CODING

Topics to be Covered:

1. Introduction

2. ICD-9-CM

3. CPT/HCPCS

4. Global Surgery

5. Major Surgery

6. Minor Surgery

7. Ancillary Services

8. Modifiers

INTRODUCTION

Medical coding consists of a system designed to

uniformly represent and report medical services

CPT (Current Procedural Terminology)

Level I HCPCS (Healthcare Common Procedure Coding System) code or

an alphanumeric Level II HCPCS code.

The process of assigning a CPT code to a procedure or service is dependent on both the supporting documentation and the procedure recorded.

Assignment of an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code, which must also be well-documented in the medical record, is required to support medical necessity.

Some Common Terms to be Understood:

Medical Necessity refers to services rendered to a patient to affect a cure or change in the condition for which the patient is being seen. The medical record should have supporting documentation that the services ordered, rendered, and/or billed were necessary based on current standards of medical care.

Medical Record outlines the patient’s care and treatment rendered. All services provided to a patient must be documented in the medical record.

NCCI (National Correct Coding Initiative) is a database developed by CMS of CPT coding relationships that identifies CPT services considered inherently included (bundled) in other services. The database also identifies fragmentation or unbundling of services that could be captured with a single CPT code. When once procedure is included in another procedure, it should not be billed separately.

Covered Services are those services that are payable in accordance with the terms of the benefit plan contract by the payer.

ICD-9-CM Originated in the 17th century England. Developed by the World Health Organization (WHO). Introduced in 1979. Diagnosis codes serve to identify and justify the medical necessity of services

provided by describing the circumstances of the patient’s condition..

XXX.XX

Sub-category

Category

Sub-classification

Types of ICD-9 codes:

Numeric Codes:

The selection of codes 001.0 through 999.9 is frequently used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries.

Alpha-numeric Codes:

V-codes are used to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of factors Influencing Health Status and Contact with Health Services (V01.0 – V83.89) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problems.

E-codes, from the subsection Supplementary Classification of External Causes of Injury and Poisoning (E800 – E999) are used to code how an injury occurred.

V-codes:

• Identify something that could affect the patient in the future but is not a current illness or injury.

•Identify when a person with a known disease or injury, whether it is current or resolving, meets the provider for a specific treatment of that disease or injury.

•Simply state a fact.

V codes are used for describing encounters when a patient presents without a dx, sign or symptom, or for patients suspected of having an abnormal condition or disease, but after examination, the disease is not found.

V codes are also used for general medical exams.

E codes:• Used to facilitate the classification of environmental events, circumstances & conditions that are the cause of injury, poisoning, & other adverse effects.

•Never used as the primary diagnosis.

HCPCS/CPT-4

Three levels of HCPCS: Level 1 – CPT codes

5 digit numeric codes contained in CPT-4 published by the AMA. describes physician and hospital outpatient procedures and services.

Level 2 – National Codes Alphanumeric codes assigned by CMS. These 5 digit codes begin with an alphabetical character, A to V and are use to report

services or supplies that include ambulance, dental, medical & other unique services, supplies (DME, orthotics, prosthetic), drugs, or procedures not included in CPT-4.

Include codes for non-physician procedures, such as ambulance services, durable medial equipment, specific supplies, and administration of injectable drugs

Level 3 – Local Codes Alphanumeric codes developed & assigned by the local Medicare carrier or fiscal

intermediary. Local codes are five-digit, alphanumeric codes using the letters S, and W through Z. Local codes are used to denote new procedures or specific supplies for which there is

no national code.

Coding Sections

Evaluation & Management: 99201 – 99499. Anesthesia: 00100 – 01999 and 99100 - 99140 Surgery: 10021 – 69990. Radiology: 70010 – 79999 ** Pathology & Laboratory: 80048 – 89399 Medicine: 90281 – 99199

** Radiology includes diagnostic radiology, ultrasound, CT, MRI, nuclear medicine, interventional radiology, special procedures & radiation therapy.

Ancillary Services

Services other than routine room & board charges that are incidental to the hospital stay.

These services include: Operating room Anesthesia Blood administration Pharmacy Radiology Laboratory Medical Surgical & central supplies Physical, occupational, speech pathology & inhalation therapies Other diagnostic services.

National Correct Coding Initiative (NCCI)

Medicare established the CCI in Jan 1, 1996. CCI sets standards for billing with CPT & HCPCS codes. The CCI identifies mutually exclusive codes or those that should not be

billed together. CCI was introduced to:

Establish standards of medical billing. Identify codes that may be a potential for fraud & abuse. Identify codes that are components of another code & should not be unbundled &

billed on the same encounter by the same physician.

