coding certification blitz handouts - medical coding · coding certification review blitz day 1:...

Coding Certification Review Blitz Day 1: 8:00 Registration 8:15 – 9:15 60 minutes Introduction - Exam Taking Tips

Medical Terminology & Anatomy Review HCPCS

1

9:15 – 10:15 45 minutes Modifiers 10:15 – 10:30 15 minutes Break 10:30 – 12:00 90 minutes ICD-9-CM 2 12:00 – 12:45 45 minutes Lunch 12:45 – 2:15 90 minutes E&M 3 2:15 – 2:25 10 minutes Quick Bio Break 2:25 – 3:25 60 minutes Anesthesia, Radiology 4 3:25 – 3:35 10 minutes Quick Bio Break 3:35 – 5:05 90 minutes Path & Lab, Medicine 5 Day 2: 8:00 Registration 8:15 – 9:45 90 minutes Intro to surgery

10,000 surgery series (Integumentary) 6

9:45 – 10:45 60 minutes 20,000 surgery series (musculoskeletal) 7 10:45 – 11:00 15 minutes Break 11:00 – 12:15 75 minutes 30,000 surgery series (respiratory and

cardiovascular) 8

12:15 – 1:00 45 minutes Lunch 1:00 – 2:30 90 minutes 40,000 surgery series (digestive)

50,000 surgery series (genitourinary) 9

2:30 – 2:45 15 minutes Break 3:00 – 5:00 120 minutes 60,000 surgery series (endocrine, nervous, eye,

ear) 10

Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC Phone 609-965-8820 Email: [email protected]

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CPC EXAM – SAMPLE ANSWER GRID SECTION 1

43 Questions 31 correct / 12 wrong*

SECTION 2 60 Qustions

42 correct / 18 wrong*

SECTION 3 47 Questions

33 correct / 14 wrong* 1 ① ② ③ ④ 44 ① ② ③ ④ 104 ① ② ③ ④ 2 ① ② ③ ④ 45 ① ② ③ ④ 105 ① ② ③ ④ 3 ① ② ③ ④ 46 ① ② ③ ④ 106 ① ② ③ ④ 4 ① ② ③ ④ 47 ① ② ③ ④ 107 ① ② ③ ④ 5 ① ② ③ ④ 48 ① ② ③ ④ 108 ① ② ③ ④ 6 ① ② ③ ④ 49 ① ② ③ ④ 109 ① ② ③ ④ 7 ① ② ③ ④ 50 ① ② ③ ④ 110 ① ② ③ ④ 8 ① ② ③ ④ 51 ① ② ③ ④ 111 ① ② ③ ④ 9 ① ② ③ ④

Inte

gum

enta

ry (9

)

52 ① ② ③ ④ 112 ① ② ③ ④ 10 ① ② ③ ④ 53 ① ② ③ ④ 113 ① ② ③ ④ 11 ① ② ③ ④ 54 ① ② ③ ④ 114 ① ② ③ ④ 12 ① ② ③ ④ 55 ① ② ③ ④

E&M

(12)

115 ① ② ③ ④

Medi

cal T

erm

inol

ogy (

13)

13 ① ② ③ ④ 56 ① ② ③ ④ 116 ① ② ③ ④ 14 ① ② ③ ④ 57 ① ② ③ ④ 117 ① ② ③ ④ 15 ① ② ③ ④ 58 ① ② ③ ④ 118 ① ② ③ ④ 16 ① ② ③ ④ 59 ① ② ③ ④ 119 ① ② ③ ④ 17 ① ② ③ ④ 60 ① ② ③ ④ 120 ① ② ③ ④ 18 ① ② ③ ④ 61 ① ② ③ ④

Anes

thes

ia (6

)

121 ① ② ③ ④ 19 ① ② ③ ④

Musc

ulos

kelet

al (1

0)

62 ① ② ③ ④ 122 ① ② ③ ④ 20 ① ② ③ ④ 63 ① ② ③ ④ 123 ① ② ③ ④ 21 ① ② ③ ④ 64 ① ② ③ ④ 124 ① ② ③ ④

Anat

omy (

9)

22 ① ② ③ ④ 65 ① ② ③ ④ 125 ① ② ③ ④ 23 ① ② ③ ④ 66 ① ② ③ ④ 126 ① ② ③ ④ 24 ① ② ③ ④ 67 ① ② ③ ④ 127 ① ② ③ ④ 25 ① ② ③ ④ 68 ① ② ③ ④ 128 ① ② ③ ④ 26 ① ② ③ ④ 69 ① ② ③ ④ 129 ① ② ③ ④ 27 ① ② ③ ④ 70 ① ② ③ ④

Radi

olog

y (9)

