Ashworth College Medical Coding 1 Exam

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User Generated

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abezna21

Subject

Health Medical

School

Ashworth College

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i will send questions when i pick someone will have two hours for 40 questions

Text Readings

Comprehensive Health Insurance: Billing, Coding, and Reimbursement, Chapters 6 and 7

Additional Readings

Required Readings

Supplemental Readings

Supplemental Videos

Lecture Notes

USING THE CPT TO CODE FOR PROCEDURES AND SERVICES

When the doctor sees a patient in the office, he or she checks off all the services and procedures performed during that visit, in addition to the diagnoses for that visit. Sometimes the nurse or medical assistant will assist in checking off the procedures.

CPT codes are usually marked on the encounter form or routing slip, but other services might be handwritten. Codes are then added to the claim form, and they must be consistent with the diagnosis from the patient visit. By the time this encounter form gets to you, the patient will be long gone, and you’ll have to decipher the checks and marks the physician made on this form. If you aren’t receiving clear and complete information, you must communicate this with the office manager or physician to remedy the situation. With the federal government increasingly rooting out fraud and abuse, proper CPT coding and billing can decrease your chances for a Medicare audit and will help avoid the recoding of your services by insurers.

The process of coding procedures is accomplished by finding the correct description of the procedure in Level I of the HCPCS system. The Level II codes are applied to the supplies, medications, therapeutic substances, medical equipment, and certain specialized services needed by the patient. We’ll be discussing more about HCPCS Level II codes in the next lesson. In this lesson, we’re concentrating on the Level I CPT codes.

The CPT code book that includes the Level I codes is broken down into six sections, each with a list of consecutive code numbers available to describe the procedures found in that section. Your text explains each section and the symbols and conventions that are used.

You’ll remember from studying the ICD-10 code books that all notes, symbols, indents, and headings have meaning and must be utilized in arriving at the correct code. Like the ICD volumes, the CPT manual has an index, which is the first place you should look when trying to determine an appropriate code. It’s important to remember to never to code solely from the index.

A two-digit modifier is added when further explanation is needed, or to give some additional information. Some modifiers affect reimbursement, whereas others are more informational in nature. Some modifiers are used for evaluation and management services, whereas others are used for radiology or surgical procedures. Failure to use modifiers can result in rejection of the claim or reduced payment. There’s a complete listing of all CPT Level I modifiers in Appendix A of your CPT manual. It’s very helpful to flag this section for easy reference. Sometimes you may even have to submit more than one modifier for a single code.

Coding procedures for surgery can be challenging. Surgery is normally coded from postoperative notes and other documents provided by the surgeon. Your text discusses the numerous guidelines for coding surgery cases. One of the most important surgical coding guidelines is the concept of unbundling procedures. According to the CPT system, procedure codes have either an asterisk, indicating a minor surgical procedure, or no asterisk, indicating a major surgical procedure. CPT rules about surgical coding are different from the rules set by Medicare. Most insurance payers follow Medicare’s policies, but it’s important for you to learn CPT rules to have a complete understanding of the process.

There are numerous guidelines for the various types of procedure coding. Laceration repair coding, for example, is one you likely will encounter and is found in the beginning of the integumentary section. Lacerations are classified into three types: simple, intermediate, and complex. The classification depends on the extent of the laceration. You should become familiar with the differences between the different levels of repair. Repairs of lacerations are coded according to the sum of the length of the repairs measured in centimeters (cm) for lacerations of similar classification. This means that if there’s more than one laceration of a particular classification, you would add the length of each laceration together and code the entire group with one code.

HISTORY OF CPT

CPT stands for Current Procedural Terminology. It’s part of the Healthcare Common Procedure Coding System. The CPT codes are used for reporting medical services and procedures. They provide a standard and a uniform way for healthcare facilities to report services and procedures. There are several different levels within the HCPCS classification system, with the most commonly used level being the CPT level.

