Lesson 4
Procedural Coding
Objectives
Procedural Coding
The CPT-4 and HCPCS are used for procedural coding. Procedural codes represent the procedure performed in response to the physician's diagnosis. Procedural codes are used to describe services, procedures, and supplies.
The services and procedures can be medical, surgical, or diagnostic. A diagnostic procedure is not the same as a diagnosis. A diagnostic procedure is a procedure that helps the physician diagnose the patient. For example, X-rays and MRIs are diagnostic procedures.
Procedural codes are five digits long. Two-digit modifiers may be required after the five-digit code. A modifier is used to give further details related to the procedure. It may indicate the complexity of the service or note what part of the service was performed. The modifier may increase or decrease the amount, or level, of reimbursement owed to the practice.
Coding the Claim Form
Insurance carriers use procedural codes to determine reimbursement levels. The procedural code on the claim must be related to the diagnostic code. If the procedure is not medically necessary in relation to the diagnosis, the claim will be denied.
Insurance carriers also want to be sure that the procedure was coded correctly. Sometimes, further documentation will be needed.
Levels of Procedural Coding
HCPCS is organized into three levels:
Level I: CPT-4
Level II: HCPCS National Codes
Level III: Local Codes
Level II is made up of HCPCS National Codes. They were developed to cover procedures and services not included in the CPT-4, including prescription drugs and durable medical equipment. They are required on Medicare and Medicaid claims.
CPT codes were adopted as part of the HCPCS procedural coding system. The CPT-4 makes up Level I of HCPCS. These codes are five digits, followed by two modifying digits, as needed. While the CPT-4 codes are considered to be a part of the HCPCS system, they are published separately.
Parts of the CPT-4
The CPT-4 is divided into the following parts:
The introduction of the CPT-4 provides information on using the manual. The introduction shows the layout and formatting of the main sections. This includes a description of all the symbols used. It also summarizes the appropriate use of add-on codes, modifiers, and place of service codes. Finally, it points assistants in the direction of further resources and references. Assistants might find these resources helpful to learn more about the coding system and to stay current on coding practices.
Main Sections of the CPT-4
The main body of the CPT-4 is made up of six sections:
Assistants should read each section's guidelines before coding from that section.
The first main section, Evaluation and Management
(E & M), will be used often. It is used to classify the patient and the type of visit. Office visits almost always use an E & M code.
Main Sections of the CPT-4
E & M codes identify:
Patient status refers to whether the patient is new to the office or an established patient. Level of service refers to the type of office visit. Contributing factors to level of service include counseling, coordination of care, and nature of the problem.
The introductory guidelines of this section are particularly important. They will explain how to determine a patient's status and give criteria for determining the level of service.
Appendices
The CPT-4 has thirteen appendices, located before the index section:
�Appendix A – Modifiers�Appendix B - Summary of Additions, Deletions, and Revisions�Appendix C - Clinical Examples�Appendix D - Summary of CPT Add-on Codes�Appendix E - Summary of CPT Codes Exempt From Modifier 51�Appendix F - Summary of CPT Codes Exempt From Modifier 63
Appendix G - Summary of CPT Codes That Include Moderate (Conscious) Sedation
Appendix H - Alphabetic Index of Performance Measures by Clinical Condition or Topic
Appendix I - Genetic Testing Code Modifiers
Appendix J - Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves
Appendix K - Product Pending FDA Approval
Appendix L - Vascular Families
Appendix M - Crosswalk to Deleted CPT Codes
Index of the CPT-4
The index of the CPT-4, located at the very back of the manual, is similar to Volume 2 of the ICD-10-CM. It is organized alphabetically by main terms. The index is the first place the assistant should look for appropriate procedural codes. However, coding should never come from the index alone. The code or code ranges provided in the index should always be cross-referenced in the main section.
The CPT-4 index looks much like a phone book. It is laid out in columns and organized alphabetically, by main terms. For many main terms, there are subterms indented underneath. For each term, there is a code or range of codes given. Unlike the ICD-10-CM index, there are no symbols.
�There are, however, cross-references. A cross-reference will be indicated by the word "see" in italics after a term. If the instruction is given to see another term, the assistant should investigate that term and its subterms as well before looking up the code or codes in the main section.
CPT-4 Index: Main Terms
The CPT-4 Index is the first place to look up a procedure. Like Volume 2 of the ICD-10-CM, the CPT-4 Index is organized alphabetically by main terms.
The four types of main terms that can be found in the index are:
Notice that unlike the ICD-10-CM, the CPT-4 manual includes anatomic sites as main terms.
CPT-4 Index: Subterms
Subterms will also be found in the CPT-4 index, indented under the main terms. They can indicate a more specific procedure. Being specific will lead to more accurate code selection.
Remember to always cross-reference codes from the index with the codes in the main sections. If given multiple codes or a range of codes, all codes included should be investigated to find the most appropriate. Also, pay close attention to notes or special instructions. Determine the most specific and the most correct code.
Format of CPT-4 Main Sections
There are also symbols used in the main sections:
added or revised.
Much like the ICD-10-CM, the main sections of the CPT-4 are numerically ordered. After a code or range of codes is found in the index, the assistant should look up those codes in the main sections. Read through all codes noted in the index to find the most appropriate one to the procedure.
Coding Procedures
Unlike in the ICD-10-CM, main terms in the CPT-4 can be anatomic sites. This gives the assistant many more terms in a procedure to choose from when referencing the index. This can be helpful, especially when the first term chosen has numerous subterms. As with the ICD-10-CM, the assistant should try to look up the most specific main term first.
Also unlike the ICD-10-CM, the exact code for a procedure is not always given in the index. Sometimes, code ranges are given instead. Assistants must read through all codes within the range and select the most appropriate one.
Modifiers
Modifiers in the CPT-4 manual have a different purpose than the modifiers in the ICD-10-CM; they do not further specify what the procedure is. Rather, modifiers change the code description to give more information about how the procedure was performed.
Also unlike the ICD-10-CM, codes in the main sections will not indicate whether or not a modifier is needed. It is up to the assistant to determine whether or not a modifier would be appropriate to add.
All modifiers are listed on the inside front cover of the manual. Also, Appendix A gives descriptions and uses of each of those modifiers.
Always use a modifier when:
HCPCS Level II
Level II of HCPCS is structured much like the other coding manuals:
HCPCS Level II codes are supplementary to codes in the CPT-4. If something cannot be found in the CPT-4, it is likely in the HCPCS Level II. For example, HCPCS is often used to code durable medical equipment. As with the other indexes, the Index of Main Terms is organized alphabetically. Office assistants should look for codes in this section first.
Downcoding
Reimbursement from insurance carriers is based on procedural codes entered on the claim form. For the insurance carrier to approve reimbursement, the procedure must be medically necessary and appropriate to the diagnosis.
If the insurance carrier finds the procedural code to be vague or ambiguous, it will be downcoded. This means the code will be reduced to its most basic form, and reimbursement will be made at the lowest possible level. If this occurs, the medical office may lose money.
Procedure for Performing Procedural Coding
Individual offices may have specific procedures that their employees must follow. The following process is an example of a procedural coding procedure that might be found at any office:
Procedure for Performing Diagnostic Coding
Prepare for Procedure
Procedure for Performing Diagnostic Coding
Determine the Procedure
Procedure for Performing Diagnostic Coding
Use the ICD-10-CM
Procedure for Performing Diagnostic Coding
Assign the Code
Summary