130 ① ② ③ ④ 28 ① ② ③ ④ 71 ① ② ③ ④ 131 ① ② ③ ④ 29 ① ② ③ ④

Resp

. / Ca

rdio

(10)

72 ① ② ③ ④ 132 ① ② ③ ④ 30 ① ② ③ ④ 73 ① ② ③ ④ 133 ① ② ③ ④ 31 ① ② ③ ④ 74 ① ② ③ ④ 134 ① ② ③ ④ 32 ① ② ③ ④ 75 ① ② ③ ④ 135 ① ② ③ ④

ICD-

9 (11

)

33 ① ② ③ ④ 76 ① ② ③ ④ 136 ① ② ③ ④ 34 ① ② ③ ④ 77 ① ② ③ ④ 137 ① ② ③ ④ 35 ① ② ③ ④ 78 ① ② ③ ④ 138 ① ② ③ ④ 36 ① ② ③ ④ 79 ① ② ③ ④ 139 ① ② ③ ④ 37 ① ② ③ ④ 80 ① ② ③ ④

Path

& L

ab (1

0)

140 ① ② ③ ④ HCPC

S (5

) 38 ① ② ③ ④ 81 ① ② ③ ④ 141 ① ② ③ ④

39 ① ② ③ ④

Dige

stive

(10)

82 ① ② ③ ④ 142 ① ② ③ ④ 40 ① ② ③ ④ 83 ① ② ③ ④ 143 ① ② ③ ④ 41 ① ② ③ ④ 84 ① ② ③ ④ 144 ① ② ③ ④ 42 ① ② ③ ④ 85 ① ② ③ ④ 145 ① ② ③ ④

Codi

ng C

once

pt

43 ① ② ③ ④ 86 ① ② ③ ④ 146 ① ② ③ ④ 87 ① ② ③ ④ 147 ① ② ③ ④ 88 ① ② ③ ④ 148 ① ② ③ ④ 89 ① ② ③ ④ 149 ① ② ③ ④ 90 ① ② ③ ④ Me

dicin

e (10

)

150 ① ② ③ ④ 91 ① ② ③ ④

Geni

tour

inar

y (11

)

92 ① ② ③ ④

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93 ① ② ③ ④ 94 ① ② ③ ④ 95 ① ② ③ ④ 96 ① ② ③ ④ 97 ① ② ③ ④ 98 ① ② ③ ④ 99 ① ② ③ ④ 100 ① ② ③ ④ 101 ① ② ③ ④ 102 ① ② ③ ④

Nerv

ous/E

ye/E

ar (6

0)

103 ① ② ③ ④ * These are just estimates. The AAPC no longer states how many you can get wrong and still pass. These figures are based on 2004 guidelines from the AAPC.

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11

BLITZ!

Coding CertificationReview

BLITZ!

By Laureen Jandroep,OTR, CPC-EMS, CPC-H, RCC

CPC Exam Layout

3 sections to CPC exam5 continuous hours You must pass EACH section43 - 60 questions per sectionYou can get approximately 12 - 18 wrong per section

and still pass!**

Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC2

and still pass!You have two tries to pass for the same fee

Exam Tips

The exam is NOT specialty specificTesting a GENERAL BROAD knowledgeFocus on principles of good codingThrow out your BILLING & REIMBURSEMENT

knowledge!Confidence and time management are vital

Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 3

g

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22

Time Management

MethodsDot Method Hour Method

Plan on having some unanswered questions –don’t freak out!

Don’t over think or read into a question – stick to


qyour job!

Pick the BEST of the possible answers

Time Management

Compare and contrast the answersMark up your books to draw your eye to

groupings and key words that make the code different from the others


Medical Terminology

13 Questions on Medical Terminology9 Questions on AnatomyMastery of medical terminology means efficient

test taking


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33

Medical Terminology Basics

Word Parts Prefixes RootsSuffixesCombining formPut it all together = medical terminology


Know where help is in your manuals

Prefixes – Numbers

NullinonePrimi-FirstMono-, uni-One

Tri-ThreeQuad-, quadri-, tetra-FourHemi-, semi-H lf tl


OneBi-, di-Two

Half, partlyMulti-, poly-many

Prefixes – Numbers

Hyper-Excessive, more than

normalHypo-beneath or below

Macro-largeMicro-small


beneath or below normal

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44

Prefixes - Color

Alb/o, albin/oWhiteChlor/oGreenCyan/o

Erythr/oRedMelan/oBlackXantho/o

ll


Blue yellow

Prefixes – Direction or Position

Ab-Away fromAd-TowardAnte-, pre-, pro-BeforeDia

En-, endo-InsideEpi-Above, onHypo-, sub-Beneath, under


Dia-ThroughEcto-, ex-, exo-Out, without, away from

Inter-BetweenIntra-within

Prefixes – Direction or Position

Meso-MiddlePeri-AroundPost-Aft b hi d

Behind, backwardSuper-, supra-Above, beyond


After, behindRetro-

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55

Prefixes – Misc.