Place of Service

11 - Office 12 – Home 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency Room - Hospital 24 – Ambulatory Surgery Center 26 – Military Treatment Facility (MTF) 31 – Skilled Nursing Facility 32 – Nursing Facility 34 – Hospice 65 – ESRD Treatment Facility 81 – Independent Lab

Global Surgery

Each surgical procedure CPT code has a global surgical postoperative period assigned to it.

These post op global periods are 0, 10 and 90 days. 0 global days –

No pre or postoperative care is included in the procedure. All follow-up visits, including those related to the surgery are billed

separately. There are no follow-up visits included with the procedure. 10 global days (minor surgery) –

Global period begins the day of the procedure & continues for 10 days. 90 global days (major surgery) –

Global period begins the day before the procedure & continues for 90 days.

Services Included in Global Surgery

Pre-op visits, day before for major surgeries & day of for minor procedures. Complications not requiring additional trips to the OR. Post-op visits related to recovery from surgery – All surgery related post-op visits

are to be billed using 99024. Post-op pain management provided by the surgeon. Related supplies. Routine supplies used as part of the surgery itself cannot be billed by the

provider. Examples of supplies & services that would be included when billing for the

provider’s services include: Dressing changes Local incisional care Removal of operative pack Removal of cutaneous sutures & staples Line wires, tubes, drains, casts & splints Replacement lines Nasogastric & rectal tubes Changes or removal of tracheostomy tubes

Services NOT Included in Global Surgery

Initial E/M service to determine need for surgery. The E/M service that was performed that resulted in the decision for surgery is billable, even when performed

on the day before or the day of a major surgery.

Services of other physicians. Global surgery period only applies to the physician or group specialty that provided the surgery.

Visits unrelated to original diagnosis. Diagnostic tests & procedures.

Any diagnostic test, including radiology & lab procedures are not considered part of the global surgery package.

Distinct surgical procedures during post-op period. If the patient presents to the physician for another surgical procedure that is clearly unrelated to the initial

procedure, then the separate procedure may be billed.

Treatment for post-op complications, return to the OR. If the post-op complication necessitates a return trip to the OR, the treatment for complication may be billable.

Less extensive procedure failed & more extensive procedure is required.

Bundled Services

Routinely Bundled – Separate payment is never made for routinely bundled services & supplies.

Injection services (90782 – 90784, 90788, 90799) included in the fee schedule are not paid for separately if the physician is paid for any other physician fee schedule service rendered at the same time. Carriers must pay separately for those injection services only if no other physician fee schedule service is being paid. In either case, the drug is separately payable.

Modifiers

2-digit numeric or alphanumeric character reported with a HCPCS code, when appropriate.

The means by which the reporting physician can indicate that a performed service or procedure performed has been altered by some specific circumstances, but not changed by definition or code assigned.

Modifiers are used to communicate additional information regarding a CPT code.

Why Are Modifiers Used?

To indicate: A service has both technical & professional components, but both

components are not applicable. A service was performed by more than one physician. A service has been increased or reduced. Only part of the service was performed. A bilateral service was performed. Unusual events occurred. Physical status of a patient for the administration of anesthesia.

Modifier 24 : Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period

The physician may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. The circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

For example, a patient who is being followed by her gynecologist during a pregnancy comes in for an additional visit because she has developed acute bronchitis. The bronchitis is unrelated to the pregnancy and necessitated an additional visit over and above her regular pregnancy check-ups. The E/M code for the visit is billed to the insurance carrier with a –24 modifier and the diagnosis code used is 466.0 for Acute Bronchitis.

Modifier 25: Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above & beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.

Modifier 26: Professional Component

Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.

For example, consider the simple chest X-ray described in code 71010. If the radiograph of the patient's chest is taken in the physician's office utilizing both the physician's equipment and staff, the charge for the chest X-ray will include the use of the equipment, film, chemicals, and staff time as well as the physician's time to interpret the X-ray itself. As such, the charge for code 71010 will include both the technical and professional components.

In contrast to the above example, suppose that the physician does not have X-ray equipment, and refers the patient to a local hospital where the "picture" will be taken. The hospital, in turn, sends the X-ray to a radiologist who interprets the chest X-ray The radiologist would bill the patient for interpreting the radiograph only and use the "-26" professional component modifier as shown below.

