In the fast-paced world of coding today, many coders specialize in either inpatient or outpatient coding. This is a necessity in many large institutions, but for the coder contemplating the certified coding specialist (CCS) exam, a lack of familiarity with the basics of CPT coding can be a detriment. This column will provide an overview of CPT coding basics for the coding professional who is primarily experienced in inpatient coding.
Although there are many who profess that one system is superior to another, it's more important to realize that both systems have their unique advantages that the coder should be aware of and capitalize on. Because most people learn by comparing new information to what they already know, it's important to understand the major differences between CPT and ICD-9-CM volume 3 procedures. At the most basic level, the major difference between CPT and ICD-9 is that while ICD-9 classifies procedures primarily by the service itself (e.g., ORIF, incision and drainage, etc.), CPT classifies procedures primarily based on anatomic body site.
There are specific guidelines to be applied in each particular section of CPT (e.g., Evaluation and Management, Surgery, etc.), but there are also formatting and other guidelines that apply to all CPT codes. For example, to conserve space some CPT code descriptions aren't printed in their entirety but some refer back to a common portion of the description for the previous code. Within any indented series of codes the coder should refer back to the first left-justified code (the parent code) and apply all terminology that is to the left of the semicolon. This is demonstrated below:
12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
||2.6 cm to 7.5 cm|
||7.6 cm to 12.5 cm|
||12.6 cm to 20.0 cm|
||20.1 cm to 30.0 cm|
||over 30.0 cm|
The full code description for code 12004 above is actually: "Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm." The code terminology of parent code 12001 that precedes the semicolon applies to all codes in the indented range.
Coders should be aware of several symbols that are used throughout the CPT system. One is the plus (+) symbol, which designates add-on codes. Add-on codes are used to denote a code that is closely related to a previous code in the same section and may be identified by specific language in the code description, such as "each additional" or "(List separately in addition to primary procedure)." The most important things to remember about add-on codes is that they are always performed in addition to the primary procedure and may not be reported alone or without the parent code they relate to. For example, review the two codes below:
19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion
+ 19126 each additional lesion separately identified by a radiological marker (List separately in addition to code for primary procedure)
(Use 19126 in conjunction with code 19125)
In this example, code 19126 could never be assigned alone because a single lesion would be reported with code 19125. Code 19126 is only reported when a second or subsequent lesion is identified by preoperative needle localization and then excised separately from the first lesion.
Other symbols that are important include the bullet ( ) symbol, indicating a new code in CPT and the triangle (s) symbol, indicating CPT codes with significantly altered descriptions. Similarly, sideways triangles ( ) denote substantially new or revised text, such as new parenthetical notes or guideline language. In each case, the coder should ensure that they understand the use of the new or revised codes and/or guidelines.
Coders should understand the appropriate use of unlisted CPT codes. Unlisted codes are used for those services that may be performed by physicians or other health care professionals that aren't represented by a specific code. The unlisted code, typically one that ends in "99" is general in scope, such as 26989 (Unlisted procedure, hands or fingers), should only be assigned if no other more specific CPT code is available. It's particularly important that the hospital coder try to find the most appropriate specific CPT code for surgical services because the majority of unlisted CPT codes are grouped to APCs with little or no reimbursement. However, coding compliance guidelines dictate that the unlisted code be assigned if no more specific code is available; a "close" CPT code should not be selected based primarily on reimbursement. It should be a fairly unusual situation in which an unlisted code is assigned. In most cases they're assigned to represent new services or procedures or unexpected unusual procedures.
Many coders will use computerized encoders when assigning CPT codes, but to understand the CPT system it's important to become familiar with the CPT manual index. In addition, the CCS exam does not allow the use of encoding systems, so a thorough working knowledge of the manual index is mandatory. In CPT there are four primary classes of main indexed entries:
1. Procedure or service, such as biopsy, debridement, evaluation and management, laparoscopy;
2. Organ or other anatomic site, such as intestines, prostate, bladder, esophagus;
3. Condition, such as abscess, dislocation, esophageal varices, varicose veins;
4. and Synonyms, eponyms and abbreviations, such as McBride operation (bunionectomy), Mazet operation (knee disarticulation), Baldy-Webster operation (uterine suspension).