A-, an-No, not, withoutAnti-, contra-AgainstBrady-SlowDys-Bad difficult

Mal-BadPara-Near, beside, or abnormalPer-Through or by


Bad, difficultEu-Good, normalIn-not or inside (in)

Tachy-fast

Suffixes – symptoms & diagnosis

-algia, -dyniaPain-celeHernia-ectasisDilation, stretching

-emesisVomiting-ia, iasisCondition-ItisInflamation


-edemaswelling

Inflamation-lepsyseizure


-malaciaAbnormal softness-maniaExcessive

preoccupation-oid

-osisCondition, disease-pathyDisease-ptosisProlapse, sagging


Resembling-omaTumor

p , gg g-rrhexisRupture-rrhagia

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66


-rheaFlow, dischargeSclerosis Hardening-stasis


-stasisStopping, controlling

Suffixes – Surgery

-centesisPuncture-ectomyExcision, surgical

removal-lysis

-plastyRepair-rrhaphySuture-scopeInstrument used for

Laureen Jandroep, OTR, CPC-EMS, CPC-H, 17

Destruction-pexySurgical fixation

viewing-scopy visualy examining

Suffixes – Surgery

-stomyForming artificial

opening-tomeCutting instrument-tomy


tomyIncision-tripsycrushing

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77

Anatomy

Remember the figures in the front of CPTThere are also many pictures throughout CPTDon’t forget the ICD-9-CM Manual!


HCPCS

Three levelsLevel 1 – AMA CPTLevel 2 – National (the book)Level 3 – Regional (phased out)Some abbreviations listed in front


HCPCS

Who used HCPCSMedicare & MedicaidMany 3rd Party Payors

SymbolsModifiers

Ambulance


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88

HCPCS Layout

A – V CodesTable of DrugsAppendixWatch for measurementsRead all answers and look carefully at

differences


differences

Coding Concepts

5 questions on the CPC board examThese are general coding questionsPerhaps regarding who maintains the

manualsWhen do they come out each year etc.Most information should be available right in


Most information should be available right in your manuals

“Modifier$……It’$ All About The Money!

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“Modifiers – It’s All About the Money!” Grid © Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information)

Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS ~ Phone: (609)965-9585 ~ Fax: (609)965-6547 [email protected] ~ www.crn-institute.com

Part of the Coding & Reimbursement Network www.codingandriembursement.net

Type Key: GP = Global Package Modifier BUN = related to bundling or CCI E/M only = Appended to E/M codes only # = Related to number of surgeons Anes = Anesthesia Related Lab = Laboratory Related Oth = All Others

$$ Key: = $$ goes up; = $$ claim gets paid - without it claim would be denied; = $$ goes down; = $$ Stays the same (informational only)

Mod Short Description – (For Full Description see Appendix A of CPT)

Type $$

E/M Anesthesia Surgery Radiology Path & Lab

Medicine ASC & Hosp

Global Package Modifiers -24 Unrelated* E/M service by the same

physician during a postop period GP E/M E/M

-57 Decision for surgery

GP E/M E/M Medicine

-58 Staged or related procedure

GP, BUN Surgery Radiology Medicine ASC &

Hosp -76 Repeat procedure by same physician

GP ,

Surgery Radiology Medicine ASC &

Hosp

-77 Repeat procedure by another physician

GP

Surgery Radiology Medicine ASC & Hosp

-78 Return to OR for a related procedure during the postop period

GP Surgery Radiology Medicine ASC & Hosp

-79 Unrelated procedure or service by the same physician during the postop period

GP

Surgery Radiology Medicine ASC & Hosp

-54 Surgical care only

GP Surgery

-55 Postoperative management only

GP Surgery Medicine

-56 Preoperative management only

GP Surgery Medicine

© Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information) Bundling or CCI Modifiers

-25 Significant separately identifiable E/M service

BUN GP E/M E/M ASC &

Hosp -26 Professional component BUN Surgery Radiology P&L Medicine -58 Staged or related procedure

GP, BUN Surgery Radiology Medicine ASC &

Hosp -59 Distinct procedural service BUN Anesthesia Surgery Radiology P&L Medicine ASC &

Hosp Evaluation & Management Only Modifiers

-21 Prolonged E/M services

E/M

E/M

-24 Unrelated E/M service by the same physician during a postop period

GP E/M E/M

-25 Significant separately identifiable E/M service

GP E/M E/M ASC &

Hosp -57 Decision for surgery

GP E/M E/M Medicine

-27 Multiple outpatient hospital E/M encounters on the same date

E/M

ASC & Hosp

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“Modifiers – It’s All About the Money!” Grid © Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information)

Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS ~ Phone: (609)965-9585 ~ Fax: (609)965-6547 [email protected] ~ www.crn-institute.com

Part of the Coding & Reimbursement Network www.codingandriembursement.net

Number of Surgeons Modifiers -62 Two surgeons

# Surgery Radiology

-66 Surgical Team

# Surgery

-80 Assistant surgeon

# Surgery Radiology

-81 Minimum assistant surgeon

# Surgery

-82 Assistant surgeon (when a qualified resident is not available)

# Surgery

Anesthesia Related -23 Unusual anesthesia

Anes Anesthesia

-47 Anesthesia by surgeon Anes Surgery

© Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information) Laboratory Related

-90 Reference (outside) laboratory

Lab P&L

-91 Repeat clinical diagnostic laboratory test

Lab P&L ASC & Hosp

Other Modifiers -22 Unusual procedural services

Oth Anesthesia Surgery Radiology P&L Medicine

-32 Mandated services

Oth , E/M Anesthesia Surgery Radiology P&L Medicine

-50 Bilateral procedure

Oth Surgery Radiology Medicine ASC & Hosp

-51 Multiple procedures

Oth Anesthesia Surgery Radiology Medicine

-52 Reduced services

Oth E/M Surgery Radiology P&L Medicine ASC & Hosp

-53 Discontinued procedure

Oth Anesthesia Surgery Radiology P&L Medicine

-63 Procedure Performed on Infants less than 4 kg

Oth Surgery (not Integ.)

-73 Discontinued outpatient hospital/ASC procedure prior to anesthesia

Oth ASC & Hosp

-74 Discontinued outpatient hospital/ASC procedure after anesthesia

Oth ASC & Hosp

-99 Multiple modifiers Oth Surgery Radiology Medicine * Per CPT Assistant May 1997 “"Modifier -24 is used when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an evaluation and management service unrelated to the problem requiring the surgery." Note it does not say unrelated to the surgery itself.

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99

Two Levels

HCPCS Level I ModifiersAMA CPT Manual Appendix A

HCPCS Level II ModifiersFound in Federal Register or in HCPCS book

published by Medicode or St. Anthony etc.


What do they do?

Modify the code description without changing the core meaning

Provide additional information regarding the service provided

Tells the “story” more clearlyIntegral part of CPT and the HCPCS coding


Integral part of CPT and the HCPCS coding system

Modifier Types

GP = Global Package ModifiersBUN / CCI = Related to bundling or CCI editsE/M = Only appended to E/M procedures# = Refers to number of surgeons involvedAnes = Anesthesia Related


Lab = Laboratory RelatedOth = All other modifiers

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1010

$ Key

= $$ goes up = $$ claim gets paid - without it claim

would be denied = $$ goes down = Stays the same (informational


only)

Global Package Modifiers

-24-57-54, -55, -56-58-76, -7778 79


-78, -79

Global Package Concept

Package includes: Pre-OpOperationPost-Op

CMS definition found in the MCM at


http://www.cms.hhs.gov/transmittals/downloads/R1770B3.pdf

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1111

Pre-Op Visit

Subsequent to Decision for Surgery VisitOne related E/M on the day

immediately prior to or on the day of procedure

I I l d d i th P k


Is Included in the Package

Operation

Operation per seLocal infiltrationmetacarpal/digital blocktopical anesthesia


Postoperative follow-up care

CMS clearly states 0, 10 or 90 days see Medicare Physician Fee Schedule Database

(MPFSDB)http://cms.hhs.gov/physicians/pfs/

Or your software vendor/ service like CodeCorrect http://crn.codecorrect.com


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1212

Modifier –24 ($ )

Unrelated Evaluation and Management by the Same Physician during the postoperative period

Append to E/M codes onlyWhat it says: “I know this is during the global

period for a previous procedure but this


period for a previous procedure but this visit is unrelated – pay up”

Must know definition of your payors global period

Modifier –57 ($ )Decision for SurgeryAppend to E/M Codes only (& some

ophthalmological codes in the Medicine section)

What It Says: “I know there is going to be a claim in the next day or so for a surgery


which includes the pre-op visits – but today was the day I decided to do that surgery so it is not a pre-op visit – don’t consider this as part of the global package”

Modifier –58 ($ )Staged or Related Procedure or Service by the Same

Physician During the Postoperative PeriodAppend to CPT code when the procedure is second

and/or related to the original or first procedure.Note: A new postop period begins when the next

procedure in a staged or related procedure is provided.


provided. Don’t use for return to OR see –78Don’t use for unrelated procedures in the global

period – see -79

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1313

Modifier –76 ($ )

Repeat Procedure by Same PhysicianAppended to CPT codes to indicate when the

same physician repeats the same service, sometimes on the same day

Same CPT code as done previouslyWhat it says: “I know this is the same CPT


What it says: I know this is the same CPT code as above (or reported earlier) but it is a repeat not a duplicate”

Modifier –77 ($ )

Repeat Procedure by Another PhysicianSame as –76 but repeated by a different

physicianSame CPT code as previously done by first

physician


DG: An explanation of the medical necessity for the repeat service is necessary.

