CPT and HCPCS Coding

CPT Category 1

CPT (Current Procedural Terminology) level one codes are procedure codes generally used by physicians and in other outpatient settings. They are updated annually. 

A procedure is any action taken by the doctor and staff for the treatment or diagnosing the patient. CPT can also be divided in to category as follows:

Anesthesia: This is the practice of giving pain numbing medicines to patients for surgery. (00001-09999)

Evaluation and Management: These are services where the doctor will assess your problem, make a diagnosis and recommend treatment, but does not do any surgery or testing. Previously we noticed a pattern in bold print spelling out SOAP. SOAP is a common evaluation and management method. It also helps the doctor know what to write in his/her notes.  (99201-99255)

Surgery: These are invasive codes, meaning to go through the skin. The surgery section is further divided by body system such as musculoskeletal (skin, muscle and bone) or cardio-vascular and respiratory (heart, veins and arteries and lungs). (10000-69999)

Radiology: Radiology describes diagnostic or therapeutic procedures involving several different forms of x-ray. (7000-79999)

Pathology: These services include the analysis of blood, tissue and urine (80000-89999)

Medicine: The medicine section encompasses all other medical services that do not fit in to the sections above including non radiology diagnostic services and non surgical therapeutic treatments, physical therapy and chiropractic. (90000-99100)

Category II and III

Both category 2 and 3 codes are for reporting purposes. They report medical treatment outcomes and assessments of clinical trials and new technologies.  They are generally not reimbursable (they don’t get paid) and are used in addition to traditional CPT level 1 codes as appropriate.  Not all physicians report using these codes so it is important to ask the provider is they do or if they are involved in clinical trials. To follow is the official description of category 2 and 3 codes from the AMA web site:

“Category II CPT Codes are intended to facilitate data collection by coding certain services and/or test results that are agreed upon as contributing to positive health outcomes and quality patient care. This category of CPT codes is a set of optional tracking codes for performance measurement. These codes may be services that are typically included in an Evaluation and Management (E/M) service or other component part of a service and are not appropriate for Category I CPT codes.”

“The purpose of this category of codes is to facilitate data collection on and assessment of new services and procedures. These codes are intended to be used for data collection purposes to substantiate widespread usage or in the FDA approval process. As such, the Category III CPT codes may not conform to the usual CPT code requirements that:

Services/procedures are performed by many health care professionals across the country;    FDA approval be documented or be imminent within a given CPT cycle; and the service/procedure has proven clinical efficacy.”  (http://www.ama-assn.org/ama/pub/category/12886.html)

HCPCS

HCPCS codes include all products or items used in medical treatment and service codes which have not yet been assigned to CPT. It also includes non-medical care such as ambulance transportation. An example of HCPCS are known as durable medical equipment (DME) which are supplies provided to patients that can be used repeatedly such as crutches or a wheel chair. Other examples of HCPCS are medications or drugs, surgical trays, and bandages. 

ICD-9 Coding Overview

ICD-9 (International Classification of Diseases 9^th Revision) codes are diagnosis and status codes. These tell why the patient went to the doctor’s office. There are three main types of diagnosis codes. They are:

Numeric codes (000-999.99) which are used for problems, illnesses or injuries

V codes are used to indicate a status such as pregnancy, exposure to an illness (that the patient has no symptoms of contracting but needs checking), high-risk behavior, or a significant medical history or family history. You can see that these are not sicknesses but need to be checked on by a doctor

E codes are external causes. An external cause is the reason behind an illness or injury. An example would be a diagnosis (numeric code) indicating a cut (laceration) on the forehead, the E code would tell us how it happened for example a car accident. Since E codes are used to explain another diagnosis they cannot be the first diagnosis and they cannot be used alone.

ICD-9 coding is very simple, but requires accuracy. Assigning an incorrect diagnosis to a patient can label the patient with a disease that they don’t really have. Mislabeling can result in problems for the patient getting life insurance or health insurance coverage.

Although this report’s purpose is not to prepare you for a coding certification, a brief description on reading the ICD-9 book is in order. I highly recommend that the reader study coding prior to trying to do any coding.

The ICD-9 book is divided in to two. The first section at the front of the book is an alphabetical listing of diagnosis words. The second section is the numeric listing of the diagnosis ordered by their assigned code. In order to select the correct code you must first look up the words in the alphabetical listing then reference the numeric listing for the actual, full code description and additional code details.

If you have an ICD-9, open it up and look in the alphabetical index for the word diabetes. You should find a reference to the 250 section of the numeric section. Now refer to the numeric listing for the 250 codes. There are a lot of diabetes codes for one single disease! Look at the codes you will see most of them have two digits after a period making the diabetes codes 5 numbers (250.XX). The additional digits after the period explain the condition further. Read the descriptions to get an idea of what I mean. 

