for encounter/visit

I. Uncertain diagnosis

J. Chronic diseases

K. Code all documented conditions that co-exist

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Section IV: Diagnostic Coding and Reporting Guidelines for

Outpatient Services

L. Patients receiving diagnostic services only

M. Patients receiving therapeutic services only

N. Patients receiving preoperative evaluations only

O. Ambulatory Surgery

P. Routine outpatient prenatal visits

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CPT®, Surgery Guidelines, HCPCS

Level II, and Modifiers

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Introduction to CPT®

•The CPT®code set includes three categories of medical

nomenclature with descriptors.

–Category I

–Category II

–Category III

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Introduction to CPT®

•Instructions for use of the CPT®code book

–Unlisted procedure

–CPT®use by any qualified health care professional

–Parenthetical notes

–Accuracy and quality of coding

•Related guidelines

•Parenthetical instructions

•Other coding resources

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CPT® Guidelines

•Referenced in the introduction of each section and

subsection of the CPT® manual

•Applicable to the section being referenced

•Define the information necessary for choosing the correct

code

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CPT® Conventions and Iconography

Used throughout the CPT®manual and include:

–Indentations

–Code symbols - iconology

–Parenthetical instructions

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CPT®Conventions and Iconography

;The semicolon and the conventional use of indentions

The use of the semicolon divides the description of a code into

two parts:

• The ―stand-alone‖ code or the ―common portion of the

procedure‖ code descriptor

•The indented descriptor is dependent on the preceding

―stand-alone‖ code

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CPT®Conventions and Iconography

+ The ―add-on‖ code symbol - Add-on codes

are never reported alone

Example:

+11201 each additional ten lesions, or part thereof

(Use 11201 in conjunction with 11200)

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CPT®Conventions and Iconography

lThe red bullet - new procedure code

Example:

l31660 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,

when performed; with bronchial thermoplasty, 1 lobe

pThe (blue) triangle - code revision

Example:

p32551 Tube thoracostomy, includes connection to drainage system, (eg,

water seal), when performed, open (separate procedure)

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CPT®Conventions and Iconography

ut Opposing triangles - indicate new and

revised text other than the procedure

descriptors

29581 Application of multi-layer compression system; leg (below knee), including

ankle and foot

u (Do not report 29581 in conjunction with 29540, 29580, 29582, 36475,

36478) t

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CPT®Conventions and Iconography

The circle with a line through it - exempt from the use of

modifier 51

Example:  20974 Electrical stimulation to aid bone healing; noninvasive

(nonoperative)

8 The bulls eye - includes moderate sedation

Example: 8 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without

collection of specimen(s) by brushing or washing (separate procedure)

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CPT®Conventions and Iconography

The lightening bolt symbol - codes for vaccines that are

pending FDA approval.

Example: 90661 Influenza virus vaccine, derived from cell cultures, subunit,

preservative and antibiotic free, for intramuscular use

AMA CPT® ―Category I Vaccine Codes‖ website: www.ama-assn.org

# The number symbol - Resequenced and are out of

numerical order

Example: 46947 Code is out of numerical sequence. See 46700-46947.

# 46947 Hemorrhoidopexy (for prolapsing internal hemorrhoids) by stapling

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Category I CPT® Codes

The CPT®coding manual divides Category I CPT®codes

into six main section titles:

–Evaluation and Management

–Anesthesiology

–Surgery

–Radiology

–Pathology and Laboratory

–Medicine

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Category I CPT® Codes

•Section titles have subsections divided by anatomic location,

procedure, condition, or descriptor subheadings.

•The subheadings, structured by CPT®conventions, may list alternate

coding suggestions in parenthetical instructions.

•Example:

•Section: Surgery (10021-69990)

•Subsection: Integumentary System

•Subheading: Skin, Subcutaneous and Accessory Structures

•Category: Debridement

» (For dermabrasions, see 15780 –15783)

» (For nail debridement, see 11720-11721)

» (For burn(s), see 16000-16035)

» (For pressure ulcers, see 15920-15999)

Alternate coding

suggestions

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The CPT® Coding Manual

•CPT®Sections

•Section Guidelines

•Section Table of Contents

•Notes

•Category II codes (0001F –7025F)

•Category III codes (0019T –0318T)

•Appendices A-O

•Alphabetic Index

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CPT® Code Basics

•Review medical documentation thoroughly and gather

additional reports

•Reference the alphabetical index for a CPT®numerical

code and/or code range.

–Condition

–Procedure or service

–Anatomic site

–Synonyms, eponyms and abbreviations

•Review the numerical code and/or code range for

specific descriptions

•Follow CPT®Guidelines, Conventions and Iconology

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National Correct Coding Initiative (CCI)

•Implemented by CMS

•Promotes correct coding methodologies

•Controls the improper assignment of codes that results in

inappropriate reimbursement

Medicare publishes CCI:

http://www.cms.hhs.gov/NationalCorrectCodInitEd/

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Sequencing

•Based on RBRVS

–Physician Work

–Practice Expense

–Professional Liability/Malpractice Insurance

•Highest RBRVS listed first

www.cms.hhs.gov/PhysicianFee-Sched/

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•Articles answering everyday coding questions

•CCI bundling information

•E/M billing guidance

•Current code use and interpretation

•Case studies demonstrating practical application of codes

•Anatomical illustration charts and graphs for quick

reference

•Information for appealing insurance denials

•Information to validate code usage when audited

CPT®Assistant

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Category II CPT® Codes

• Alphanumeric format, with the letter ―F‖ in the last position,

eg, 0001F

• Optional ―performance measurement‖ tracking codes

•Physician Quality Reporting Initiative (PQRI)

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Category III CPT®codes

•Temporary codes

• Alphanumeric structure, with a ―T‖ in the last position, eg,

0019T

•Can be reported alone, without an additional Category I

code

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CPT®Appendices

Appendix A - Modifiers categorized:

–Modifiers applicable to CPT® codes

–Anesthesia Physical Status Modifiers

–CPT® Level I Modifiers approved for Ambulatory Surgery

Center (ASC) Hospital Outpatient Use

–Level II (HCPCS/National) Modifiers

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CPT®Appendices

•Appendix B - changes and additions to the CPT®codes

from the previous year

•Appendix C - clinical E/M examples for different specialties

•Appendix D –Add-on Codes

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CPT®Appendices

•Appendix E –Exempt from the use of modifier 51 (multiple

procedures)

•Appendix F –Exempt from the use of Modifier 63

(procedures performed on infants less than 4kg)

•Appendix G –Include Moderate (Conscious) Sedation

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CPT®Appendices

•Appendix H –Alphabetic Index of Performance Measures

by Clinical Condition or Topic

–Available only on the AMA website

–www.ama-assn.org.

•Appendix I –Genetic Testing Code Modifiers

–Removed from the 2013 code set

•Appendix J - Electrodiagnostic Medicine Listing of

Sensory, Motor, and Mixed Nerves

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CPT®Appendices

•Appendix K - Product Pending FDA Approval

•Appendix L - Vascular Families

–Based on the assumption that a vascular catheterization has a

starting point of the aorta

•Appendix M - Crosswalk to Deleted CPT®Codes

•Appendix N - Summary of Resequenced CPT®Codes

•Appendix O –Multianalyte Assays

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CPT®Global Surgical Package

•Includes a standard package of preoperative,

intraoperative, and postoperative services

•Payer policies may vary

•May be furnished in any service location

–For example, a hospital, an ambulatory surgical center (ASC), or

physician office

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CPT®Global Surgical Package

Included in the surgery package and not separately billable:

–Local infiltration, metacarpal/metatarsal/digital block or topical

anesthesia

–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

–Evaluating the patient in the postanesthesia recovery area

–Writing orders

–Typical postoperative follow-up care

Inclusive

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CMS Global Surgical Package

•Major Surgery: Has a preoperative period of 1 day with 90

days for the postoperative period.

•Minor Surgery: The preoperative period is the day of the

procedure with a postoperative period of either 0 or 10

days depending on the procedure.

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HCPCS Level II

•Types of Level II Codes

–Permanent National Codes maintained by the CMS HCPCS

Workgroup

•Responsible for additions, deletions, revisions

•Updated annually

–Temporary National Codes maintained by the CMS HCPCS

Workgroup

•Responsible for additions, deletions, revisions

•Updated quarterly

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HCPCS Level II

Types of Temporary Codes

•G codes

–Professional health care procedures/services with no CPT ®

codes

–Example:

•G0412 –G0415 –unilateral or bilateral

•27215 –27218 –unilateral only, use modifier 50 for bilateral

•H codes

–Used by State Medicaid Agencies for mental health services

such as alcohol and drug treatment services

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HCPCS Level II

Appendices:

–Level II modifiers

•May be used with some CPT®codes, i.e., LT/RT

–Table of Drugs

•Names of Drugs, dosage, delivery method, J code

–Medicare References

–Jurisdiction List

–Deleted Code Crosswalk

(each publisher may have different appendices)

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Modifiers

•22 –Increased Procedural Service

–Service provided is greater than that usually required for the

listed procedure

•24 - Unrelated E/M by the same physician during a

postoperative period

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Global Package Modifiers

•25 - Significant, separately identifiable evaluation and

management service by the same physician on the same

day of the procedure or other service

•57 - Decision for surgery

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Global Package Modifiers

•58 - Staged or related procedure or service by the same

physician during the postoperative period

•78 - Unplanned return to the operating/ procedure room

by the same physician following initial procedure for a

related procedure during the postoperative period

•79 - Unrelated procedure or service by the same

physician during the postoperative period

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Surgical Modifiers

•50 - Bilateral Procedure

•51 - Multiple Procedures

•52 - Reduced Services

•53 - Discontinued Procedure

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Modifier 59 - Distinct

Procedural Service

•Procedures not normally reported together

•Different Session or Patient Encounter

•Different Procedure or Surgery

•Different Site or Organ System

•Separate Incision/Excision

•Separate Lesion

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Modifiers

•Modifier 63 - Procedures Performed

on Infants Less than 4kg Increased work intensity

•Modifier 76 - Repeat Procedure or Service by Same

Physician

•Modifier 77 - Repeat Procedure or Service by Another

Physician

67 67

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Multiple Surgeon Modifiers

•62 –Two Surgeons

–Work together as primary surgeons

–Perform distinct parts of a procedure

–Dictate op report of their distinct part

–Each will submit the same code and append modifier 62

•66 –Surgical Team

–Highly complex procedures

–Require differently specialties

–Modifier 66 appended to procedures coded by the surgical team

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Assistant Surgeon Modifiers

•80 –Assistant Surgeon

–Assistant surgeon present for entire or substantial portion of the operation

–Reports the same surgical procedure with modifier 80 appended

•81 –Minimum Assistant Surgeon

–Circumstances present that require the services of an asst surgeon for a short

time. Minimal assistance.