Modifier –78 ($ )

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

Global package modifier that does not reset global days from previous surgery

Used when treatment for complications requires a return to the OR


qDifferent CPT code from original surgeryUsually paid at 70 to 80%

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1414

Modifier –79 ($ )

Unrelated Procedure or Service by the Same Physician During the Postoperative Period

Appended to surgical codes to indicate that an unrelated procedure was performed by the same physician during the postoperative period of the original procedure


procedure.Otherwise payer’s computer system would

kick it out as being part of the follow period for the previous surgery.

Modifier –54, -55, -56 ($ )Surgical Care Only; Postoperative

Management; Preoperative ManagementTo use correctly there must be an agreement

for the transfer of care between physicians.

Use box 19 to indicate date of transfer of responsibility


espo s b tyWithout transfer then the services of the

non-surgeon are reported with regular E/M codes

Append to surgical codes only

CCI or Bundling Modifiers

-25-26-59


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1515

Modifier –25 ($ )

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Append to E/M codes only to indicate it was separate from that required for the procedure


and a clearly documented, distinct and significantly identifiable service was rendered

Many 3rd party payers will not accept when billed with a minor procedure on the same day

Modifier –26 ($ )

Professional ComponentTotal fee split between professional and

technical componentUse only on global service codes not on codes

that are only for professional component by definition. (I.e.. 94014 is a total and 94016


(is a PC)

Use when a physician is providing the interpretation of the diagnostic test/study performed

Modifier –59 ($ )

Distinct Procedural ServiceIndicates procedure was distinct or

separate from other services provided on same date

Alert!: The “unbundling” modifier – allows bypassing of payor edits (CCI) – be


yp g p y ( )careful!

Modifier of last resortDG: Need good supportive documentation

to use this modifier.

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1616

E/M Only Modifiers

-21-24 (already discussed with Global Package Modifiers)

-25 (already discussed in BUN group)-27 (out-patient only)-57 (already discussed with Global Package


Modifiers)

Modifier –21 ($ )Prolonged Evaluation and Management

ServicesWhat it says: “I have met the description

for the highest level of care but I still spent more than the usual time.”

Only use on the highest level E/M in any given category


given categoryDon’t use on prolonged services, critical

care or neonatal care codes

Modifier –24 ($ )Unrelated Evaluation and Management by the

Same Physician during the postoperative period

Append to E/M codes onlyWhat it says: “I know this is during the global

period for a previous procedure but this visit


is unrelated – pay up”Must know definition of your payors global

period

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1717

Modifier –25 ($ )Significant, Separately Identifiable

Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Append to E/M codes only to indicate it was separate from that required for the


was separate from that required for the procedure and a clearly documented, distinct and significantly identifiable service was rendered

# - Number of Surgeon Modifiers

-62-66-80-81-82


Modifier –62 ($ )Two SurgeonsSame CPT code is used for each surgeon,

each appends –62For different specialties – many payors will

deny if used by surgeons of the same specialty

Only applicable to certain codes (see MFSDB


Only applicable to certain codes (see MFSDB etc.)

DG – good medical necessity documentation needed

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1818

Modifier –66 ($ )

Surgical TeamFor highly complex proceduresUsed by each participating surgeon on the

same CPT codeDG: This is a “by report” modifier so be

prepared to submit documentation with


prepared to submit documentation with claims and have good medical necessity to warrant team surgery

Modifier –80 ($ )

Assistant SurgeonSame CPT code as primary surgeonCan be used with other modifiers such as –50

and –51Check for coverage guidelines such as MFSDB

to see if payor will pay for an assist at


to see if payor will pay for an assist at surgery

DG: Medical necessity documentation is key

Modifier –81 ($ )Minimum Assistant SurgeonUsed when the services of a second or third

assistant surgeon are requiredDG: Medical necessity is keyRarely recognized by Medicare – doesn’t

even show on the MFSDB


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1919

Modifier –82 ($ )

Assistant Surgeon (when qualified resident surgeon not available)