There may be several indented entries under each main indexed term that must be reviewed before cross-referencing the selected codes in the tabular portion of the CPT manual. Any cross-references also should be reviewed to ensure appropriate code selection. There are two types of cross-references in the index:
1. "See:" used primarily for eponyms, synonyms and abbreviations.
2. "See also:" used to direct the user to refer to another main term if the procedure is not listed under the first main index entry.
When coding from the surgical portion of the CPT manual, it's important to ensure that the information is taken directly from the entire operative report. This is essential for appropriate CPT coding because the final procedures performed may vary significantly from what was initially planned. This is why a quick review of the headings at the top of the report (including "preoperative diagnosis, postoperative diagnosis and operation performed") is insufficient. Additional procedures or diagnoses may be documented in the body of the operative report that should be coded, regardless of whether or not they're included in the report headings. Detailed information is especially crucial when assigning CPT codes because in many cases, there are more codes from which to choose for a given procedure. For example, laceration suturing is primarily assigned to only one code in ICD-9-CM: 86.59 (Closure of skin and subcutaneous tissue of other sites). The same service may be reflected by one of more than 40 different CPT codes in the 12001 13150 range, based upon the anatomical site, length of the repair and depth of repair. If the detailed information is not present in the medical record, the physician should be queried for clarification.
Another CPT issue that coders must be familiar with involves the concept of bundling and unbundling. There are many CPT codes that describe specific components of other procedures; these component codes are necessary because in some cases the component service may be the only procedure performed. However, when the entire comprehensive procedure is performed, it's important that only the comprehensive code is reported. If the component code is reported in addition to the comprehensive one, it's considered unbundling, is inappropriate and the facility may realize reimbursement that it's not entitled to receive. To help coders identify some of these component procedures, CPT has designated some as "separate procedures," which appears in their code description. When a code is so designated, it means that the service or procedure may be:
considered an integral component of another procedure/service
distinct from other procedure(s)/service(s) provided at that time
There may be instances in which it is appropriate to assign a code designated as a separate procedure with another CPT code. In this case, a CPT or HCPCS modifier may be required to ensure appropriate reimbursement is realized. Future CCS Prep! columns will cover the topic of modifiers. Until then, test your knowledge of basic CPT coding principles with the quiz below:
1. The "bullet" symbol is used in CPT to denote:
a. New code descriptions
b. Deleted code designations
c. New guidelines
d. Revised guidelines
2. Which of the following statements is false?
a. Add-on codes should never be reported alone.
b. Operative reports are a necessity when assigning CPT surgical codes.
c. The semicolon is used in CPT to separate bundled from unbundled codes.
d. Unlisted CPT codes should only be assigned if no other more specific CPT code is available.
3. Which of the following are not included in the four primary classes of CPT indexed entries?
a. Anatomic site
c. Procedure or service
d. Status Indicator
4. Unlisted procedure codes:
a. Are only assigned if there is no other available CPT code generating more reimbursement.
b. Should only be assigned if the physician indicates that the procedure is unusual.
c. Are assigned to reflect relatively unusual procedures or services.
d. May only be assigned as a secondary procedure code.
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.
Answers to CCS PREP!: 1. a: The bullet symbol is used in CPT to designate new code descriptions; 2. c: The semicolon is used in CPT as a space-saving device. All code terminology of a parent code that's in front of the semicolon is applied to all indented codes below it; 3. d: Status indicators are used in the APC reimbursement system, but are not found in the CPT manual; all other responses are classes of CPT indexed entries; 4. c: Unlisted codes are assigned in unusual situations or their assignment is unrelated to reimbursement or physician designation. They may be assigned as the primary or only procedure code on a case.