–Reports the same surgical procedure with modifier 81 appended

•82 –Assistant Surgeon (when qualified resident surgeon not

available)

–Used in a teaching hospital that employs residents

–No residents available and another surgeon is used

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Ancillary Modifiers

•Global –a procedure containing both a technical and a

professional component

•Modifier 26 –Professional Component

•Modifier TC –Technical Component

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Laboratory Modifiers

•90 –Reference (Outside) Laboratory

–Used to bill for lab services purchased from an outside lab

•91 –Repeat Clinical Diagnostic Lab Test

–Not used to confirm results

–Not used to repeat a test due to equipment malfunction

•92 –Alternative Lab Platform Testing

–Single use

–HIV testing

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Anesthesia Modifiers

•23 - Unusual Anesthesia

•47 –Anesthesia by Surgeon

•Physical Status Modifiers

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Integumentary System

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Anatomy of the Skin

•Epidermis

–Top layer

•Made up of 4-5 layers; function is protection

•Dermis

–Mid layer

•Blood vessels, connective tissue, nerves, etc.

•Subcutaneous Tissue

–Connective tissue and adipose tissue

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ICD-9-CM: Integumentary

•Chapter 2 –Neoplasms

•Chapter 12 –Diseases of the Skin and Subcutaneous Tissue

•Chapter 17 –Injury and Poisoning

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ICD-9-CM: Integumentary

Chapter 12: Diseases of the Skin and Subcutaneous Tissue

–Skin infections (bacterial and fungal)

–Inflammatory conditions of the skin

–Other disorders of the skin

•Corns and calluses

•Keloid scars

•Keratosis

•etc.

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Inflammatory Conditions of the Skin

•Erythema multiforme:

–Code for erythema multiforme

–Code associated manifestation

–Code percent of skin exfoliation (695.50-695.59)

–An additional E code if drug induced

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Pressure Ulcers

•Decubitus ulcers/bed sores

•Coding

–Identify the location of the ulcer

–Identify the stage of the ulcer

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Injury and Poisoning

•Open Wounds (870-897)

•Superficial Injury (910-919)

•Contusion with Intact Skin Surface (920-924)

•Burns (940-949)

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Burns

•Location

•Severity (degree) of burn

•Total Body Surface Area (TBSA)

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Disorders of the Breast

•Category 610 - Mammary dysplasia

•Category 611 - Disorders of the breast

•Category 612 –Deformity and disproportion of reconstructed

breast

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Skin, Subcutaneous,

and Accessory Structures

•Incision and Drainage

–Simple

–Complicated*

* Complicated = placement of a drain, presence of infection,

hemorrhaging that requires ligation, extensive time

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Debridement

•Debridement

–Method for removing dead tissue, dirt, or debris from infected

skin, burn or wound

–Based on percent of body surface area

•Debridement of necrotizing soft tissue

–Based on area of body being debrided

•Medicine codes

–97597-97602

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Biopsy

•11100 single lesion

•11101 each separate/additional lesion

•Three lesions

–11100 and 11101 x 2

•Obtaining of tissue during another procedure is not

considered a separate biopsy

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Skin, Subcutaneous,

and Accessory Structures

•Removal of Skin Tags

–11200 up to and including 15 lesions

–11201 add-on code for each additional 10 lesions

•Shaving of Epidermal Lesions 11300-11313

–Include local anesthesia & chemical/electocauterization of

wound

–Select codes on size and anatomic location

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Skin, Subcutaneous,

and Accessory Structures

•Excision of Lesions

–Measurement

•Lesion diameter plus narrowest margins

•Code Selection

–Benign or Malignant

–Size in centimeters

–Anatomical location

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Nails

•Fingernails and/or toenails

•Trimming or Debridement

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Integumentary System

•Pilonidal Cyst

–Coded according to complexity of excision

•Introduction

–Intralesional Injections

–Tattooing

–Tissue Expansion

–Contraceptive Capsule insertion/removal

–Hormone implantation

–Drug Delivery Implants

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Repair

•Three factors

–Length of wound in centimeters

–Complexity of repair

–Site of wound

•Wound closure includes sutures, staples tissue adhesive

•Wound repair using only adhesive strips report with E/M

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Repair

•Adjacent Tissue Transfer or Rearrangement

–Z-plasty

–W-plasty

–V-Y plasty

–Rotation Flaps

–Advancement Flaps

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Repair

•Skin Replacement Surgery & Skin Substitutes

–15002-15005 based on size of repair and site

–15040-15261 reported for autografts and tissue cultured

autografts

–15271-15278 reported for skin substitute grafts

–15050 is pinch graft measured in centimeters

–All other skin graft codes are determined by the size of the

defect in square centimeters

–Square centimeters calculation

length in cm x width in cm

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Repair

•Other Procedures

–Dermabrasion

–Chemical Peels

–Cervicoplasty

–Blepharoplasty

–Rhytidectomy

–Abdominoplasty

–Lipo-suction

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Destruction

•Ablation by any method other than excision

–Electrosurgery

–Cryosurgery

–Laser treatment

–Chemical treatment

•Benign/premalignant based on number of lesions

•Malignant lesion according to location and size in

centimeters

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Destruction

•Mohs Micrographic Surgery

–Removal of complex or ill-defined skin cancer

–Physician acts as surgeon and pathologist

–Removes tumor tissues and performs histopathologic exam

–Repair of site may be reported separately

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Breast

•Incision

•Excision

•Introduction

–Preop needle localization wire

•Repair

•Reconstruction

•Biopsy

–Percutaneous

–Incisional

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Breast

•Mastectomy

–Muscles and lymph nodes involved will determine code selection

•Repair Reconstruction

–Reconstruction after mastectomy

•Mastopexy (breast lift)

•Reduction mammoplasty (breast reduction)

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Musculoskeletal System

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Anatomy

–Skeleton

•Axial

•Appendicular

–Muscles

•Assist with heat production

•Posture

–Ligaments –attach bones to other bones

–Tendons –attach muscles to bones

–Cartilage –Acts as a cushion between bones in a joint

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ICD-9-CM Coding

Fifth Digit Specification

0—Site unspecified

1—Shoulder region (Acromioclavicular joint, Clavicle, Glenohumeral joint(s), Scapula,

Sternoclavicular joint(s))

2—Upper arm (Elbow joint, Humerus)

3—Forearm (Radius, Ulna, Wrist joint)

4—Hand (Carpals, Metacarpals, Phalanges (fingers))

5—Pelvic region and thigh (Buttock, Femur, Hip joint)

6—Lower leg (Fibula, Knee joint, Patella, Tibia)

7—Ankle and foot (Ankle joint, Digits (toes), Metatarsals, Phalanges, foot, Tarsals, Other

joints in foot)

8—Other specified sites (Head, Neck, Ribs, Skull, Trunk, Vertebral column)

9—Multiple sites

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Diseases of the Musculoskeletal System and

Connective Tissue

•Arthropathy –pathology or abnormality of a joint

•Dorsopathies –disorders affecting the spinal column

•Rheumatism –non-specific term for any painful disorder of

the joints, muscles, or connective tissue

•Enthesopathies –disorders of ligaments

•Bursitis –inflammation of the bursa

100

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Injury and Poisoning

•Sprains and Strains

•Fractures

–Comminuted

–Impacted

–Simple

–Greenstick

–Pathologic

–Compression

–Torus or Incomplete

101

CPC®Certification Review

CPT® : Musculoskeletal System

Formatted by anatomic site:

–General

–Head, Neck (soft tissues)

and Thorax

–Back and Flank

–Spine (vertebral column)

–Abdomen

–Shoulder, Humerus and

Elbow

–Forearm and Wrist

–Hand and Fingers

–Pelvis and Hip Joint

–Femur and Ankle Joint

–Foot and Toes

–Application of Casts and

Strapping

–Endoscopy/ Arthroscopy

102

CPC®Certification Review

Musculoskeletal System

• ―General‖ subheading

–Many different anatomic sites

•Other subheadings

–Divided by anatomic site, procedure type, condition and

description

•Incision, excision, introduction or Removal, Repair, Revision and/or

Reconstruction, Fracture and/or dislocation, Arthrodesis, Amputation

103

CPC®Certification Review

Guidelines

Types of Fracture Treatment

•Closed - the fracture site not surgically exposed.

•Open –used when fractured bone is surgically exposed

•Percutaneous skeletal fixation

104

CPC®Certification Review

General

•Not specific to anatomic site

•Incision of soft tissue abscess

–Associated with deep tissue

•Wound Exploration

–Traumatic wounds

–Include surgical exploration/enlargement, debridement, removal of

foreign bodies, ligation/coagulation minor blood vessels

105

CPC®Certification Review

General

•Excision & Biopsy

–Muscle or Bone

–Depth of wound or tissue excised

•Introduction or Removal

–Injections

–Foreign body removal

106

CPC®Certification Review

Anatomical Subheadings

•Based on anatomic site

•Divided based on procedure

–Incision

–Excision

–Fracture

•Read notes carefully

107

CPC®Certification Review

Spine

•Anatomy

–Cervical C1-C7

•C1 Atlas

•C2 Axis

–Thoracic T1-T12

–Lumbar L1-L5

•Spinal Instrumentation

–Segmental

–Non-segmental

108

CPC®Certification Review

Endoscopy/Arthroscopy

•Divided by body area

–Elbow

–Shoulder

–Knee

•Surgical endoscopy/arthroscopy includes a diagnostic

endoscopy/arthroscopy

•Multiple surgical procedures performed through scope

may be reported

• ―Separate procedure‖ – included in more extensive

procedure

109

CPC®Certification Review

HCPCS Level II

•Orthotic and Prosthetic

•Basic Orthopedic Supplies

–Crutches

–Canes

–Walkers

–Traction Devices

–Wheelchairs

–Other orthopedic supplies

110

CPC®Certification Review

Respiratory,

Hemic, Lymphatic, Mediastinum and

Diaphragm

111

CPC®Certification Review

Respiratory System

•Nose

•Larynx

•Pharynx

•Trachea

•Bronchi

•Bronchioles

•Lungs

•Alveoli

–Located at the ends of the

bronchioles

–Function is gas exchange

(CO2and O2)

•Pleura

112

CPC®Certification Review

Mediastinum and Diaphragm

•Mediastinum-thoracic cavity between the lungs that contains

the heart, aorta, esophagus, trachea, thymus gland

•Diaphragm-muscle that divides the thoracic cavity from the

abdominal cavity

113

CPC®Certification Review

Hemic and Lymphatic Systems

•Network of channels

•Structures dedicated to circulation and production of

lymphocytes

•Three interrelated functions

–Removal for interstitial fluid from tissues

–Absorbs and transports fatty acids to circulatory system

–Transport antigen presenting cells to lymph nodes

114

CPC®Certification Review

Hemic and Lymphatic Systems

•Spleen

–Located left side of stomach

–Reservoir for blood cells

–Produces lymphocytes involved in fighting infection

115

CPC®Certification Review

ICD-9-CM: Respiratory

•Acute Respiratory Infections (460-466)

•Other Disease of the Upper Respiratory System (470-478)

•Pneumonia and Influenza (480-488)

•COPD and Allied Conditions (490-496)