71010-26 Interpretation, single view chest X-rayBy the use of this modifier, the radiologist can restrict his or

her charge to the professional component -- the interpretation.

Modifier 50: Bilateral Procedure

Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session, should be identified by adding modifier 50 to the appropriate CPT code.

For example, Otoplasty is performed one a patient's left and right ears:

69300-RT Otoplasty, protruding ear RIGHT

69300-LT Otoplasty, protruding ear LEFT Some payers accept an alternative method of billing bilateral procedures. This

method involves listing the procedure once and adding the "-50" modifier as shown below:

69300-50 Otoplasty, protruding ear, bilateral

Modifier 51: Multiple Procedures

When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).

For example, the repair of a simple neck wound and the closed treatment of a clavicle fracture would be coded as:

23500 Treatment closed clavicle fracture without manipulation12005-51 Simple closure neck wound

Note that the higher charge procedure (fracture treatment in this case) is listed first and the multiple procedure modifier is added to the lesser or secondary service. If three procedures had been performed, the services would be ranked from highest to lowest charge on the claim form and the "-51" modifier would be added to all but the first (highest charge) procedure.

Modifier 59: Distinct Procedural Service

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

On Monday, a dermatologist performs a biopsy on the face. On Thursday, following the results of the biopsy, he removes the 2 cm malignant lesion and does another biopsy of a different site on the face. The services performed on Thursday are reported as follows:

11642 Excision malignant lesion, face11100-59 Biopsy

Modifier 76: Repeat Procedure by Same Physician

The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure/service.

Modifier 77: Repeat Procedure by Another Physician

The physician may need to indicate that a basic procedure/service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure/service.

A patient is brought to the hospital with internal hemorrhaging that is repaired surgically. Three days after surgery, the patient begins hemorrhaging again and the surgeon must perform the same repair again. Would you use the repeat procedure modifier on the second repair? Yes, assuming that the same procedure code was being reported. If a different physician had performed the second repair, he/she would use the 77 modifier.

Modifier 78: Return to the Operating Room for a Related Procedure During the Postoperative Period

The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding modifier 78 to the related procedure.

A patient’s operative site bleeds after an initial surgery and requires a return to the operating room to stop the bleeding, the same procedure is not repeated. Thus a different code, 35860, exploration for postoperative hemorrhage, thrombosis or infection; extremity, would be reported with the -78 modifier appended. Since the same procedure is not repeated, modifier –76 would not be appropriate to use.

Modifier 79: Unrelated Procedure/Service by the Same Physician During the Postoperative Period

The physician may need to indicate that the performance of a procedure/service during the postoperative period was unrelated to the original procedure. This may be reported by using modifier 79.

A patient has a femoral-popliteal graft (35556) and goes home. The incision and graft heal well. However, the patient develops acute renal failure a week after being home and is hospitalized. The patient does not respond to medical treatment of the renal failure. Hemodialysis is indicated, and a second physician inserts a cannula for hemodialysis (36810).

The services of the second surgeon are reported as 36810-79 because this service is unrelated to the femoral-popliteal bypass graft performed during the previous hospitalization.

If the –79 modifier is not appended to this procedure, the third-party payer may not know that this service is not related to the femoral-popliteal graft (i.e., the computer program used by the third-party payer may not be able to distinguish that this service is not related to the previous surgery and may automatically reject this claim).

Modifier 80: Assistant Surgeon

Surgical assistant services may be identified by adding modifier 80 to the usual procedure code.

To report a closure of intestinal cutaneous fistula, the primary operating surgeon reports code 44640, and the assistant surgeon reports 44640-80. The individual operative report submitted by each surgeon should indicate the distinct service provided by each surgeon.

Miscellaneous Modifiers

Modifier 99: Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.

Modifier AA: Anesthesia services performed personally by anesthesiologist

Modifier QX: CRNA with medical direction by a physician

Modifier QY: Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

Important Abbreviations ASC – Ambulatory Surgical Center CMS – Centers for Medicare & Medicaid CPT-4 – Current Procedural Terminology, 4th Edition DRG – Diagnosis Related Groups ESRD – End Stage Renal Disease HCPCS – Healthcare Common Procedure Coding System ICD9-CM – International Classification Of Diseases, Vol. 9, Clinical

Modification RVU – Relative Value Unit LCD – Local Coverage Determination LMRP – Local Medical Review Policy RBRVS – Resource-Based Relative Value Unit