Now look at the code 250 (no additional digits), notice that there is a little (4) next to the code, this indicates that a 4^th digit is required. Notice next that the code 250.0 has a little (5) next to it, this means that it needs a 5^th digit. The code 250 is a disease classification for diabetes, the 4^th digit is the sub-classification indicating the type of diabetes (juvenile or adult onset a.k.a. type 1 or type II) and the 5^th digit tells you of any manifestations or problems resulting from the disease.

In billing it is imperative to complete the diagnosis code to the highest level of specificity meaning use all possible digits as indicated by the presents of the little 4 or 5 if applicable. Now look up the code 496 in the numeric listing, note that there is no little 4 or 5. Code 496 is fully specific without any more digits. The example of code 496 is to show you that not all codes need additional digits but if there is a little 4 or 5 you must code using those digits.

Q. So what happens if you do not use the additional digits?

A. The medical bill (claim) will not pay and the insurance rejection will say something about the code not being specific enough or truncated. Truncated means shortened or reduced.

Q. But what if you don’t know the additional details about the condition that are required to choose a more specific code?

A. You have two options. First you can ask the provider to be more specific, show the provider the ICD-9 book and ask them to clarify based on your options. Second option is NOS or NEC. NOS means not otherwise specified by the doctor and NEC means not elsewhere classified within ICD-9. These can be used to indicate that missing information. It is often indicated by the presents of a 0 or a 9 as the final digit after the period in a code. Be careful though, because NOS codes are not always acceptable for an insurance to consider payment on a claim.

Q. What if the options for the extended digits don’t have the sub-classification or manifestation that I need to report the condition?

A. After you have double checked that the correct digit does not exist and verified it with the provider you may opt to use an NEC code. NEC means not elsewhere classified.

ICD-9 coding hints

• Most importantly in ICD-9 coding, you must read. There are very important notes and rules associated with codes that must be followed. Some codes cannot be used alone, or without another code and some code descriptions will appear similar on initial review. Take careful note of the sub-classifications, manifestations and conditions that are included and excluded from a particular code.
• Never code or bill using diagnosis that the provider describes as “possible”, “probable” or “rule out”. Only use the conditions, diseases or symptoms that are confirmed.
• Do not use an “E” code as a primary diagnosis (the first one)
•  Be sure that the diagnosis justifies the procedure performed (this is called medical necessity and we will talk more on this later). 

Medical and Surgical Coding Introduction

Ok, here is where it gets more challenging (not really, coding is easy once you learn how)... We are entering the wonderful world of coding.


After a patient is seen by the doctor a coder must translate the office visit in to codes. The codes used are called ICD9, CPT and HCPCS. The codes are a different language used to tell a story about the patient’s doctor's office visit. The codes are all maintained by different agencies  and updated periodically. Here is a list of which agency is responsible for which code set.

• The National Center for Health Statistics (division of the Centers for Disease Control) maintains ICD-9-CM (diagnosis codes), http://www.cdc.gov/nchs/
• The Centers for Medicare and Medicaid Services maintains HCPCS codes (supply and service codes), www.cms.hhs.gov
• American Medical Association owns and maintains CPT-4^® codes (medical service codes), http://www.ama-assn.org/

(It should be noted that the United States is planning to begin using ICD-10 (10th revision) in 2013. Since we are still using ICD-9 as of the time of this post, I will only discuss ICD-9 at this time. I will talk more on ICD-10 in later posts.)

Before beginning a coding overview, I want to clarify one common misconception about coders (BTW, I am a Certified Coder). This misconception, I find, scares a LOT of people away from coding. So, here is what you need to understand. Coders do not memorize every code. We do not know everything about every disease or procedure in existence. Given, we know a lot of codes. After using them enough, you would too. So, you ask, what makes a coder so special if we do not memorize 25,000+ codes? 

Here is the truth about coders (that some don't want you to know because, in general, we like that you think we are brilliant)... All we coders really know are coding rules, how to use the coding books, where to find the best resources, and anatomy. THAT'S IT! 

In the next few posts, I will share most of this with you in a summary form. It won't be enough to run out and take the CPC or CCS exams, but hopefully, this will remove some of the fears associated with coding. 

So, now we will begin with ICD-9...  

An Intro to Doctors Office Operations and Documentation

Most people are familiar with going to the doctor’s office. You call to make an appointment, the receptionist offers an appointment weeks away. Once you get there, you fill out long forms, present your insurance card, and pay your copay. By the magic of medicine that is all you have to think about. There are few people who recognize medicine as a business.