116

CPC®Certification Review

ICD-9-CM

•Mediastinum and Diaphragm

–Diaphragm Herniation

–Diaphragmatic Paralysis

–Thymic hyperplasia

•Hemic and Lymphatic Systems

–Lymphoma

–Lymphadenitis

–Hypersplenism

–Splenic Rupture

–Leukemia

117

CPC®Certification Review

•Respiratory procedures

–Progress downward from the head to the thorax

•Parenthetical statements

–Directions on how to use specific codes

–Apply to codes above parenthetical note; not below

•Most codes are unilateral

•Use modifier 50 if bilateral procedure performed

–Unless code descriptor states bilateral

Rules/Guidelines

118

CPC®Certification Review

•Rhinotomy

•Excision

–Biopsy code

–Removal of lesions, cysts, and/or polyps

–Turbinates

•Rhinectomy

Nose

119

CPC®Certification Review

•Introduction

–Therapeutic turbinate injection

–Prosthesis for deviated nasal septum

•Plug placed by physician

•Removal of foreign body

–Office setting

–Facility setting

•General anesthesia

Nose

120

CPC®Certification Review

•Repair

–Rhinoplasty

–Septoplasty, Atresia. Fistulas, Dermatoplasty

•Destruction

–Turbinate mucosa

•Other procedures

–Control of epitaxis (nose bleed)

–Fracturing of turbinates

Nose

121

CPC®Certification Review

•Four pairs of sinuses

•Procedures

–Obliterative

–Non-obliterative

•Endoscopies

–Diagnostic/Surgical

–All surgical endoscopies always include a diagnostic endoscopy

Accessory Sinuses

122

CPC®Certification Review

•Laryngotomy

•Laryngectomy

•Pharyngolarungectomy

•Arytenoidectomy

•Incision

–Emergency endotracheal intubation

–Change of tracheotomy tube

The Larynx

123

CPC®Certification Review

•Endoscopy

–Use of operating microscope or telescope

•Parenthetical statement instructs not to code the operating microscope

–Direct visualization

•View anatomical structures via bronchoscope inserted into laryngoscope

–Indirect visualization

•Structures viewed in a laryngoscopic mirrored reflection

The Larynx

124

CPC®Certification Review

•Endoscopy

–Many bronchoscopy codes

•Use common portion of main or parent code (up to the semicolon) as the first

part of each indented code descriptor under the parent code

•Bulls eye icon –code includes moderate sedation and is not reported

separately when performed

–Bronchoscopy codes

•Bronchial lung biopsies

•Foreign body removals

•Stent or catheter placements

•Flexible or rigid scopes

•Many parenthetical statements

Trachea and Bronchi

125

CPC®Certification Review

•Excision and Repair

–Carinal reconstruction

•Needed after removal of cancer at this site

–Tracheal tumor excision

•Thoracic and intrathoracic

–Stenosis and anastamosis excision

–Injury suturing

–Tracheostomy scar revision

Trachea and Bronchi

126

CPC®Certification Review

•Incision codes

–Thoracostomy

–Thoracotomy

–Pneumonostomy

–Pleural scarification

–Decortication

Lungs and Pleura

127

CPC®Certification Review

•Excision

–Biopsies

•Read parenthetical statement directions

–Pleurectomy

•Removal

–Pneumocentesis

–Thoracentesis

–Total pneumonectomy

–Lobectomy

–Resections

Lungs and Pleura

128

CPC®Certification Review

•Introduction and Removal

–Thoracostomy (chest tube)

•Endoscopy

–Diagnostic vs. surgical

–VATS

Lungs and Pleura

129

CPC®Certification Review

•Lung Transplantation

–Three steps

•Harvesting

•Backbench

•Insertion

–Live donors

•Rare

•Only one lobe donated

–Cadaver donors

•Most commonly used

Lungs and Pleura

130

CPC®Certification Review

•Surgical collapse therapy/thoracoplasty

–Resection

–Thoracoplasty

•Other procedures

–Lung lavage

–Tumor ablation

–Unlisted - 32999

Lungs and Pleura

131

CPC®Certification Review

•Ventilator Management

•Other Procedures

–Spirometry

–Pulmonary capacity studies

–Respiratory flow studies

–Pulmonary stress testing

–Inhalation treatment

–Oxygen uptake

–Pulse oximetry

Pulmonary

132

CPC®Certification Review

Mediastinum & Diaphragm

•Mediastinum

–Mediastinotomy –based on approach

–Excision (cyst, tumor)

–Endoscopy

•Diaphragm

–Hernia repair

–Resections

133

CPC®Certification Review

Hemic and Lymphatic Systems

•Spleen

–Splenectomy

•Code selection based on type

–Splenorrhaphy

•Reported when a ruptured spleen is repaired

•General

–Bone Marrow or Stem Cell Services

134

CPC®Certification Review

Hemic and Lymphatic Systems

•Lymph Nodes & Lymphatic Channels

–Drainage of lymph node abscess

–Biopsy or Excision

•Code selection based on method and location

–Lymphadenectomy

•Limited –removes only lymph nodes

•Radical –removal of lymph nodes, glands and surrounding tissue

–Injection Procedures

–Lymphangiography

135

CPC®Certification Review

Cardiovascular System

136

CPC®Certification Review

Heart

•4 Chambers

–Two atria

–Two ventricles

•Three layers

–Myocardium

–Epicardium

–Pericardium

•Valves

–Atrioventricular valves

•Tricuspid

•Bicuspid

–Semilunar valves

•Pulmonary

•Aortic

137

CPC®Certification Review

RA > tricuspid valve > RV

RV > pulmonary valve > pulmonary artery

LUNGS (gas exchange)

LA > mitral valve > LV

LV > aortic valve > BODY via arteries

BODY > via veins > RA

Oxygenation Process

138

CPC®Certification Review

–Conduction begins in sinoatrial node of right atrium

• Nature’s pacemaker

•Firing causes contraction of muscle

–Moves to atrioventricular node

•Then to Bundle of His along septum

•Then to Purkinje fibers along the surface of ventricles

Electrical Conduction in the Heart

139

CPC®Certification Review

Coronary Arteries &

Blood Vessels

•Arteries

–Carry oxygenated blood

–Take blood away from heart to the body

•Veins

–Carry deoxygenated blood

–Bring blood back to the heart from the capillary beds

•Capillaries

–Connect arteries and veins

140

CPC®Certification Review

Circulations

•Pulmonary Circulation

–Pushes deoxygenated blood into the lungs

–Carbon dioxide removed and oxygen added

–Blood flows to the left atrium

•Systemic Circulation

–Blood flows from left atrium into the left ventricle

–Pumped to the body to deliver oxygen and remove carbon

dioxide

141

CPC®Certification Review

ICD-9-CM Coding

Chapter 01 –Infectious and parasitic diseases

Chapter 02 –Neoplasms

Chapter 07 –Diseases of the Circulatory System

Chapter 14 –Congenital Anomalies

Chapter 16 –Signs, Symptoms and Ill-Defined Conditions

142

CPC®Certification Review

•Hypertensive Disease

–401 Essential hypertension

–402 Hypertensive heart disease

–403 Hypertensive chronic kidney disease

–404 Hypertensive heart and chronic kidney disease

ICD-9-CM: Hypertension

143

CPC®Certification Review

•CAD of native coronary artery (414.01)

–The patient is not a heart transplant

–The patient has CAD with no history of CABG

–The patient had a prior PTCA of native coronary artery and the

patient is admitted with re-occlusion of this lesion

ICD-9-CM: Arteriosclerosis

144

CPC®Certification Review

•Endocarditis

•Heart Failure

•Pericarditis

•Peripheral Arterial Disease (PAD)

•Valve Disorders

•Myocardial Infarction (MI)

–Acute MI

–Chronic MI and Old MI

ICD-9-CM Coding

145

CPC®Certification Review

•Surgical Section

•Radiology Section

–Heart

–Vascular

–Diagnostic Ultrasound (various CPT ® s)

–Radiologic Guidance

–Nuclear Medicine

•Medicine Section

–Cardiovascular

–Noninvasive Vascular Diagnostic Studies

CPT®Coding

146

CPC®Certification Review

•Pacemaker System

•Pacing cardioverter-defibrillator system

•Codes

–Insertion or replacement

–Implanted pacemakers

–Biventricular (2 ventricles)

Pacemakers/Defibrillators

147

CPC®Certification Review

•Aortic Valve

•Mitral Valve

•Tricuspid Valve

•Pulmonary Valve

Cardiac Valve Procedures

148

CPC®Certification Review

•Coronary Artery Bypass Graft

–Venous

–Arterial-Venous

–Reoperation

–Arterial

–Arterial Graft

•Transluminal Angioplasty

CABG & Transluminal Angioplasty

149

CPC®Certification Review

Bypass Grafts

•Non-coronary vessels

–Vein

–In-situ vein

•Vein is left in native location

–Other than vein

•Code by type/location

150

CPC®Certification Review

Central Venous Access Devices (CVAD)

•Placed for frequent access to bloodstream

•Tip of catheter must terminate in the:

–Subclavian

–Brachiocephalic

–Iliac

–Inferior or superior vena cava

•Code by

–Procedure (insertion, repair, replacement, removal, etc.)

–Tunneled or not

–With pump or port

–Patient age

•See CVAP table in CPT®

151

CPC®Certification Review

Interventional Procedures

•Vascular Injection Procedures

–Selective catheterizations should be coded to the highest level

accessed within a vascular family

–The highest level accessed includes all of the lesser order

selective catheterizations used in the approach

–Additional second and/or third order arterial catheterization

within a vascular family of arteries or veins supplied by a single

first order should be coded

152

CPC®Certification Review

CPT®: Cardiovascular

•Hemodialysis (36800-36822)

•Portal Decompression (37140-37183)

–Treat hypertension/occlusion of portal vein

–TIPS (37182, 37183) diverts blood from the portal vein to the hepatic

vein

•Transcatheter Procedures

–Removal of clot

•Arterial (37184-37186)

•Venous (37187-37188)

•Other (37191-37216)

•Foreign body retrieval, stent placement, etc.