Same as modifier –80 but for teaching hospitals that have residency programs

Must have documentation on file that a qualified resident was not available


q

Anesthesia Related

-23-47


Modifier –23 ($ )

Unusual AnesthesiaRestricted to anesthesiologistsDon’t append to surgical codesUsed for procedures that would normally not

need anesthesia or would only need local anesthesia


anesthesiaDo not use for local anesthesia

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2020

Modifier –47 ($ )

Anesthesia by SurgeonDo not attach to anesthesia codesFor use of regional or general anesthesia. Not covered by Medicare and many

M di id


Medicaid programs

Lab Modifiers

-90-91


Modifier –90 ($ )

Reference (Outside) LaboratoryUsed on lab procedures that are performed

by a party other than the treating or reporting physician but billed by the physician’s office

Not allowed by Medicare


Not allowed by Medicare

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2121

Modifier –91 ($ )Repeat Clinical Diagnostic Laboratory TestAppend to lab procedures to indicate repeat lab

tests or studies performed on the same day on the same patient

Only use when additional test results are obtained subsequent to the administration or performance of the same test(s) on the same


performance of the same test(s) on the same day.

Don’t use if CPT descriptor itself indicates it is a repeat or series of tests as in 82951, glucose; tolerance test (GTT), three specimens.

Other Modifiers-22-32-50-51-5253


-53-99

Modifier –22 ($ )

Unusual Procedural Services“I did extra work or spent an unusual amount

of time due to _________, pay me more”DG: Document in detail the circumstances that

make the case unusual.


Tip: Send in documentation with claim.Alert: Overuse can trigger an audit.

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2222

Modifier –32 ($ )

Mandated ServicesUse when the physician is aware of third-party

involvement regarding mandated servicesWho and why must be clearly documentedConsidered informational and when used,

many insurers allow 100% reimbursement i h d d ibl


without a deductible or copay.No effect on Medicare payment

Modifier –50 ($ )

Bilateral ProcedureOnly use when the code description does not

already state it is bilateralUse only when the exact same service/code is

reported for each bilateral anatomical siteFor Medicare enter as one line-item with a unit


of one. Payment is 150%“One or both” - no need for -50

Modifier –51 ($ )

Multiple ProceduresUse to indicate that more than one surgical

service was performed by the same physician on the same session.

Usually some shared component to the workW t h f b l th t i di t th d i


Watch for symbols that indicate the code is –51 exempt + and

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2323

Modifier –52 ($ )

Reduced ServicesWhat it says: “I did this procedure but did not

complete it fully as described in CPT.”Intended for procedures that accomplished some

result, but less than expected for the procedure

Performed at a lesser levelBil t l d l d id


Bilateral procedure was only done on one sideDG: – Send with documentation that supports a

reduction of procedure code description to prevent payment delays

Modifier –53 ($ )Discontinued ProcedureWhat it says: “Due to extenuating circumstances I

elected to terminate procedure due to patient risk”

The procedure was actually started but was discontinued before completion due to the patient’s condition


patient s conditionDG: – Send with documentation that supports a

reduction of procedure code description to prevent payment delays

-52 vs. -53

Decision Matrix -52Reduced

-53Discontinued

Anesthesia Stopped Before Usually Stopped After


Cancelation Elective by patient or physician

Physician decision due to patient risk

Result Some benefit No benefit

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Modifier –63 ($ )Procedure Performed on Infants less than 4

kgNew to 2003Unless otherwise designated, this modifier

may only be appended to procedures/services listed in the 20000-


69999 code series.Smaller bodies mean more complex surgeries

and should be paid at a higher rate – this modifier tells that story.

Modifier –99

Multiple ModifiersOnly use if payors computer system does not

accept multiple modifiers on the same lineEnter modifiers in box 19 on HCFA 1500 form1=22, 2=51 The 1 and 2 indicate which line

item the modifiers refer to


item the modifiers refer toRarely used

Questions?

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2525

BREAK

ICD-9-CM

Know the layout of the book2 Volumes

Volume 1 Tabular17 Chapters Appendix A-E

Volume 2 Index (usually in front)Index to DiseasesTable of Drugs & Chemicals


Table of Drugs & ChemicalsIndex to E Codes

ICD-9-CM Conventions

NotesIncludesExcludesCode First Underlying DiseaseUse Additional Code


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[ ] Brackets[ ] Slanted Brackets( ) Parentheses: Colon{ } Braces



NEC – “Not Elsewhere Classifiable”Books Fault

NOS – “Not Otherwise Specified”Doctors Fault

SEESee Also


See Also

ICD-9-CM = MN

Medical Necessity IS ICD-9-CM codingSpecificity is keyPrimary Dx Code is the chief reason for the

encounter (there are a few exceptions)Other codes are supporting codes –

they “round out the story”


they “round out the story”