CPT codes are published and maintained by the AMA, which first developed the codes in 1966. A second, expanded edition was published in 1970. Throughout the 1970s, the codes were expanded and updated to meet the needs of the ever-changing medical field. The codes were then adopted for use by the CMS (then called HCFA) in 1983.

Visit the AMA webpage “How a Code Becomes a Code” at http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-process-faq/code-becomes-cpt.page .

In August 2000, CPT codes were named as the national standard of codes under HIPAA. According to the AMA, HIPAA officially names CPT (including codes and modifiers) and HCPCS as the procedure code set for

Physician services
Physical and occupational therapy services
Radiological procedures
Clinical laboratory tests
Other medical diagnostic procedures
Hearing and vision services
Transportation services, including ambulance

UNDERSTANDING CPT CODES

CPT codes are five-digit numerical codes used to describe the procedures and services from providers, especially those from physician offices. For example, a physician may perform a physical checkup on a patient and report the CPT code 99396, which translates to “Established Patient Preventive Medicine Services.”

You may be wondering how ICD codes differ from CPT codes. ICD-10 includes both diagnoses and procedure codes, used mainly for inpatient hospital settings and diagnosis reporting. CPT codes are procedure (or service) codes used mainly in outpatient and physician settings for billing and reporting.

CPT CATEGORIES

CPT is organized into three categories:

Category I: Widely performed procedures
Category II: Supplementary tracking codes
Category III: Temporary codes for emerging technology, services, and procedures

CPT Category I

Category I codes are the most widely used. They’re the codes used the most by physician offices and outpatient providers. These codes are made up of five digits and are updated annually by an AMA board. Within Category I, the codes are broken down even further:

Evaluation and Management (E/M)
Anesthesiology
Surgery
Radiology
Pathology and Laboratory
Medicine

An example of a Category I CPT code is: 99253 Initial inpatient consultation.

CPT Category II

Category II CPT codes collect information about the care by providing codes for services or test results and help to measure performance. Category II CPT codes are alphanumeric. They have four digits followed by an F. For example, 0001F is a Category II CPT code for blood pressure measured.

CPT Category III

Category III CPT codes are used for emerging technology. They’re used for data collection and tracking for new procedures or services. Category III codes are five characters—four digits followed by a T.

CPT Coding Basics

Just like ICD coding, CPT coding also has specific nomenclature and guidelines. In coding, it’s important to pay attention to the symbols, descriptions, and guidelines that appear in your book and with any coding software that you use. The nomenclature is what will help you assign the correct codes for reporting and reimbursement. Nomenclature is the descriptive terms, guidelines, and identifying codes for reporting medical services and procedures.

Another way CPT codes differ from ICD codes is that they use modifiers. Modifiers are made up of a hyphen and then two digits, like this: -25. The modifiers are placed after the main CPT code to supply additional details. Be careful using modifiers, because some insurance companies will deny claims with certain modifiers.

The following are common modifiers:

-22: The procedure was unusually complicated and took more time than the general CPT code allows.

-51: More than one surgical procedure was performed during the same operation.

-76: The doctor performed the same procedure more than once during the visit (same patient).

-91: The doctor repeated the same diagnostic test, usually on the same day.

An important part of CPT coding is understanding the place of service. As your textbook discusses, the Evaluation and Management (E/M) section is divided into sections: offices, hospitals, consultations. These sections are then further subdivided.

Be sure to review the CPT code ranges for places of service on pages 136–137 of your textbook.

LEVEL OF E/M SERVICE

Remember, E/M stands for “evaluation and management.” E/M codes represent physician–patient encounters reported for billing. Different E/M codes stand for different types of encounters, such as physician office or hospital visits. Within each type of encounter, there are also different levels of care.

Key components meet the documentation requirements explained in the E/M guidelines. This means that patient documentation must support the E/M code assignment for E/M coding unless you’re coding based on time. If time is the controlling factor, there are no specific documentation requirements for the three key components mentioned here.