153

CPC®Certification Review

Endovascular Revascularization

•Treat occlusive disease in lower extremities

•Three territories

–Illiac

–Femoral/Popliteal

–Tibial/Peroneal

•Codes arranged in a hierarchy for each territory

–stent placement with atherectomy (highest)

–stent placement

–atherectomy

–angioplasty (lowest)

154

CPC®Certification Review

Bundled into Endovascular Revascularization

•conscious sedation

•vascular access

•catheter placement

•traversing the lesion

•imaging related to the intervention (previously billed as the

supervision and interpretation code for the specific

intervention)

•use of an embolic protection device (EPD)

•imaging for closure device placement

•closure of the access site

155

CPC®Certification Review

Interventional Radiology

•Consider

–The number of catheter access sites

–The number of catheter end points

–The number of vessels visualized

•Vascular Family Order

–Review Appendix L

156

CPC®Certification Review

Radiology Vascular Procedures

•Diagnostic angiography

–Sometimes separately reportable

–Diagnostic angiography performed at a separate setting from an

interventional procedure is separately reportable

–Diagnostic angiography performed at the time of an

interventional procedure is NOT separately reportable if it is

specifically included in the interventional code descriptor

157

CPC®Certification Review

Radiology

•Heart

–Cardiac MRI & CT

•Cardiovascular System

–Cardiac SPECT

–Blood pool imaging

–PET

158

CPC®Certification Review

Medicine Section

•Therapeutic services and procedures

•Cardiography

•Cardiovascular monitoring services

•Implantable wearable cardiac device evaluations

•Echocardiography

•Cardiac Catheterizations

•Intracardiac Electrophysiological Procedures/Studies

•Peripheral Arterial Disease Rehabilitation

•Noninvasive physiologic studies and procedures

•Other procedures

159

CPC®Certification Review

Digestive System

160

CPC®Certification Review

Digestive System

•Lips/Mouth

–Teeth

–Gums

–Tongue

•Pharynx

–Conduit for respiration and digestion

•Esophagus

–Conduct food from the pharynx to the stomach

–Peristaltic action moves the food

161

CPC®Certification Review

Digestive System

•Stomach

–Cardia

–Fundus

–Pylorus (antrum)

–Body

•Small Intestine (small bowel)

–Duodenum

–Jejunum

–Ileum

•Large Intestine (large bowel)

–Cecum (appendix attached)

–Colon

•Ascending colon

•Transverse colon

•Descending colon

•Sigmoid colon

•Rectum

•Anus

162

CPC®Certification Review

Digestive System

•Pancreas

–Endocrine and exocrine organ

–Secretes insulin into the bloodstream

•Liver (Hepatic)

–Largest organ and largest gland

•Gallbladder/Biliary System

163

CPC®Certification Review

ICD-9-CM: Digestive

Chapter 1 –Infectious and Parasitic Diseases

Chapter 2 –Neoplasms

Chapter 9 –Disease of the Digestive System

Chapter 14 –Congenital Anomalies

Chapter 16 –Signs, Symptoms, and Ill-Defined Conditions

164

CPC®Certification Review

Diseases of the Digestive System

•Esophageal and Swallowing Disorders

– Barrett’s Esophagus

–Esophagitis

–Esophageal varices

–Mallory-Weiss Tear

–Hiatal Hernia

–Swallowing Disorders/Dysphagia

•Gastritis and Peptic Ulcer Disease

•Gastrointestinal Bleeding

•Gastroenteritis

165

CPC®Certification Review

Diseases of the Digestive System

•Inflammatory Bowel Disease (IBD)

•Irritable Bowel Syndrome (IBS)

•Foreign Bodies

•Diverticular Disease

–Diverticulosis

–Diverticulitis

166

CPC®Certification Review

Diseases of the Digestive System

•Anorectal Disorders

–Rectal prolapse

–Abscess

–Hemorrhoids

–Anal fissure

–Anal fistula

•Pancreatitis

•Benign and Malignant Neoplasms of the Gastrointestinal

Tract

•Congenital Disorders

167

CPC®Certification Review

CPT®: Digestive

•Organized by anatomic site and procedure

•Endoscopy

–Visualization of a hollow viscus or canal by means of an endoscope

or scope

–Laparoscope is an endoscope

168

CPC®Certification Review

CPT®: Digestive

•Lips

–Vermilionectomy

–Cheiloplasty

•Mouth

–Vestibuloplasty

–Glossectomy

–Palatoplasty

169

CPC®Certification Review

CPT®: Digestive

•Pharynx, Adenoids and Tonsils

–Tonsillectomy

–Adenoidectomy

–Biopsy

–Pharyngoplasty

–Pharyngostomy

•Esophagus

170

CPC®Certification Review

CPT®: Digestive

•Endoscopy

–Select and report an appropriate code for each anatomic site

examined

–Esophagoscopy

–Upper GI Endoscopy (EGD)

–Endoscopic retrograde cholangiopancreatography (ERCP)

171

CPC®Certification Review

CPT®: Digestive

•Stomach

–Gastrectomy

–Bariatric and Gastric Bypass

–Endoscopic procedures

172

CPC®Certification Review

CPT®: Digestive

•Intestines (except rectum)

–Incision

•Enterolysis

•Exploratory procedures

–Endoscopic

•Small intestines

•Beyond the second portion of the duodenum and stomal endoscopy

•Colonoscopies

–Enterostomy

173

CPC®Certification Review

CPT®: Digestive

•Rectum

–Incision –drainage of abcesses

–Excision

•Proctectomy –partial or complete

–Endoscopy

•Proctosigmoidoscopy

•Sigmoidoscopy

•Colonoscopy

•Anus

–Hemorrhoids

174

CPC®Certification Review

CPT®: Digestive

•Liver

•Biliary Tract

•Pancreas

175

CPC®Certification Review

CPT®: Digestive

•Abdomen, Peritoneum, and Omentum

–Exploratory laparotomy

–Drainage of abscess –open or percutaneous

–Laparoscopy

–Hernia codes

•Type of hernia

•Strangulated or incarcerated

•Initial or subsequent repair

176

CPC®Certification Review

HCPCS

•Colorectal cancer screening

–G0104-G0106

–G0120-G0122

177

CPC®Certification Review

Urinary System and

Male Genital System

178

CPC®Certification Review

Anatomy: Urinary System

•Two kidneys (filters)

•Renal pelvis/one per kidney (funnels urine into ureters)

•Two ureters (to bladder)

•One bladder (storage)

•One urethra (exit)

Nephro = kidney

Renal = related to kidney

Pyelo = renal pelvis

179

CPC®Certification Review

Anatomy: Male Reproductive System

•Testicles (sperm production, contained in scrotum)

•Duct system (transport sperm)

–Epididymis

–Vas deferens

•Accessory glands (contribute to ejaculate)

–Seminal vesicles

–Prostate gland

•Penis

–shaft

–glans

–prepuce

180

CPC®Certification Review

ICD-9-CM: Urinary

Look primarily to 580-629

•Listed anatomically

–Kidney

–Ureters

–Bladder

–Urethra

181

CPC®Certification Review

ICD-9-CM: Urinary

•Inflammation

–Nephritis (583)

–Glomerulonephritis (580-582)

•Renal failure (584-586)

•CKD (585)

–ESRD

–With hypertension (403-405)

182

CPC®Certification Review

ICD-9-CM: Urinary

•Renovascular disease (588)

–Report underlying condition first

•Central diabetes inspidus (253.5)

•Nephrogenic diabetes insipidus (588.1)

•Small Kidney (589)

•Pyelonephritis (590)

•Hydronephrosis (591)

•Calculi (592)

183

CPC®Certification Review

ICD-9-CM: Urinary

•VUR (593.7x)

–Backflow or urine into ureter

•Cystitis (595)

–Bladder inflammation

•Voiding disorders (596)

–Urinary incontinence (788.3x)

•UTI (599)

–Report organism, when known

184

CPC®Certification Review

ICD-9-CM: Male Genital System

Look primarily to 600-608

•Listed anatomically

–Prostate

–Testes

–Penis

Also…

•Congenital Anomolies

•Neoplasms

•Signs/Symptoms

185

CPC®Certification Review

ICD-9-CM: Male Genital System

•BPH

•Hyperplasia

•Prostatitis

•PSA

•Dysplasia

–PIN III

–PIN I or II

186

CPC®Certification Review

ICD-9-CM: Male Genital System

•Spermatic cord, Testis, Tunica Vaginalis, Epididymis

–Hydrocele

–Orchitis

•Penis

–Phimosis

–Balantitis

–Routine circumcision

–Male infertility

– Peyronie’s disease

187

CPC®Certification Review

ICD-9-CM: Male Genital System

•Congenital Anomalies

–Cryptorchidism

–Hyposadias

–Epispadias

•Neoplasms (by location)

•Injury

•Signs and Symptoms

188

CPC®Certification Review

CPT®: Urinary

•Arranged by location/procedure type

–Incision, excision, repair, etc.

•Bilateral vs. Unilateral

•Operating Microscope (69990) may be separate

•Surgical endoscopy always includes diagnostic endoscope

189

CPC®Certification Review

CPT®: Kidney

• Incision (―otomy‖)

–Nephrotomy = incision of kidney

–Pyelotomy = incision of renal pelvis

–Nephrolithotomy

–Percutaneous removal of calculi

•Nephrostomy tract

•Excision (―ectomy‖)

–e.g., nephrectomy

–Radical

–Ablation

190

CPC®Certification Review

CPT®: Kidney

•Repair

–Ureteral repair

–Creation of ureteral conduit

•Introduction (aspiration, injection, instillation)

–Ureteral stents

–Catheter changes

–Bladder irrigation and/or instillation

191

CPC®Certification Review

CPT®: Urinary

•Laparoscopy

–Code by procedure

•Endoscopy

–Performed through natural or created opening

•Other Procedures of Kidney

–Renal Transplantation

–Lithotripsy

–Percutaneous ablation of renal tumors

–Cryotherapy for renal tumors

•Urodynamics

192

CPC®Certification Review

CPT®: Male Genital System

Penis

•Incision

•Destruction

•Excision

–Excision of plaque

–Penectomy

–Circumcision

•Introduction

•Repair

–Hypospadia/epispadia

–Prosthesis

•Manipulation

CPC®Certification Review

Female Genital System

194

CPC®Certification Review

Anatomy

External genitalia

•Mons pubis

•Labia (majora and minora)

•Hymen

• Bartholin’s glands

•Clitoris

•Urethra

Internal Genitalia

•Vagina

•Uterus

•Cervix

• Fallopian tubes (―tubes‖ or

oviducts)

•Ovaries

195

CPC®Certification Review

ICD-9-CM: Female Genital System

Chapter 10: Disease of the Genitourinary System

Chapter 11: Complications of Pregnancy, Childbirth, and the

Puerperium

Chapter 2: Neoplasms

Chapter 18: V Codes

196

CPC®Certification Review

ICD-9-CM: Female Genital System

•Female Genitourinary System

•Complications of Pregnancy, Childbirth, and the

Puerperium

–Have sequencing priority

–Report any condition that affects pregnancy (labor, delivery,

post-partum)

–If pregnancy is incidental to condition treated, report V22.2 as

secondary code

•Must document that condition treated does not affect

pregnancy

–Only for mother, not newborn

197

CPC®Certification Review

ICD-9-CM: Female Genital System

•Routine outpatient prenatal visits w/o complication

–First pregnancy

–Subsequent pregnancy

–First-listed Dx

–Not to be used with other Chapter 11 Codes

High-risk Pregnancy

•Code from category V23

•First-listed dx.

•May be reported with other Ch. 11 codes

198

CPC®Certification Review

CPT®: Female Genital System

Surgery

• Arranged by anatomy ―outside to inside‖

–Terms used to describe external female genitalia

•Perineum

•Vulva

•Pudenda

•Introitus

•Consider terminology to determine procedure

–-ectomy = removal

–etc.