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ICD-9-CM Linkage

Each procedure code should be matched with an appropriate diagnosis code

HCFA 1500 has 4 spaces for Dx codes6 lines for procedures codesThis linkage show the medical necessity linkageL t f dit


Largest source of payor edits

Coding Diagnosis Codes

Find key term(s)Use indexFollow Cross ReferencesVERIFY in tabularFollow instructions in tabular


Tabular Instructions

ChapterSection

Category (3-digit)Sub-category (4th digit)

Sub-Classifiction (5th digit)

Instructions are found at all of these levels


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ICD-9-CM Special Areas

Late EffectsE-CodesV-Codes


ICD-9-CM Chapter Specific

InfectionNeoplasmsMyocardial InfarctionsMentalInjuries & Trauma

WoundInjury


InjuryFractureBurn

ICD-9-CM Special Areas

ObstetricalPerinatalMental Disorders


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BREAK

Section 3

47 Questions33 Needed to Pass14 Can be wrong

E&M – 12 QuestionsAnesthesia – 6 Questions

di l 9 Q i


Radiology – 9 QuestionsPathology – 10 QuestionsMedicine – 10 Questions

E&M

Three Main StepsDetermine Location/CategoryDetermine HEM or Time (if dominant)Determine Overall Level (2 of 3 vs. 3 of 3)For the exam it will be spelled out most of the

ti


time

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E/M Leveling Exercise Remember, When it’s 3 of 3 code to the lowest and when its 2 of 3 drop the lowest

HEM (history, exam, MDM)

Office New Patient Level 3 of 3

(just use 1,2,3,4,or 5)

Office Established Patient 2 of 3

Level (just use 1,2,3,4, or 5) PEL CCM CCS CDM CEH DPH EDM EPH EDS EDL CDM PEM DEL CES PDL DDH EEM CDL DDL EDH CPH CPS CEM EES DDM PEH CDH PPL PPM PPH EPS EPL ECS EPM ECL ECM EEH

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E&M Location

Start with the table of Categories and Subcategories (page 5 of pro. Version)

Write the page numbers next to each subcategory

Be mindful of “status” vs. location


E&M Categories

Office or Other OutpatientHospital ObservationHospital InpatientConsultsEmergency Department


Critical Care Services

E&M Categories

Neonatal Intensive CareNursing Facility ServicesDomiciliary, Rest Home or Custodial CareHome ServicesProlonged ServicesC M t


Case Management

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E&M Categories

Case Management ServicesCare Plan Oversight Preventive Medicine ServicesNewborn CareSpecial E&M


Other E&M

E&M Determine the HEM3 Key AreasHistoryExamMedical Decision MakingContributory AreasCounseling


Coordination of CareNature of presenting problem

E&M History

History Levels(P) Problem Focused(E) Expanded Problem Focused(D) Detailed(C)Comprehensive


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E&M Exam

Exam Levels(P) Problem Focused(E) Expanded Problem Focused(D) Detailed(C)Comprehensive


E&M Medical Decision Making

Medical Decision Making (MDM) Levels(S) Straightforward(L) Low Complexity(M) Moderate Complexity(H) High Complexity


E&M Leveling

Mark your margins3 of 3

“Code to the lowest”

2 of 3“Drop the lowest”


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3333

BREAK

Anesthesia

PackageTime ReportingModifiersPhysical StatusQualifying CircumstancesCPT Appendix A Modifiers


CPT Appendix A ModifiersHCPCS ModifiersCrosswalk

Anesthesia

TypesGeneral

InhalationIntravenous

RegionalPeripheral Nerve Blocks

Other TypesLocal (Included in

surgical package)Conscious Sedation

(in medicine section)


Peripheral Nerve BlocksSpinalEpidural

section)

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Anesthesia

UnbundlingSpecialized Services – Bill SeparateSwan-Ganz catheter placement and monitoring

(93503)Arterial (ART) lines (36620-36625)MAC – Monitored Anesthesia Care


All but the “knock out”-QS modifier

Radiology

Global ServiceProfessional ComponentTechnical Component

PlanesPositioning TermsAdministration of Contrast


Administration of ContrastOral and rectal don’t count

Supervision & Administration

Radiology

Four Main SectionsDiagnostic Radiology

ViewsX-ray vs. MRI etc.

Diagnostic UltrasoundRadiation Oncology


gyTreatment Sessions

Nuclear Medicine

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BREAK

Pathology & Laboratory

PanelsDrug TestingEvocative/Suppression TestingPath ConsultChemistry Tests


Anatomic PathologySurgical Pathology

Medicine

Stick & StuffPsychiatryDialysisOphthalmologyENTC di l t t t


Cardiovascular treatmentCardiac CatheterizationPulmonaryAllergy & Clinical Immunology

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Medicine

NeurologyChemoPM&ROsteo Manipulative & Chiropractic TxSpecial Services, Procedures, and ReportsConscious SedationOth


Other

Questions?