Coding for E/M is based on three key components:

History
Physical examination
Medical decision making

Medical decision making means the complexity of establishing a diagnosis through

The number of possible diagnoses and/or the number of management options that must be considered
The amount and/or complexity of the patient’s health record, diagnostic tests, that must be obtained, reviewed, and analyzed
The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem, the diagnostic procedure and/or the possible management options

UNDERSTANDING THE CPT CODE INDEX

The CPT index appears after the appendix of the CPT code book. It’s organized by main terms into four main entries:

Procedure or Service
Organ or Other Anatomic Site
Condition
Synonyms, Eponyms, and Abbreviations

In medicine, an eponym is an illness, condition, or procedure named after the person who is believed to have discovered it.

STEPS TO CPT CODING

Read the patient record or source document completely.
Review the procedure to identify the main term and modifying terms.
Locate the main term in the CPT index.
Look for subterms indented below the main term.
Write down the tentative code range for the procedure (or each procedure if there are more than one).
In the main text, locate each tentative code, reading any notes and paying attention to symbols and nomenclature.
Verify that the code matches the procedure information provided in the patient’s record.
If necessary, find the modifier.
Assign the CPT code.

Remember, the index isn’t a substitute for coding from the main portion of the CPT book.

UNDERSTANDING UNBUNDLING

One of the biggest mistakes coding and billing professionals can make is to “unbundle” CPT codes; that is, to report more codes than is required. Many areas of CPT, such as surgery, consist of bundled codes, or a single code used to report a group of procedures. When individual codes are reported instead of the one CPT code that covers all the procedures, it’s known as unbundling or fragmented billing.

Most unbundling occurs as an error. However, the CMS may view this as fraudulent and fine an organization that’s regularly practicing unbundling.

Text Readings

Comprehensive Health Insurance: Billing, Coding, and Reimbursement, Chapter 8

Additional Readings

Required Readings

Supplemental Readings

Lecture Notes

INTRODUCTION TO HCPCS AND CODING COMPLIANCE

There will be many times when you’ll have to speak with insurance company representatives—perhaps to inquire about the status of your claim, to find out why an item or service was not paid, or to discuss other insurance-related issues. In many situations, the insurance company representatives can be a help to you by giving suggestions and pointing out rules that you may have overlooked. However, sometimes you may encounter uncooperative insurance carrier personnel. In all cases, remember to be professional and bring any problems to the attention of your supervisor.

To work in health care, it’s imperative that you become familiar with what constitutes correct documentation because reimbursement for the physician’s services is based on what’s documented. Because of the importance of correct documentation, we’ll spend some time here detailing the importance of correct documentation.

It’s important to have sound health records that chronologically document all patient care because these records serve the following functions:

They enable the physician and other healthcare professionals to plan and evaluate the patient’s treatment.
They enhance communications and promote continuity of care among physicians and other healthcare professionals involved in the patient’s care.
They facilitate claims review and payment.
They reduce hassles related to medical review.
They serve as a legal document to verify the care provided, which can be helpful in defending against an alleged professional liability claim.

The health record should be complete and legible. Most physicians dictate their patient encounters and then have the dictation transcribed. The physician should read, sign, and date all dictated medical records before they’re placed in the patient’s chart. A signature alongside the note indicates that the physician read the transcription and approved the information. When Medicare audits a medical record and the record can’t be read by at least two people, it’s considered illegible, and the services won’t be reimbursed.

Payers differ in signature requirements, but obtaining a full signature is the best practice. CMS, which administers Medicare, doesn’t specify whether a full signature is required or whether initials are permitted. Many commercial payers don’t require signature or initials, but because medical records can and often do become legal documents, a full signature is generally the best practice.

The documentation of each patient encounter should include the date, reason for the encounter, appropriate history and physical exam, review of lab and/or x-ray data, assessment, and plan for care. The CPT and ICD codes reported on the health insurance claim form should reflect the documentation in the medical record and support the medical necessity. An important phrase to remember in the insurance world is, “if it wasn’t documented, it wasn’t done.”