199

CPC®Certification Review

CPT®: Female Genital System

•Vulva

•Vagina

–57022 - Only CPT® code related to obstetrical complications NOT

in labor/delivery section

•Cervix Uteri

–Os = opening of cervix

200

CPC®Certification Review

CPT®: Female Genital System

•Uterus

–Endometrial sampling

–D&C

–Hysterectomy

•Total

–Removal of fundus + cervix (e.g., 58150)

–TAH = removed through abdomen

–TVH = removed through vagina

•Partial

•Oviduct/Ovary

201

CPC®Certification Review

Maternity Care/Delivery

Antepartum care

•Initial visit during pregnancy

•Ongoing visits during pregnancy

–Average of 13 visits (global OB package)

• OB package includes…

–Antenatal care

–Delivery

–Episiotomy and repair

–Postpartum care

202

CPC®Certification Review

Maternity Care/Delivery

Postpartum care includes…

•Hospital visits

•6-week checkup in the office

•Services related to cesarean delivery

–e.g., two week incision check

Unrelated encounters are reported separately

203

CPC®Certification Review

Maternity Care/Delivery

• ―Partial‖ maternity/delivery care

–Patient moves

–Change of coverage, etc.

•Cesarean Delivery

•Twin delivery

•Ultrasound

–NOT included in OB global package

•Some payers may include one U.S. in global package (standard of care)

–More than one U.S. may be performed

204

CPC®Certification Review

Abortion

•Spontaneous

–Miscarriage

•Complete

•Missed

–D&C may be required

•Induced

–Therapeutic (medical termination of pregnancy)

•Failed induced abortion

–Hysterotomy

205

CPC®Certification Review

Endocrine and Nervous System

206

CPC®Certification Review

Anatomy: Endocrine

•Comprised of ductless glands that secrete hormones into the

circulatory system

–Thyroid

–Parathyroid

–Thymus

–Adrenal glands

•Medulla

•Cortex

207

CPC®Certification Review

Anatomy: Endocrine

•Pancreas

–Endocrine and digestive functions

•Carotid body

–Contains glandular tissue

•Pituitary gland

–Anterior and posterior lobes

•Pineal gland

•Structures classified elsewhere

–eg, kidneys, testes, ovaries

208

CPC®Certification Review

Anatomy: Nervous System

•Comprised of two components

–CNS

•Brain

•Spinal Cord

–PNS

•Nerves running throughout the body

209

CPC®Certification Review

Anatomy: Nervous System

Nerve Plexi

•Cervical

–Head, neck, shoulders

•Brachial

–Chest, shoulders, arms, hands

•Lumbar

–Back, abdomen, groin, thighs, knees, calves

•Sacral

–Pelvis, buttocks, genitals, thighs, calves, feet

•Solar (Coccygeal)

–Internal organs

210

CPC®Certification Review

Anatomy: Nervous System

•Spinal cord functions:

–Motor information to muscles

–Sensory information to brain

–Reflex coordination

•Segment (bone) vs. interspace (space between)

•Segments (Body, Lamina, Process [Spinous, Transverse],

Foramen)

•Facet joints

–One per side, where segments meet

211

CPC®Certification Review

Anatomy: Nervous System

The Brain

–Frontal lobe

•Cerebrum

–Two temporal lobes

–Parietal lobes

•Primary sensory cortex

–Occipital lobe

–Cerebellum

–Brainstem

–Ventricles

212

CPC®Certification Review

ICD-9-CM: Endocrine

Categories 240-279, by location

–Thyroid

–Parathyroid

–etc.

Neoplasms (Chapter 2)

–Report neoplasm first

–Additional dx. as a result of neoplasm are secondary

213

CPC®Certification Review

ICD-9-CM: Endocrine

• Addison’s disease

•Primary hyperparathyroidism

•Diabetes (250.xx)

–4th digit complications/manifestations

•Report complications/manifestations as secondary

–5th digit type I/II and controlled/uncontrolled

•Secondary diabetes (249.xx)

–Always has an underlying cause

214

CPC®Certification Review

ICD-9-CM: Nervous System

•Inflammation

–Meningitis (lining of brain/spinal cord)

–Encephalitis (brain)

–Myelitis (spinal cord)

–Encephaolomyelitis (brain and spinal cord)

•Sleep disorders

•Hereditary/degenerative disease of CNS

–Report underlying disease when instructed

215

CPC®Certification Review

ICD-9-CM: Nervous System

•Pain (NEC)

–Pain control is reason for visit

–Do not report as primary if you know the underlying cause, and

visit is to manage that dx.

–Acute vs. Chronic

•Disorders of CNS

–Migraine

•Fifth digit for status migrainosus

•Headache NOS

216

CPC®Certification Review

ICD-9-CM: Nervous System

•Disorders of PNS

–Trigeminal nerve disorder

–Neuritis

•CTS

•Neoplasms

–Search in Vol. 2

–Use neoplasm table, by location and type

217

CPC®Certification Review

CPT®: Endocrine

•Thyroid

•Parathyroid, Thymus, Adrenals, Pancreas

•Unlisted

•Endocrinology

218

CPC®Certification Review

CPT®: Nervous System

•Skull, Meninges, and Brain

–Twist drill

–Burr holes

–Craniectomy/craniotomy

•Skull base surgery

–Approach

–Definitive procedure

–Repair/reconstruction

•Endovascular therapy

–Balloons or stents to treat arterial disease

219

CPC®Certification Review

CPT®: Nervous System

•AV malformation

–Simple vs. complex

•Intracranial aneurysm

–Simple vs. complex

•Other techniques

•Anastomosis to bypass aneurysm

•Stereotaxis/Radiosurgery

–Lesion treatment

220

CPC®Certification Review

CPT®: Nervous System

•Cranial neurostimulators

–Pulse generator

–Electrodes

•eg, for Parkinson's, epilepsy

•Repair of skull

–Skull fracture

–Encephalocele

221

•Neuroendoscopy

•CSF Shunt

–Drain accumulation of CSF

–May require revision

CPC®Certification Review

CPT®: Nervous System

•Spine and Spinal Cord

–Injection, Drainage, Aspiration

•Pay careful attention to notes and parentheticals

•Spinal tap (diagnostic /thereaputic)

•Neurolytic injections

– ―Pain pumps‖

–Intrathecal catheter

–Laminectomy vs. Laminotomy

•Complete vs. partial excision of lamina

•Code by spinal region

•Include decompression

222

CPC®Certification Review

CPT®: Nervous System

•Decompression

–Must consider approach

–Discectomy

–Osteophytectomy (removal of bony outgrowth)

–Corpectomy (vertebral body resection)

•Intra/extradural excision of intraspinal lesion

•Stereotaxis/radiosurgery

•Spinal Neurostimulators

–Electrodes

–Pulse generator

223

CPC®Certification Review

CPT®: Nervous System

•Extracranial nerves, PNS, Autonomic

–12 pair cranial nerves

–31 pair spinal nerves

–Autonomic ganglia/plexi

•PNS

–Somatic nerves

–Autonomic nerves

•Sympathetic and parasympathetic

224

CPC®Certification Review

CPT®: Nervous System

•Facet Joint injections

–Nerve block

•Unilateral

• Focus on ―joint‖ between vertebrae

– Nerve ―destruction‖

–Somatic or sympathetic nerve

–Number of levels

–If infused, duration

225

CPC®Certification Review

CPT®: Nervous System

•Injection of sympathetic nerves

•Peripheral Neurostimulators

–surface or percutaneous

•Destruction by neurolytic agent

•Neuroplasty

–Freeing of nerves from scar tissue

•Transection/avulsion (divide/tear away)

226

CPC®Certification Review

CPT®: Nervous System

•Excision

–By nerve

•Neurorrhaphy

–Suturing of nerve

–Without or with graft

–By nerve

•Operating microscope

–Beware bundling issues

227

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CPT®: Nervous System

Neurology/Neuromuscular

•Sleep studies

•EEG

•Muscle/ROM testing

•EMG

•Chemo guidance

•EP/Reflex testing

•Neurostimulator analysis/programming

228

CPC®Certification Review

Eye and Ocular Adnexa, Auditory

Systems

229

CPC®Certification Review

Anatomy: Eye and Ocular Adnexa

•Eyeball

–Sclera

–Cornea

–Pupil and Iris

–Choroid –vascular layer

–Retina –pigmented nerve layer

•Optic nerve and Optic disc

230

CPC®Certification Review

Anatomy: Ear and Auditory System

•Middle ear

–Tympanic membrane

–Ossicles –malleus, incus,

stapes

–Eustachian tube

231

•Inner ear

–Labyrinth

–Membranous labyrinth –hair

cells

–Vibrations into nerve

impulse

–Cochlea, Vestibule,

Semicircular canal

–Balance –utricle, saccule

–Oval window, round window

CPC®Certification Review

ICD-9-CM: Sense Organs

•Alphabetic index ; Tabular List

•Chapter 6: Diseases of Nervous System and Sense Organs

–Disorders of the Eye and Adnexa

–Diseases of the Ear and Mastoid Process

•Chapter 2: Neoplasms

232

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Eye and Ocular Adnexa

•Infection and Inflammation

•Neoplastic disease

•Injury

•Glaucoma

•Cataracts

•Retinopathy

•Retinal detachment

•Strabismus

233

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Ear and Mastoid Process

•Diseases of the Ear and Mastoid Process

•Infectious and inflammation

•Neoplastic disease

•Injury

•Vertigo

•Hearing loss

•Congenital disorders

234

CPC®Certification Review

CPT®: Eye and Ocular Adnexa

•Eyeball

-evisceration

-exenteration

-enucleation

•Secondary Implant(s) Procedures

235

CPC®Certification Review

CPT®: Eye and Ocular Adnexa

•Intraocular Lens Procedures (IOL)

–Cataract removal with IOL

–Intracapsular

–Extracapsular

–IOL exchange

236

CPC®Certification Review

CPT®: Eye and Ocular Adnexa

•Ocular Adnexa

–Strabismus

•horizontal

•vertical

•transposition

237

CPC®Certification Review

CPT®: Eye and Ocular Adnexa

•Operating Microscope

–Most procedures on the eye are performed with a microscope and

are included in the procedure code.

