The The Complete Procedure Complete Procedure

Coding BookCoding Book

By By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHAShelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA

Chapter 2Chapter 2

Introduction to Coding and CPTIntroduction to Coding and CPT

Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved

McGraw Hill/Irwin

Learning OutcomesLearning Outcomes

• Explain the purpose of diagnosis coding.

• Relate diagnosis coding to procedure coding.

• Apply correctly the steps to coding.

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Learning OutcomesLearning Outcomes

• Use official guidelines provided to apply the best code.

• Follow the organization of CPT to determine the best code.

• Comply with notations and symbols to code accurately.

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IntroductionIntroduction

Coding is interpreting health care terms and definitions into numbers or number/letter combinations that specifically relate to diagnoses and procedures.

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Medical NecessityMedical Necessity

• Diagnosis codes report the reason why the physician provided the service or treatment.

• Diagnosis codes explain the medical necessity of providing the service or treatment.

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ProceduresProcedures

• Procedure codes report what the physician provided for the patient.– CPT codes– HCPCS Level II codes– ICD-9-CM volume 3• Services, treatments, counseling,

surgery, testing, etc.

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CPTCPT

CPT stands forCurrent Procedural

Terminology

Developed and maintained by the American Medical Association

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Steps to Accurate CodingSteps to Accurate Coding

1. Read through the notes completely.

2. Highlight key words.3. Query the physician

regarding any confusing, conflicting, or missing information.

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Steps to Accurate CodingSteps to Accurate Coding

4. Code the diagnoses.5. Code the procedures.

- Look up key words relating to WHAT the physician provided.

- Verify the code’s description.

6. Link every procedure code to at least one diagnosis code.

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Coding From Physician’s Coding From Physician’s NotesNotes

• More accurate than coding from a superbill.

• More complete than coding from a superbill.

• Official guidelines state that coding should be done from notes and not superbills.

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CPT Coding BookCPT Coding Book

Report • Physician services• All procedures performed in

an outpatient facility– Physician’s office– Ambulatory care center– Clinic

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Organization of CPTOrganization of CPT

• Sections of the main body of CPT– Evaluation and Management– Anesthesia– Surgery– Radiology– Pathology– Medicine

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Organization of CPTOrganization of CPT

• Second part of CPT includes- Category II codes

- Category III codes

- Appendixes A through I

- Alphabetic index

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Alphabetic IndexAlphabetic Index

• Procedures, services, and treatments listed by:• Procedure or service• Anatomical site• Condition• Eponym, synonym, or

abbreviations

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Official GuidelinesOfficial Guidelines

• Guidelines are located:• In front of each of the six

sections.• Within each section, leading into

appropriate subsection.

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Codes Formats Codes Formats

• CPT codes: 12345• Category II: 1000F• Category III: 0001T• Modifiers: -12 or

-A1 • HCPCS Level II: A1234• ICD-9-CM Vol. 3 12.34

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CPT Book FormatsCPT Book Formats

• Indented information attaches to the description above it….up to the semi-colon ( ;)

• 35501 Bypass graft, with vein; carotid

• 35506 carotid-subclavian

The complete description is read:35506 Bypass graft, with vein;

carotid-subclavian

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NotationsNotations

See– Directs you to an alternate

listing

+ (plus sign)– Identifies an add-on code

(List separately in addition…)– Identifies an add-on code

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SymbolsSymbols

• (bullet)– Identifies a new code

∆ (triangle)– Identifies a revised code

>< (sideways triangles)– Identifies revised guidelines

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SymbolsSymbols

– Identifies a code that includes

reimbursement for moderate sedation

– Identifies a code that cannot

be used with modifier 51

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Chapter SummaryChapter Summary

CPT contains thousands of codes used to report services, treatments, and procedures. The book includes guidelines for each section, as well as notations, symbols, and references to assist you in reporting the most accurate code.

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