Payers define medically necessary services as those that adhere to standards of good medical practice, match up with the diagnosis, and provide the most appropriate level of care in the most appropriate setting. The definition of medical necessity may differ among insurers. Medically necessary services may or may not be covered services, depending on the health plan.

The most important step in coding protocol is to code and report only those conditions and procedures that are documented in the medical record. If you know a service or procedure was provided, but it’s not stated in the medical record, either you must have the physician make an addendum to the record or you must not code for the undocumented service.

Choosing the primary diagnosis and then linking the diagnosis to the procedure are critical steps for proper reimbursement. Many insurance carriers have code-linkage edits (ICD/CPT matching) built into their claims-processing systems. The physician’s claim can be denied for ICD/CPT “mismatch.” For example, a claim is submitted and the diagnosis billed is migraine headache, but the procedure billed is a chest x-ray. Now that’s a mismatch that probably will kick out the claim!

“SOAP notes” are a popular method for physicians to document their findings. Many times it’s the medical assistant or nurse who documents the patient’s chief complaint and the description of the presenting problem. The medical assistant or nurse can also record the patient’s current, past, and social medical history and the patient’s family history. When a patient completes a questionnaire as part of the registration process, that questionnaire becomes part of the medical record as well. It’s important that the physician sign and date any patient questionnaire and nursing notes to indicate that he or she read the information.

Coding from operative reports can be difficult. You must have a good understanding of medical terminology as well as a correct idea of the actual procedure performed. Effective communication with the physician is essential for accurate coding.

Working in a physician office, you’ll often encounter Evaluation and Management codes. The Evaluation and Management (E/M) codes cover those services generally considered to be the office visit, hospital visit, consultation, or ER visit. To determine the proper code for these types of services, numerous factors must be taken into account. These codes are used frequently by coders. In a pediatric or family practice, it’s entirely possible that most of your codes will come from this category.

More and more healthcare employers are learning how experienced coders can make a difference in their office’s reimbursement practices. After you’ve gained some billing and coding experience, you might want to consider taking a national coding certification examination. This course hasn’t focused on coding, except as an entry-level skill for medical billing specialists. But with experience on the job, you can become skilled as a coder, and obtaining the certification shows that you’re a coding professional as well as an expert. These certifications are becoming well known in the industry, and now many healthcare providers will only hire those who are certified for some advanced coding positions.

HCPCS

In the previous lesson, we touched on HCPCS when we talked about CPT. Remember, HCPCS is the Healthcare Common Procedure Coding System. There are several different levels within the HCPCS classification system, with the most commonly used level being the CPT level, or Level I, codes that we discussed previously. Level II HCPCS codes are known as national codes.

According to the CMS, Level II codes are used mainly to identify products, supplies, and services not included in the CPT-4 codes. These can include

Ambulance services
Durable medical equipment
Prosthetics
Orthotics
Nonphysician supplies

Ambulance services, durable medical equipment, prosthetics, orthotics, and supplies are often referred to by the acronym DMEPOS.

These Level II codes were created to provide reporting and billing mechanisms for codes not covered under CPT. Unlike the Level I (CPT) codes, which consist of five-digit codes, the Level II HCPCS codes consist of four digits preceded by an alphabetical character ranging from A through V.

You can access the HCPCS Level II codes (provided by the CMS for free) by following these steps:

Go to the CMS website (http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html?redirect=/HCPCSReleaseCodeSets/).
Click on HCPCS - General Information.
Scroll down to the “Related Links” section and click on Alpha-Numeric HCPCS.
Click on 2018 HCPCS Index.
Click on 2018 HCPCS Index (PDF, 206KB).
Save the document to your hard drive for your personal use.
Repeat these steps to download the 2018 Alpha-Numeric HCPCS File (ZIP, 1MB) and the 2018 HCPCS Table of Drugs (PDF, 309KB).