–Do not report 69990 with 65091-68850

238

CPC®Certification Review

CPT®: Auditory System

Auditory System

•Removal foreign body from external auditory canal

- both ears

239

CPC®Certification Review

CPT®: Auditory System

Middle Ear

•Tympanostomy

•Mastoidectomy; complete

-modified radical

-radical

•Tympanoplasty

240

CPC®Certification Review

CPT®: Auditory System

Inner Ear

•Labyrinthectomy

•Temporal Bone, Middle Fossa Approach

•Microsurgery

241

CPC®Certification Review

CPT®: Auditory System Medicine Section

•Special Otorhinolaryngolocic Services

•Otolaryngologic examination under general anesthesia

•Vestibular Function Tests

•Audiologic Function Tests with Medical Diagnostic Evaluation

242

CPC®Certification Review

Anesthesia

243

CPC®Certification Review

Definition

Anesthesia is a state in which

the patient feels no pain

244

CPC®Certification Review

Organization of Codes

•Head

•Neck

•Thorax

•Intrathoracic

•Spine and Spinal Cord

•Upper Abdomen

•Lower Abdomen

•Perineum

•Pelvis

•Upper Leg

•Knee and Popliteal Area

•Lower Leg

•Shoulder and Axilla

•Upper Arm and Elbow

•Forearm, Wrist, and Hand

•Radiological Procedures

•Burn Excisions or Debridement

•Obstetric

•Other Procedures

Organized by anatomical location

245

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Finding the CPT®Code

•Start in the Index

•Look up Anesthesia

•Anatomical location

•Type of surgery

•Surgical approach

CPC®Certification Review

Types of Anesthesia

•Local

–Included in CPT®code

–No separate anesthesia code

•MAC - Monitored Anesthesia Care

–Decreased awareness

•Regional

–Blocks

–Spinals

–Epidurals

•General

–Unconscious 247

CPC®Certification Review

Anesthesia Terminology

•One-Lung Ventilation (OLV)

•Pump Oxygenator

•Intraperitoneal –within the peritoneum

•Extraperitoneal/Retroperitoneal - space in the abdominal

cavity behind the peritoneum

248

CPC®Certification Review

Anesthesia Guidelines

•Services included with the anesthesia code:

–Preoperative visits

–Postoperative visits

–Anesthesia during the procedure

–Administration of fluids/blood

–Usual monitoring

•Unusual forms include CVP, Arterial line insertion, and Swanz-Ganz and

are coded separately

249

CPC®Certification Review

Physical Status Modifiers

•Assigned by the provider

•Coder would need to look for a diagnosis to report it

•Documented in anesthesia record

P1 - normal healthy

P2 - mild systemic disease

P3 - severe systemic disease (1 unit)

P4 - constant threat to patients life (2 units)

P5 - not expected to survive w/o surgery (3 units)

P6 - declared brain-dead patient

250

CPC®Certification Review

Qualifying Circumstances

•+ 99100 –under 1 or over 70

•+ 99116 - complicated by hypothermia

•+ 99135 - complicated by controlled hypotension

•+ 99140 - complicated by emergency

251

CPC®Certification Review

Modifiers

HCPCS Level II

AA - Performed by anesthesiologist

AD - Medically supervised by physician

QK - Medically directing 2-4 concurrent procedures (cases happening

at the same time)

QS - MAC (deep sedation)

QX - CRNA service medically directed

QY - medically directing CRNA single case

QZ - CRNA w/o medical direction

252

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CPT®Modifiers

53 –Discontinued Procedures

–Used if surgeon discontinues the procedure

59 - Distinct procedural services

–Example: General anesthesia during surgery, then an epidural is

placed for post op pain management.

253

CPC®Certification Review

Additional Procedures

•CVP –central venous catheter

–Monitoring

–Quick administration

•Arterial Line Insertion

–Based on technique used

•Swan-Ganz

–Included if done through the CVP

–Separate vessels code for both

254

CPC®Certification Review

Radiology

255

CPC®Certification Review

Radiologic Projections

•Oblique –slanting, neither frontal or lateral

•Lateral –side view, X-ray beam travels through the side of

the body

•Anteroposterior –X-ray beam enters the body through the

front and exits through the back

•Posteroanterior –X-ray beam enters the body through the

back and exits through the front

•Cone –focused or spot view

256

CPC®Certification Review

Additional Terms

•Proximal –closer to the point of attachment to the body

•Distal –away from the point of attachment to the body

•Flexion –bending

•Extension –straightening

257

CPC®Certification Review

Diagnosis Coding

•Code the definitive diagnosis

•Code signs and symptoms if no definitive diagnosis is

available

•Diagnostic tests

–Code sign or symptom that prompted the test

–Do not code questionable, rule out, or probably diagnoses.

•Routine radiology

–V72.5 Radiological examination, NEC

258

CPC®Certification Review

CPT® Subsections

•Diagnostic Radiology (Diagnostic Imaging)

•Diagnostic Ultrasound

•Radiologic Guidance

•Breast, Mammography

•Bone/Joint Studies

•Radiation Oncology

•Nuclear Medicine

259

CPC®Certification Review

Guidelines

•Supervision and Interpretation (S & I)

–Interventional radiologic procedures

–Report two codes:

•Surgical code; or code from the medicine section

•Radiologic supervision and interpretation

•Administration of Contrast Material

–Contrast material administered intravascularly, intra-articularly or

intrathecally

–Oral and/or rectal contrast does not qualify

260

CPC®Certification Review

Modifiers

•Technical Component (TC)

–Equipment

–Overhead

•Supplies

•Room

•Gowns

•Professional Component (26)

–Reading and interpretation

261

CPC®Certification Review

Diagnostic Radiology

(Diagnostic Imaging)

•Anatomical organization

•Radiologic procedures include:

–Standard X-rays

–MRIs

–CTs

262

CPC®Certification Review

Diagnostic Radiology

(Diagnostic Imaging)

•Code Selection:

–Anatomical location

–Type of procedure

–Number of views

–Type of view (AP, PA, etc)

–Laterality (unilateral, bilateral)

–Contrast material

263

CPC®Certification Review

Heart –Subsection Guidelines

•Heart

–Stress

•Cause the heart to work harder

–Cardiac MRI

•Physiologic evaluation of the cardiac function

•Velocity flow mapping

–Cardiac CT

•Coronary calcium

•Congenital heart disease

264

CPC®Certification Review

Vascular Procedures –Subsection Guidelines

•Aorta and arteries

–Aortography –imaging of aorta and branches

–Angiography –imaging of arteries

•Veins and lymphatics

–Lymphangiography –visualization of lymphatics

–Splenoportography –injection of contrast into the spleen to

visualize the port vessel of the portal circulation

–Venography –imaging of veins

265

CPC®Certification Review

Vascular Procedures

•Transcatheter procedures

–Supervision and interpretation codes

–Code with codes from:

•Cardiovascular section

•Medicine section

266

CPC®Certification Review

Other Procedures

76000 Fluoroscopy (separate procedure), up to one hour

physician or other healthcare professional time,

other than 71023 or 71034 (eg, cardiac fluoroscopy)

76001 Fluoroscopy, physician or other healthcare

professional time more than 1 hour, assisting a

nonradiologic physician (eg, nephrolithotomy,

ERCP, bronchoscopy, transbronchial biopsy)

267

CPC®Certification Review

Diagnostic Ultrasound

•High frequency sound waves to look at organs and other

structures inside the body

•Used to view:

–Heart

–Blood vessels

–Kidneys

–Other organs

–Fetus (during pregnancy)

268

CPC®Certification Review

Diagnostic Ultrasound

•Required:

–Permanently recorded images with measurements

– Final written report for the patient’s medical record

–Exception –biometric measure

269

CPC®Certification Review

Diagnostic Ultrasound

•Anatomic regions

–Complete –each element listed in parenthesis within the code

description

–Limited –reported if less than complete is performed.

–Not reported together

•Definitions

–A-mode

–M-mode

–B-scan

–Real-time scan

270

CPC®Certification Review

Pelvis Ultrasound

•Obstetrical

–Pregnant uterus

•Review definitions in guidelines

–Fetal

•Look for what specifically is being looked at (eg, umbilical artery in 76820)

•Nonobstetrical

271

CPC®Certification Review

Ultrasonic Guidance

Includes guidance for:

–Pericardiocentesis

–Endomyocardial biopsy

–Vascular access

–Parenchymal tissue ablation

–Intrauterine fetal transfusion or cordocentesis

–Needle placement

–Chorionic villus sampling

–Amniocentesis

–Aspiration of ova

–Placement of radiation therapy fields

272

CPC®Certification Review

Radiologic Guidance

•Fluoroscopic

•Computed Tomography (CT)

•Magnetic Resonance (MRI)

•Other

273

CPC®Certification Review

Breast, Mammography

•Computer aided detection (CAD)

•Mammary ductogram or galactogram

•Mammography

–Screening

–Diagnostic

274

CPC®Certification Review

Bone/Joint Studies

•Bone age studies

•Bone length studies

•Osseous survey

•Joint survey

•Bone mineral density studies

•Bone marrow blood supply

275

CPC®Certification Review

Radiation Oncology

•Consultation: Clinical Management

•Clinical Treatment Planning

•Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services

•Stereotactic Radiation Treatment Delivery

•Other Procedures

•Radiation Treatment Delivery

•Neutron Beam Treatment Delivery

•Radiation Treatment Management

•Proton Beam Treatment Delivery

•Hyperthermia

•Clinical Intracavitary Hyperthermia

•Clinical Brachytherapy

276

CPC®Certification Review

Nuclear Medicine

•Diagnostic - Use of small amounts of radioactive material

to examine organ function

–Thyroid function (endocrine)

–Renal (Gastrointestinal System)

–Bone (Musculoskeletal System)

–Heart (Cardiovascular system)

–Brain (Nervous System)

•Therapeutic –uses radioactive material to treat cancer and

other medical conditions affecting the thyroid gland

277

CPC®Certification Review

Pathology and Laboratory

278

CPC®Certification Review

Regulatory Terms

Clinical Laboratory Improvement Amendment (CLIA)

•CMS issues a waiver

•Approximately 80 tests

•Little risk of error

•For more info., see

http://www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp

Advance Beneficiary Notice (ABN)

•Non covered laboratory tests

•Patient is responsible for payment

• For more info., Web search ―CMS-R-131‖

279

CPC®Certification Review

Modifiers

•90 Reference or Outside Laboratory

•Billed by physician but performed by an outside laboratory

•91 Repeat clinical diagnostic lab test

•Same test same day

•Not used if due to error

•Not used if there is a better code for a series of tests

•92 Alternative laboratory platform testing

•Portable test kit

•Single use disposable chamber

•99 Multiple modifiers

280

CPC®Certification Review

Organ or Disease-Oriented Panels

•Group of test commonly ordered together

•All test in the panel must be performed

•Additional tests can be coded also

•Some panels are included in other panels and should not

be coded separately

• Be on the look out for ―or‖ ―and‖

281

CPC®Certification Review

Definitions

•Qualitative

–What is present

•Quantitative

–How much is present

•Chromatography

–Laboratory technique used to separate mixtures

•Mobile phase

•Stationary phase

282

CPC®Certification Review

Evocative Suppression Testing

•Baseline and subsequent measurement

•Supplies and drug billed separately

•Physician attendance

–Use Prolonged care codes

•Prolonged infusion codes from Medicine section

283

CPC®Certification Review

Consultations

•Requested by attending physician

•Rendered by pathologist

•Written report provided

•Patient not present

–Lab test

–Specimen

–Slide

284

CPC®Certification Review

Chemistry

•Quantitative unless specified otherwise

•Same analyte in multiple specimens

•Molecular diagnostics

–Coded by procedure not analyte

285

CPC®Certification Review

Laboratory Tests

•Hematology and Coagulation

•Immunology

•Microbiology

•Anatomic Pathology

286

CPC®Certification Review

Cytopathology

•Study of cells for disease

•Obtained by several methods

–Washing or brushing

–Smears

–Fine needle aspiration

287

CPC®Certification Review

Cytogenetic Studies

•Study of cells for inherited disorders

• Must use modifiers from Appendix I ―Genetic Testing Code

Modifiers,‖ also

288

CPC®Certification Review

Surgical Pathology

•Specimen –tissue sample

–Has to be separately identifiable

•Divided into levels of progressive complexity

–Level I –gross

–Level II-IV gross and microscopic

•Additional codes for special stains

289

CPC®Certification Review

Pathology Consultation

Four types of consultations:

