Procedural and Diagnostic Coding Review

What is the purpose of CPT codes?

To provide an accurate identification of services provided to the patient.

Steps to perform procedural coding

Identify exact procedure

Obtain the documentation from the chart

Choose the proper code book

Use the alphabetic index

Locate code or range of codes

Check descriptors

Check guidelines for any special circumstances

Determine if you need modifiers

Select the appropriate code

Where the list of CPT modifier are located

The first appendix of the CPT book (A)

Steps in proper order to perform diagnostic coding

Locate the term: alphabetic index

Refer to all notes under main term

Find the appropriate indented subordinate term

Follow relevant instructions

Cross reference the code in the tabular index

Assign the code

To clarify a CPT code you should add

A modifier

Coding system used for products, medical supplies, certain services NOT in CPT

HCPCS (level II)

Codes for orthotics or vision care are found in

HCPCS (level II)

Fraudulent activity is called

Upcoding

T or F Upcoding gives the provider more money and costs for health care increase

True

Downcoding

Less comprehensive code, less reimbursement, loss of revenue

Medical necessity relating to Diagnostic and Procedural coding

Justify reasonable, necessary and appropriate

Would you consider a diagnosis of Gout a reasonable and appropriate diagnosis to order a CXR

No

WHO

World health organization: approves changes to the coding system

Primary Code

Primary diagnosis

Late effects

Code first with current compliant the late effects

Coding without a definite diagnosis

We code with patient symptoms

ICD 10 CM

(International Classification of Diseases, Tenth Revision, Clinical Modification) A standardized system used in the US to code disease and medical conditions

How did ICD 10 CM improve coding

It introduced and provides more detailed and specific coding system

Place of service

The physical address where a service was provided

POS for services in the physician's office

POS 11 (code 11)

Medical decision making: To establish a diagnosis the provider must consider

The number of diagnosis or management option available

The amount and complexity of the data to be reviewed (Straightforward, low complexity, moderate complexity, high complexity)

Risk of complications or other problems the patient has

Number Radiology code starts with

7

Number laboratory or pathology codes starts with

8

What is meant by bundled/package coding

Bundled/package coding: grouping multiple related medical services or procedures together under a single CPT or HCPCS code

Can a package be unbundled, to charge each item separately?

No, it can lead to overpayment, claim denials, and legal issues

Two codes necessary when billing for injection

The drug itself and the administration of the drug

Fraudulent billing

Billing for services that are not performed, falsifying record and using another patient's coverage to receive reimbursement

ABN

Advanced Beneficiary Notice