HISTORY OF HCPCS

HCPCS originally stood for HCFA Common Procedure Coding System. HCFA was the acronym for the Health Care Financing Administration, which is now known as the Centers for Medicare and Medicaid (CMS), thus the coding system was named after that organization. Today, HCPCS stands for Healthcare Common Procedure Coding System.

HCPCS was established in the 1980s to provide a standardized coding system for describing the specific procedures and services in health care. In 1983, HCPCS was initially created to represent physician and nonphysician services under Medicare. As your textbook describes, prior to that time there was no uniform system for coding procedures and services, which meant that there was no good way to collect reimbursement. Since then the usage has expanded. In 2003, the HHS gave authority to the CMS to maintain and distribute HCPCS Level II codes under HIPAA. They’re updated on January 1 of each year, just like CPT (Level I) codes.

Today, Medicare, Medicaid, as well as private health insurers all use HCPCS codes for billing and claims processing. Be sure to review the HCPCS Level II example on page 186 of your textbook.

Initially, there was also a HCPCS Level III, which included the “local codes.” These codes were developed and used by state Medicaid agencies, Medicare contractors, and private insurers to cover local services not identified in HCPCS Level I or II codes. In 1996, HIPAA required CMS to adopt standards for coding systems that are used for reporting healthcare transactions. These regulations eliminated Level III local codes, and they were phased out on December 31, 2003.

HCPCS MODIFIERS

As we discussed in the previous lesson, modifiers are two-digit (alphabetical or alphanumeric) codes that are appended to the back of a HCPCS code to provide additional information about the code. Think about it as a way to help explain a procedure when there isn’t a specific code that covers it. Refer to Table 8.2 on page 187 of your textbook to see a list of HCPCS modifiers.

Modifiers are important because they help explain things that may not seem apparent on first glance from payers. For example, maybe the physician performs two procedures during one surgery on one patient. The insurer may only pay 100% of the allowed amount for the first procedure, but only a percentage of that for the second procedure. Using a modifier that indicates multiple procedures will help the payer better understand what to reimburse.

According to the CMS, U.S. healthcare insurers process over 5 billion claims for payment each year. Can you imagine what that would be like if we didn’t have a standardized coding and reporting system?

CPT CODES AND BILLING

To support billing requirements, CPT codes must be supplied on a standard form to comply with data exchange regulations. The CMS-1500 form is the standard claim form to bill Medicare and durable medical equipment regional carriers (DMERCs). The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. Visit the CMS to see a copy of the CMS-1500. Go to www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1500805.pdf.

FRAUDULENT CLAIMS

In the previous lesson, we touched on unbundling and how it can be seen as fraudulent if it continues to happen from one provider. As your textbook describes, this type of fraud is covered by the Federal Civil False Claims Act.

Believe it or not, the False Claims Act (FCA) was first enacted by Congress in 1863! Then, the government was concerned that suppliers of goods to the Union Army during the Civil War were defrauding the army. Since then (as you can imagine), the FCA has been amended several times to reflect current happenings. One of the current amendments to the FCA makes it illegal to submit claims for payment to Medicare or Medicaid that are known to be false.

HIPAA created the Healthcare Fraud and Abuse Control Program to help identify instances of fraud and abuse. As your textbook discusses, the Office of Inspector General (OIG) works with the Department of Justice (DOJ) to investigate and prosecute these claims.

NATIONAL CORRECT CODING INITIATIVE

In 1996, the CMS implemented the Medicare National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to help control improper coding and inappropriate payments. According to CMS, “NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.” The NCCI helps providers avoid coding and billing errors and payment denials by telling them which procedures and services can’t be billed to Medicare for the same patient within the same day. There’s also a NCCI for Medicaid, but it varies greatly from the Medicare NCCI.

Be sure to review Figure 8.1 in your textbook. Review Figure 8.2 and Figure 8.3 in your textbook to see examples of the Federal Civil False Claims Act in action.

Tags: medical coding CPT Coding Current Procedural Terminology CPT modifiers Medical Coding