1. Report on prepared slides

2. Report on tissue requiring prep of slides

3. Review records and specimen

4. Consultation during surgery

–Frozen sections

–Cytology examination

290

CPC®Certification Review

Evaluation and Management

291

CPC®Certification Review

ICD-9-CM Coding

•Primary diagnosis –reason for the visit

•Signs and Symptoms

–Code only if no definitive diagnosis is stated

–Routinely associated with a disease process should not be coded

separately

292

CPC®Certification Review

CPT®Coding

1. Select the category or subcategory of service and review

the guidelines;

2. Review the level of E/M service descriptors and

examples;

3. Determine the level of history;

4. Determine the level of exam;

5. Determine the level of medical decision making; and

6. Select the appropriate level of E/M service.

293

CPC®Certification Review

Categories and Subcategories

Office Visit

New Patient Established Patient

99201 –Level I

99202 –Level 2

99203 –Level 3

99204 –Level 4

99205 –Level 5

99211 –Level 1

99212 –Level 2

99213 –Level 3

99214 –Level 4

99215 –Level 5

294

CPC®Certification Review

New vs. Established Patients

•New –has not received any face-to-face professional

services from the physician/qualified health care

professional, or another physician/qualified health care of the

exact same specialty/subspecialty within the group practice,

within the last three years

•Established –has received face-to-face services in the last

three years

295

CPC®Certification Review

Office or Other Outpatient Services

•Provided in the physician's office or other outpatient clinic or

ambulatory facility

•New patient

•Established patient

296

CPC®Certification Review

Observation

•Hospital Observation Services

– Patient’s designated or admitted to observation status in the

hospital

–No CPT®guideline on length of observation stay

•Observation Care Discharge Services

–If discharge is on date other than date admitted to observation

•Subsequent Observation Care

–Patient is seen on a date other than the date of admit or

discharge to observation

297

100

CPC®Certification Review

Hospital Inpatient Services

•Codes used for inpatient facility and partial hospitalization

•Use codes 99234-99236 for admit/discharge on same

date

•Subsequent hospital care codes used for subsequent

visits while admitted

–Includes reviewing medical record, test results, etc

298

CPC®Certification Review

Hospital Discharge Services

•Codes are based on time

•Includes time spent with the final exam, paper work,

writing prescriptions, talking with patient’s family, etc.

•Parenthetical notes

–How to code for concurrent care on the discharge date

–Discharge of a Newborn see code 99463

299

CPC®Certification Review

Consultations

•Consultations

–Service provided by a physician whose opinion or advice

regarding evaluation and/or management of a specific problem

is requested by another physician or appropriate source

•Divided by location

• Three R’s to meet consultation criteria

300

101

CPC®Certification Review

Consultations

Medicare:

–Office Consultations

•Report with new and established patient codes

–Inpatient Consultations

•Report with initial hospital care codes for the first encounter regardless if

performed by the admitting physician.

•Use Modifier AI for the Principal Physician of Record

301

CPC®Certification Review

Emergency Department

•Does not distinguish between new/established

•Facility must be hospital-based and available 24

hours a day

•Physician direction of EMS emergency care,

advanced life support

302

CPC®Certification Review

Critical Care Services

•Critically ill or injured

–Acutely impairs one or more vital organ systems such that there

is a high probability of imminent or life threatening deterioration

in the patient condition.

–Services included in critical care described in critical care

guidelines.

303

102

CPC®Certification Review

Critical Care Services

•Services provided in a critical care unit to a patient who is

not considered critically ill are report with other E/M codes.

•Guidelines contain instructions for coding

–Pediatric Critical Care

–Neonatal Critical Care

•Critical Care and other E/M services may be coded on

same date by the same provider.

304

CPC®Certification Review

Critical Care Services

•Guidelines list services inclusive to critical care

–May not be reported separately

–Refer back to list to avoid unbundling services

–Beneficial to highlight each of the CPT®codes listed in the

guidelines

305

CPC®Certification Review

Nursing Facility Services

•Nursing Facility Services

–Nursing facility

–Psychiatric residential treatment center

–Divided into Initial and Subsequent

•Nursing Facility Discharge

–Similar to hospital discharge –instructions for care,

prescriptions, etc.

•Annual Assessment

–Annual assessment required by law

306

103

CPC®Certification Review

Domiciliary, Rest Home, or Custodial Care

Services

•Also includes Assisted Living

•Physician see patient in one of these types of facilities

–No medical component

•Either new patient or established patient

307

CPC®Certification Review

Domiciliary, Rest Home, or Home Care Plan

Oversight Services

• Physician provides oversight of the patient’s care plan

•Review the case management plan

•Write new orders

•Make a new care plan

308

CPC®Certification Review

Home Services &

Prolonged Services

•Home Services

–Seen in home by physician

–Separated by new and established patient

•Prolonged Services

–Direct patient contact or without direct patient contact

–Settings are office/outpatient and inpatient

–Most are add-on codes

•Exception is Standby Code

309

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Standby Services

•Used to report time when a provider is on standby at the

request of another provider

•Only report for more than 30 minutes duration

•Reported with additional units for each additional 30

minutes

•Do not report if the period of standby results in the

performance of a procedure

310

CPC®Certification Review

Case Management &

Medical Team Conference

•Case Management Services

–Anticoagulant Management

•Receive INR testing

•Alter dosage

•Medical Team Conference

–Requires three healthcare professionals

–Divided by direct contact or without direct contact

311

CPC®Certification Review

Care Plan Oversight Services

•Home Health Agency

•Hospice

•Nursing Facility

–Billed on a monthly basis

–For the amount of time physician spends overseeing care of

patient

312

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Preventive Medicine Services

•Annual Physical Exam

• Divided by new and established patient and by patient’s

age

•If abnormality is encountered and is significant to require

additional work

–Appropriate code from 99201-99215 reported with modifier 25

appended to the office/outpatient code

313

CPC®Certification Review

Counseling Risk Factor Reduction and Behavior

Change Intervention

•For patient without symptoms or established illness

•No distinction between new and established patient

•Preventive Medicine, Individual Counseling

•Behavior Change Intervention

•Preventive Medicine, Group Counseling

314

CPC®Certification Review

Non-Face-to-Face

Physician Services

•Telephone Services

–Must be provided by a physician

–Based on amount of time

–Patient must be established

•On-Line Medical Evaluation

–Reported only once for the same episode of care during a 7-day

period

–Must be provided by a physician

315

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CPC®Certification Review

Special Evaluation and Management Services

•Basic Life and/or Disability Evaluation Services

•Work Related or Medical Disability Evaluation Services

•Specific guidelines under each code

316

CPC®Certification Review

Newborn Care Services

•Newborn Care Services

–Newborn care age 28 days or less

–Separated by location and by initial or subsequent visits

•Delivery or Birthing Room Attendance and Resuscitation

Services

–Attendance at delivery at request of delivering physician

317

CPC®Certification Review

Inpatient Neonatal Intensive Care

Pediatric & Neonatal Critical Care

•Pediatric Critical Care Patient Transport

•Inpatient Neonatal and Pediatric Critical Care

•Initial and Continuing Intensive Care Services

318

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CPC®Certification Review

Inpatient Neonatal and Pediatric Care

Services

Defined by age of patient:

–Neonates 28 days of age or less

–Infant or young child 29 days through 24 months of age

–Young child two through five years of age

319

CPC®Certification Review

Initial and Continuing Intensive Care

Services

•Used to report services to a child who is not critically ill –

but requires intensive observation and frequent

interventions

•99477 used for Initial Hospital Care

•99478-99480 used for Subsequent Intensive Care

–Code selection based on the present body weight of the child

320

CPC®Certification Review

Evaluation and Management Coding Leveling

1. Select the category or subcategory of service and review

the guidelines;

2. Review the level of E/M service descriptors and

examples;

3. Determine the level of history;

4. Determine the level of exam;

5. Determine the level of medical decision making; and

6. Select the appropriate level of

E/M service.

321

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E/M Leveling

•1995 vs. 1997 Guidelines

–Main difference –exam component

•Seven components to consider

–Relates to the level of work performed by the physician

•History

•Exam

•Medical Decision Making

•Counseling

•Coordination of Care

•Nature of Presenting Problem

•Time

322

CPC®Certification Review

E/M Leveling

Key Components

–Generally the influential factors in determining level of service

–History

–Exam

–Medical Decision Making

•Influential in the level of service unless counseling dominates the

encounter

•Categories/subcategories describe the number of key components

required

323

CPC®Certification Review

History

•History of Present Illness (HPI)

• Chronological description of the patient’s illness

–Location

–Quality

–Severity

–Timing

–Context

–Modifying factors

–Associated sign and symptoms

324

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CPC®Certification Review

History

Review of Systems

(Inventory of Body Systems)

•Constitutional

•Eyes

•Ears, nose, mouth, throat

•Cardiovascular

•Respiratory

•Gastrointestinal

•Genitourinary

•Musculoskeletal

•Integumentary

•Neurological

•Psychiatric

•Endocrine

•Hematologic/

lymphatic

•Allergic/

Immunologic

325

CPC®Certification Review

History

•A single element cannot count towards the HPI and the

ROS for the same patient encounter

•Example

–Knee pain counted as location for HPI

–Knee pain cannot count as musculoskeletal for ROS

326

CPC®Certification Review

History

•Past, Family and/or Social History (PFSH)

–Past History

• Review of patient’s past illnesses, operations, etc

–Family History

• Review of patient’s parents/siblings

–Social History

•Review of social factors, marital status, alcohol/drug habits

327

110

CPC®Certification Review

History

History of Present Illness (HPI) Review of Systems

(ROS) Past, Family, and/or Social

History (PFSH) Level of History

Brief (1-3 elements) No ROS No PFSH Problem Focused

Brief (1-3 elements) Problem Pertinent (1

system) No PFSH Expanded Problem

Focused

Extended (4 or more) Extended

(2-9 systems) Pertinent

(1 history) Detailed

Extended (4 or more) Complete

(10 or more) Complete

(2-3 history areas) Comprehensive

328

CPC®Certification Review

Exam

•Examination –may be body areas or organ systems

•Body Areas

•Head, including face

•Neck

•Chest, including breasts

•Abdomen

•Genitalia, groin, buttocks

•Back, including spine

•Each extremity

329

CPC®Certification Review

Exam

–Organ Systems

•Eyes

•Ears, nose, mouth and throat

•Cardiovascular

•Respiratory

•Gastrointestinal

•Genitourinary

•Musculoskeletal

•Skin

•Neurologic

•Psychiatric

•Hematologic/lymphatic/immunologic

330

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CPC®Certification Review

Exam

Problem Focused –a limited examination of the affected

body area or organ system.