So what happens on the back end? Let’s review the same scenario from the office staff’s perspective. A patient calls to make an appointment. The receptionist reviews the schedule. Due to the fact that it is flu season and chicken pox is going through the local school, the schedule is full. The receptionist will ask the patient what seems to be the problem; with that information he/she will try to determine the severity of your condition. The receptionist must decide if your condition warrants moving another patient’s appointment or squeezing you in risking upsetting an entire waiting room full of patients. The receptionist determines that your routine checkup is not a life threatening situation and he/she offers you an appointment in three weeks.

The day before your appointment, the receptionist calls to confirm that the patient will be coming. This is called a confirmation call or confirming an appointment. If the patient will not be able to make it, your slot can be used to accommodate one of the many patients who are waiting for an appointment.

Prior to the patient’s appointment, a chart must be prepared. This means that the office staff must gathering any reports of tests done since the last visit (x-rays, blood work, etc…). The doctors note paper (called the progress note) must be prepared and dated and the chart must be in order – often times chronological order.

Now three weeks have passed and the patient comes for the appointment. The receptionist has the patient update their medical history, demographic information (address, phone number, and insurance information). The patient is thinking, “Why is this necessary? I was here last year”? Here’s why; things change. In a year new medications can be added, surgeries are preformed, and allergies are discovered, and people move to new houses. All of these questions are for the patient’s protection. The more information that the doctor has, the fewer medical mistakes occur.

Once the patient has completed their paperwork, they wait, and wait, and wait. The patient begins to get angry, even sometimes accosting the front desk for “over booking” or accusing the doctor of greed quenched only by seeing too many patients. Now to be realistic, what is really causing the delay? There are several possibilities. First, it could be a very chatty patient who is holding up the doctor. It could also be a patient who has trouble understanding. Worst, it could be a patient who is sicker than anyone knew and now requires more time. Finally, sometimes in the midst of outbreak, it is necessary to overbook.

Now,  the patient is called and led back to an exam room. Eventually the nurse comes in and asks about the patient’s problem, takes the patient’s blood pressure, pulse and temperature. These things are called vital signs. When the doctor comes in to the room, he/she proceeds to ask questions, and touch the patient in places that do not hurt. Five minutes later, the patient is handed a prescription for blood work and told to come back next year for more of the same.

Now here is what just happened, really. The nurse took the vital signs, which the doctor will review to determine that your major organs are functioning properly and there is no immediate danger or chronic condition that may require immediate treatment. When the doctor entered, he/she asked what you may have believed were “irrelevant” questions , but these questions were actually an important part of the visit, this question and answer period is known as the subjective. The doctor listens to find patterns in the patient’s descriptions of the problem. The questions may not have a positive answer but they are relevant to the condition for which you are being treated. This subjective evaluation lets you tell the doctor what you think is wrong. 

While you tell the doctor about your condition, the doctor is also looking at the color of your eyes, at the color of your skin, smelling you, watching your behavior, reaction time, and many other obvious and visible things. This is the called the objective part of the visit. The objective will establish what the doctor thinks of your description of the condition for which you are being evaluated.

During the physical examination the doctor checks pulses and feels glands that the patient doesn’t know they have. He/she feels the temperature of the skin and looks down your throat. This hands-on, touching part is called the physical examination and it is the final glue that holds what the doctor has learned in the Subjective and Objective. This leads to a diagnosis or at least a strong suspicion about what problems the patient has. The diagnosing is referred to as the assessment.

Based on this assessment (the diagnosis) the doctor will decide on the correct course of action or treatment, called a plan.

Those who are attentive will notice that the word SOAP is in larger bold text.  SOAP is the foundation for how a physician is required to document your visit.  All visits to the doctor must be thoroughly documented by law. This documentation is cumulatively called the patient’s “medical record”. Not only is the doctor required by law to make notes, they must be in a specific format; one of the most common formats is called SOAP (subjective, objective, assessment and plan). If the physician does not properly note the visit he/she cannot bill the insurance company for the visit, therefore he/she cannot get paid for their services. Billing the insurance for services that have not been properly documented is considered fraud and can result in large fines and possible even jail time for the physician. 

The rules surrounding how a doctor must document a visit are called documentation guidelines. They were developed by the Centers for Medicare and Medicaid services and adopted by just about every insurance company thereafter. All the news that one hears relating to “Insurance fraud” relate back to documentation either directly or indirectly. Accordingly, documentation is a HUGE topic on which I will not spend much time because there is so much to cover. I do, however, recommend that the reader to some additional research.

There are two different versions of documentation guidelines. One was published in 1995 and the other in 1997. Above, I described the 1995 documentation guidelines because they are the most simple to set the stage. In practice, the 1997 are becoming more widely used, particularly with as electronic medical records make it easier to document more extensively. Still the 1995 guidelines are simple to understand and we will use these to set the foundation and understand the basic point that documentation is important.

To learn more about documentation, check out the guidelines. Here are some good resource links for you:

https://www.cms.gov/MLNProducts/Downloads/1995dg.pdf

https://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf