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CPT ✔✔current procedural terminology, owned by AMA lists procedures and services commonly performed by MD`s across the country types of CPT codes ✔✔category l codes category ll codes category lll codes category l codes ✔✔procedure codes found in the main body of CPT ,5 digits , no decimals , has descriptor category ll codes ✔✔used to track performance measures for a medical goal, alpha character for 5th digit category lll codes ✔✔temporary codes for emerging technology, services , and procedures, alpha character for 5th digit
organization ✔✔main text, appendixes, and index assignment of correct procedure code ✔✔begins by reviewing the physicians statements in the pts medical record types of Main Terms ✔✔1) name of procedure or service
- name of organ/other anatomical site
- name of the condition
- synonym/eponym for the term
- abbreviation for the term two codes ✔✔two codes either sequential or not, are separated by a comma, more than two by a hyphen cross reference ✔✔the cross reference "see" , is a mandatory instruction Main Text ✔✔after the index is used to point to a possible code, the main index is read to verify the selection of the code
bullet inside a circle-means that moderate sedation is a part of the procedure that the surgeon performs, billed in addition to the code lightening bolt - FDA approval pending, can`t be used yet add on code ✔✔procedure performed and reported in addition to a primary procedure primary procedure ✔✔most resource intensive CPT procedure during an encounter resequenced codes ✔✔CPT procedure codes that have been reassigned to another sequence,new code out of numerical sequence CPT modifier ✔✔two digit number used to communicate special circumstances involved with procedures that have been performed use of modifiers ✔✔some modifiers apply only to certain sections add-on codes cannot be modified codes that begin with a circle with a backlash cannot be modified with 51, multiple procedures
what do modifiers mean ✔✔use of a modifier means that a procedure was different from the description in CPT , but not in a way that required a different code how are modifiers shown ✔✔adding a space and a two digit code to the CPT code technical component/TC ✔✔reflects the technicians work and the equipment and supplies used in performing it professional component/PC ✔✔represents a physicians skill, time, and expertise used in performing it steps for assigning correct code ✔✔1) review complete medical documentation 2)abstract the medical procedures from the documentation
- identify main term for each procedure 4 ) locate main terms in the CPT index
- verify the code in the CPT main index
- determine the need for modifiers
- determine complexity of medical decision making documented
- analyze requirements to report the service level
- identify the service level based on the nature of the presenting problem, time , counseling & care coordination
- verify documentation is complete
- assign the code key components to select code from 3-5 digit code range ✔✔1) MD documented history
- examination that was documented
- medical decisions the MD documented history ✔✔HPI - history of present illness ROS - review of symptoms PMH - past medical history FH - family history SH - social history PFSH - histories documented after HPI as a group
extent of examination ✔✔1) problem focus-limited exam of affected body area/system
- expanded problem focused
- detailed
- comprehensive determining the complexity of medical decision making ✔✔1) straightforward
- low complexity
- moderate complexity
- high complexity key component ✔✔factor documented for various levels of evaluation and management services analyzing the requirements to report the service level ✔✔the descriptor for each E/M code explains the standards for its selection , for office visits and most other services to new pt`s and initial visits , all 3 key components must be documented. if 2 are at a higher level and a third is below that level , the standard is not met.
anesthesia codes ✔✔each anesthesia code includes the complete and usual services of an anesthesiologist structure of anesthesia codes ✔✔subsections are organized by body site , under each subsection the codes are arranged by procedures. The body-site subsections are followed by two other sub-sections: 1) radiological procedures and 2) other or unlisted procedures physical status modifiers ✔✔this modifier is added to anesthesia codes to report pt health status : P1- 6 surgical package ✔✔includes all the usual services plus the operation itself. A complete procedure includes ; operation , anesthesia, and postoperative care all covered under a single code global surgery rule ✔✔combination of services included in a single procedure code global period ✔✔days surrounding a surgical procedure when all services relating to the procedure are considered part of that surgical package
2 types of services not included in surgical package codes ✔✔1) complications or recurrences that arise after the therapeutic surgical procedures
- care for the condition for which a diagnostic surgical procedure is performed separate procedures ✔✔descriptor used for a procedure that is usually part of a surgical package but may also be performed seperately modifiers ✔✔a number of modifiers are commonly used to indicate special circumstances involved with surgical procedures bundling ✔✔using a single payment for two or more related procedure codes