1 body area or organ system

Expanded Problem Focused –a limited examination of the

affected body area or organ system and other symptomatic or

related organ system(s).

2 –7 body areas or organ systems –

limited exam

Detailed –an extended examination of the affected body

area(s) and other symptomatic or related organ system(s)

2 –7 body areas or organ systems –

detailed exam

Comprehensive –a general multi-system examination or

complete examination of a single organ system

8 or more organ systems OR complete

single organ system

331

CPC®Certification Review

Medical Decision Making

•Thought process of the physician throughout the

visit

•Three elements to consider

–Number of management options

•Minimal, limited, multiple, extensive

–Amount and/or complexity of date to be review

•Minimal or none, limited, moderate, extensive

–Risk of complications, morbidity, and/or mortality

•Minimal, low, moderate, high

332

CPC®Certification Review

Medical Decision Making

# of dx or mgmt options Amt and/or complexity of

data Risk of Complications Type of Decision Making

Minimal Minimal or none Minimal Straightforward

Limited Limited Low Low complexity

Multiple Moderate Moderate Moderate complexity

Extensive Extensive High High complexity

333

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CPC®Certification Review

E/M Leveling

Contributing Components

–Counseling: risk factor reduction, patient/family education

–Coordination of Care: arrange follow up treatment not typically

provided by the provider, eg., physical therapy

–Nature of Presenting Problem: Taken into consideration in the

medical decision making portion of the encounter

–Time: If counseling/coordination of care dominates more than 50

percent of encounter, time may be considered as the controlling

factor

334

CPC®Certification Review

Determine the Level of E/M

Established patient office visit table

HISTORY Problem focused Expanded

problem focused Detailed Comprehensive

EXAM Problem focused Expanded

problem focused Detailed Comprehensive

MDM Straightforward Low Moderate High

LEVEL OF VISIT 99212 99213 99214 99215

335

CPC®Certification Review

Determine the Level of E/M

Category: Office or Other Outpatient Services

Subcategory: Established Patient

Descriptors: ―…which requires at least 2 of these three

components.‖

336

113

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E/M Leveling

•Many factors to consider when determining a level of

Evaluation and Management Service.

•Be sure to Review the Guidelines and code descriptions.

337

CPC®Certification Review

Modifiers

•Modifier 24 Unrelated evaluation and management service by the

same physician during a postoperative period.

•Modifier 25 Significant, separately identifiable evaluation and

management service by the same physician on the same day of the

procedure or other service.

•Modifier 32 Mandated Services

•Modifier 57 Decision for surgery

338

CPC®Certification Review

Medicine

339

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CPC®Certification Review

Medicine

•Immunizations

•Vaccines, Toxoids

•Psychiatry

•Biofeedback

•Dialysis

•Gastroenterology

•Ophthalmology

•Otorhinolaryngology

•Cardiovascular

•Pulmonary

•Endocrinology

•Neurology

•Genetics

•Nutritional Therapy

•Acupuncture

•Moderate Sedation

340

CPC®Certification Review

Medicine

•Non-invasive Diagnostic Vascular Studies

•Allergy & Clinical Immunology

•Special Dermatological Procedures

•Physical Medicine & Rehabilitation

•Qualifying Circumstances for Anesthesia

•Home Health Procedures/Services

341

CPC®Certification Review

Medicine and ICD-9-CM

•Alphabetic Index to Diseases

•Tabular List

•Official Guidelines for Coding and Reporting

342

115

CPC®Certification Review

Medicine Guidelines

•Multiple Procedures

•Add-on Codes

•Separate Procedures

•Unlisted Service or Procedure

•Special Report

•Materials Supplied by Physician

343

CPC®Certification Review

Immune Globulins

•Immune globulins

•Botulinum antitoxin

•Cytomegalovirus (CMV) immune globulin

•Diphtheria antitoxin

•Hepatitis B immune globulin

•Rabies immune globulin

•Tetanus immune globulin

344

CPC®Certification Review

Vaccines and Toxoids

•Vaccines

•Vaccination

•Immunization

•Toxins

•Toxoids

345

116

CPC®Certification Review

Psychiatry

•Consultation

•Follow-up by consultant

office visits

rest home, domicile

home

•Transfer of care –new or established pt.

•Diagnostic psychiatric evaluations

346

CPC®Certification Review

Dialysis

•Hemodialysis

•Miscellaneous Dialysis Procedures

•End-Stage Renal Disease Services (ESRD)

•Other Dialysis Procedures

•Age-specific, reported once per month

outpatient; home services

347

CPC®Certification Review

Noninvasive Vascular Diagnostic Studies

•Cerebrovascular Arterial Studies

•Extremity Arterial Studies (Including Digits)

•Extremity Venous Studies (Including Digits)

•Visceral and Penile Vascular Studies

•Extremity Arterial-Venous Studies

•Duplex and Doppler

348

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CPC®Certification Review

Allergy and Immunology

•Allergy

–Allergy Testing

–Allergen Immunotherapy

•Pulmonary Studies

349

CPC®Certification Review

Medical Genetics and Genetic Counseling Services

•Chromosome

•Gene

•Genetics

•Genetic counseling

350

CPC®Certification Review

Hydration

•Hydration, Therapeutic,Prophylactic, Diagnostic Injections

and Infusions, and Chemotherapy and Other Highly complex

Drug or Highly Complex Biologic Agent Administration.

•Time based codes

351

118

CPC®Certification Review

Non-Chemotherapy Complex Drugs and

Substances

•Infusions –therapeutic, prophylactic or diagnostic

•Specific to time, technique, substances added and additional

set-up

•Multiple drugs

352

CPC®Certification Review

Chemotherapy

Services included with chemotherapy:

•Use of local anesthesia

•Iv start

•Access to indwelling IV, subcutaneous catheter or port

•Flush at conclusion of infusion

•Standard tubing, syringes and supplies

•Preparation of chemotherapy agent(s)

353

CPC®Certification Review

Chemotherapy

•Paracentesis

•Thoracentesis

•Peritoneocentesis

•Intrathecal

•Ventricular or Intraventricular

354

119

CPC®Certification Review

Physical Medicine and Rehabilitation

Treatment plan

•Problem list

•Goals

•Physician review progress each 30 days

Progress made –recorded

Modify or discontinue therapy

355

CPC®Certification Review

Modalities

•Supervised

•Constant Attendance

•Diathermy, Vasopneumatic Devices, Therapeutic Procedures

356

CPC®Certification Review

Wound Care Management

Orthotic Management and

Prosthetic Management

Active wound care

•Not to be reported with 11040-11047

Orthotic management and Prosthetic Management

•Orthotics

•Prosthetics

357

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CPC®Certification Review

Medicine Section

•Acupuncture - Face-to-face time

•Osteopathic Manipulative Treatment (O.D.)

•Chiropractic Manipulative Treatment (CMT)

358

CPC®Certification Review

Education and Training for Patient Self-Management

Education and training

•Self Management

•How many in the group?

Telephone services –patient, parent, or guardian

•24 hours

•7 days

359

CPC®Certification Review

On-line Medical Evaluation

•On-line encounter or other electronic communication mode

of the medical kind

•Includes all services provided

360

121

CPC®Certification Review

Special Services, Procedures and Reports

Miscellaneous services

•99024 – ―tracking‖

•Mandatory on-call hospital personnel

•Patient encounters outside the normal posted business hours or

special circumstances at the request of the patient.

361

CPC®Certification Review

Home Health Procedures/Services

Define home setting:

• Patient’s residence

•Assisted living apartments

•Group homes

•Nontraditional private homes

•Custodial care facilities or schools

362

CPC®Certification Review

Medication Therapy Management Services

Performed by a pharmacist

Documentation required:

•Patient history

•Current medications

•Recommendations

363

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CPC®Certification Review

Category II Codes

•Used for performance measurement

•Facilitate data collection

•Use of these codes is optional

•Used to evaluate quality of care

• Alphanumeric: example: four digits and letter ―F‖ – 2001F is

Weight recorded

364

CPC®Certification Review

Category III Codes

365

•Data collection regarding new technology

•It is preferable to use these codes rather than an unlisted

code.

• Alpha numeric listings, four digits and the letter ―T‖ Example

–0085T Breath test for heart transplant rejection

CPC®Certification Review

CPT®Appendices

Appendix A –modifiers and description

Appendix B –summary of additions and deletions

Appendix C –clinical examples

Appendix D, E F and G are summary lists

Appendix H –empty –refer to website

366

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CPT®Appendices

Appendix I –Deleted in 2013

Appendix J –Electrodiagnostic Medicine Listing of Sensory,

Motor, and Mixed Nerves

Appendix K –products pending FDA approval

367

CPC®Certification Review

CPT®Appendices

Appendix L –Vascular families

Appendix M –crosswalk to deleted CPT®codes

Appendix N –Summary of Resequenced CPT Codes

Appendix O –Multianalyte Assays

Index –back of CPT®Book

368

CPC®Certification Review

Tips for Taking an AAPC

Certification Exam

369

124

CPC®Certification Review

ICD-9-CM

•Highlight:

–Code first notes

–Use additional notes

–Excluded codes

•Make notes to reference important guidelines

370

CPC®Certification Review

CPT®

Highlight key words in subsection guidelines:

–New vs established

–Definitions such as simple, intermediate, complex repair

–Musculoskeletal section –open, closed, fixation, percutaneous,

manipulation, etc.

–Parenthetical instructions

371

CPC®Certification Review

Exam Registration

•www.aapc.com

•You will receive a confirmation email including:

–Exam date and location of exam

– Proctor’s name and telephone number

–Start time

•Arrive at the exam on time

372

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CPC®Certification Review

Day of the Exam

•Arrive 10-15 minutes early

•Bring:

–Code manuals

–Photo ID

–#2 pencils and eraser

–NO scrap paper (not allowed)

•Eat a healthy breakfast

•Bring light snacks and water (avoid loud and crunchy

snacks)

•Bring a light jacket or sweater

373

CPC®Certification Review

During the Test

•Listen carefully while proctor reads instructions

•Stay relaxed and confident

•Scan the entire test

–Answer the easiest first

•Read all choices before answering

•Pace yourself

•Answer every question

374

CPC®Certification Review

Exam Completion

•Exam results released within 5-7 business days after AAPC

receives the exam package from the proctor

•My AAPC area on the AAPC website

•Official documents mailed to you

•Exam results may NOT be released over the telephone

375

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CPC®Certification Review

The End

376

Presentation 29581 2013 CPC Study Guide Cy

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