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11

BLITZ!

Coding Certification Review

BLITZ!

By Laureen Jandroep,OTR, CPC-EMS, CPC-H, RCC

Day Two

Section Two

Surgery & Modifiers60 questions42 needed to passCan get 18 wrong


General Surgery Guidelines

Format

Separate Procedures / BundlingSurgical Package

Scope Procedures


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22

Surgery Section Format

18 Subsections (green headings in 2005)General (10021 – 10022)Integumentary (10040 – 19499)Musculoskeletal (20000 – 29909)Respiratory (30000 – 32999)Cardiovascular (33010 – 39599)


Cardiovascular (33010 39599)Hemic & Lymphatic (38100 – 38999)Mediastinum & Diaphragm (39000 – 39561)


Digestive (40490 – 49999)Urinary (50010 – 53899)Male Genital System (54000 – 55899)Intersex Surgery (55970 – 55980)Female Genital (56405 – 58999)M t it C & D li (59000 59899)


Maternity Care & Delivery (59000 – 59899)Endocrine (60000 – 60699)


Nervous (61000 – 64999)

Eye & Ocular Adnexa (65091 – 69990)Auditory (60900 – 69979)

Operating Microscope (69990)


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Guidelines

Colored guideline pages (beginning of surgery)

Subsection guidelines


Key Concepts

Separate ProceduresRelated to bundlingSay’s “Be careful I am usually part of other

procedures”OK to report when that is all that was doneOK to report if done at a separate time etc. (-59)

Complications


ComplicationsCode separately Not included in package

Key Concepts – Scopes

If a code is NOT listed under a scope heading then it is an “open” procedure

“Portal” refers to poke holes for scopeDiagnostic scopes

CAN report on their own


CAN report on their ownCAN report with open proceduresCANNOT report with “surgical” scopes

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10k – Integumentary

Lesion Excision / DestructionLaceration RepairTissue TransferSkin Grafts & FlapsBurns


Breast Procedures

BREAK

20k – Musculoskeletal

Organized by body areaFracture CareSpineCasts & StrappingScopes


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30K – Respiratory & Cardio

Respiratory SystemPay attention to anatomyBubble & highlight


30K – Respiratory & Cardio

Cardiovascular SystemPacing cardioverter –pacemaker or defibrilatorCABGAngioplasty – TransluminalAtherectomy – TransluminalComposite grafts


Vascular injection proceduresEndoscopy

BREAK

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40k – Digestive

Code organized from “in to out”Endoscopy – through natural or existing

openingScopes dominate in this section

Upper GI – Mouth down


Lower GI – anus up-52 for incomplete colonoscopy

50k – Urinary, Genital System & Maternity

Urinary SystemBe careful of Urethra vs. UreterUrodynamicsEndoscopyUreter and Pelvis


Ureter and Pelvis

50k – Urinary, Genital System & Maternity

Genital SystemMaleIntersexFemale

Vulvectomy definitions


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50k Urinary Genital System & Maternity50k – Urinary, Genital System & MaternityMaternity & Delivery Coding

PackageVaginalC-SectionVBAC


BREAK

60k – Endocrine, Nervous, Eye, Ear

Endocrine SystemNervous

Sx of skull baseSpine & Spinal Cord

Eye (Occular)Cataract Removal Coding


gEarOperating Microscope

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Homework

of 55

E/M Leveling Exercise Remember, When it’s 3 of 3 the code to the lowest and when its 2 of 3 drop the lowest

HEM (history, exam, MDM)

Office New Patient Level 3 of 3

(just use 1,2,3,4,or 5)

Office Established Patient 2 of 3

Level (just use 1,2,3,4, or 5) PEL 1 3 CCM 4 5 CCS 2 5 CDM 3 4 CEH 2 5 DPH 1 4 EDM 2 4 EPH 1 3 EDS 2 3 EDL 2 3 CDM 3 4 PEM 1 3 DEL 2 CES 2 3 PDL 1 3 DDH 3 4 EEM 2 3 CDL 3 4 DDL 3 4 EDH 2 4 CPH 1 5 CPS 1 2 CEM 2 4 EES 2 3 DDM 3 4 PEH 1 3 CDH 3 5 PPL 1 2 PPM 1 2 PPH 1 2 EPS 1 2 EPL 1 3 ECS 2 3 EPM 1 3 ECL 2 3 ECM 2 4 EEH 2 3

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