As promised, this segment of CCS Prep! provides a look at some common CPT coding conventions and a brief multiple-choice exam to test your skills in CPT, HCPCS and modifier coding. First, the conventions.
Common CPT Coding Conventions
A) Code Hierarchy. The hierarchy of procedures concept occurs when subsequent code entries--the part of a code description that follows the semicolon--are arranged in order according to resources consumed.
An example is the patient who has an incarcerated, recurrent inguinal hernia repair. Rather than use two separate codes (49520, 49521), only the incarcerated hernia code (49521) would be used because it is the higher number within the 49520-49521 range. Remember codes and descriptions listed after the semicolon includes the information before the semicolon.
A semicolon is used frequently in CPT narratives to save space. An indented code always includes the common portion of the preceding main code description as it appears up to and including the semicolon (;).
B) Separate Procedure. This is a procedure that is an integral part of a larger procedure and does not need a separate code in most cases. These codes may be reported if performed independently of, and not immediately related to, other services. In these instances, the use of modifier-59 may be necessary for hospital facility coding. "Separate Procedure" in the CPT Surgery Guidelines, should be interpreted as follows: If a surgical procedure has the words "separate procedure" listed next to it, and the physician performs a related procedure through the same incision, you should not bill for the procedure listed as a "separate procedure." Instead you would list the other procedure(s).
C) Unlisted Procedure or Service. Because there may be services or procedures physicians perform that are not found in CPT, a number of specific codes are provided for reporting unlisted procedures. Each unlisted procedure code relates to a specific section of the book. A complete list of these unlisted procedure codes is presented in the "Surgery Guidelines" section. These codes should not be used when a more descriptive code is available. Some payers may require a copy of the op report to describe the exact procedure when an unlisted code is assigned. Significant items to be included in the report are:
- adequate definition or description of the nature
- need for the procedure
- time, effort and equipment used
In most cases, a copy of the operative report must be submitted to the payer.
D) Global Surgical Package. The surgical package includes:
- The operation or procedure performed.
- Topical and local anesthetic used, in-cluding metacarpal and digital anesthetic.
- Surgical approach, wound culture and irrigation, placement of drains, catheters.
- Routine follow-up care, including suture removal, without complications.
In the surgical package concept, charges for most surgical procedures include the surgery itself and the normal uncomplicated follow-up. Not all surgical procedures have well-defined postoperative management. For example, consider minor procedures related to removal of foreign bodies lodged in subcutaneous tissues, or the excision of small cysts. In many patients, these minor procedures will require no follow-up. But in some patients, especially the elderly or those with existing systemic problems, even a minor procedure may require hospitalization or follow-up visits.
To deal with the unpredictable nature of the follow-up for these minor procedures, CPT lists stars (*) next to those procedures for which the follow-up is usually non-existent or varies with the patients' other underlying conditions. These guidelines are for physician office billing. When hospitals are billing for use of their facilities, the presence of a starred procedure has no affect on the code assignment.
Now for the quiz. See if you can answer in one or two minutes per question. We will not assign anesthesia codes. Try answering the non-coding assignment questions from memory. Accuracy and speed are important ingredients for a successful examination.
1. Reporting codes 71100 (radiologic exam, ribs, unilateral; two views) and 71010 (radiologic exam, chest; single view, fontal) is an example of what?
a.) Component Billing
c.) Separate Procedure
d.) Distinct Procedural Service
2. A patient presents for arthroscopic decompression of the subacromial space with arthroscopic excision of a distal clavicle. For physician office billing, this is coded as:
c.) 29826, 29909-51
3. The codes in question number one refer to what edit in the National Correct Coding Initiative manual?
a.) Mutually exclusive codes
b.) Comprehensive codes
c.) Excluded services
4. A Medicare patient has a history of rectal carcinoma previously removed. The patient has been brought in for outpatient surgery: colorectal cancer screening colonoscopy. Assign code:
c.) 45378, G0105-59
5. Excision of 5.5-cm inclusion cyst of left forearm, closure of deep subcutaneous tissue just into the superficial fascia with 3-0 Vicryl; skin closed with 4-0 Maxon. Steri-strips were applied.
c.) 11406, 12032
6. Name the agent that is injected directly into spasming muscles, which weakens the muscle by "disconnecting" the nerve from the muscle, but not destroying the nerve or muscle:
a.) Tiject-20 or Trimethobezamide HCI J3305
b.) Lunelle J3490
c.) Botulinum toxin or Botox J0585
7. Supervision and interpretation (professional component) for X-ray of right wrist, A/P and lateral views provided by the physician.
8. A muscle biopsy of the arm is performed on the patient in the physician's office. The specimen is sent to a pathologist for review and interpretation with microscopic examination. Which code(s) would the pathologist report?
b.) 80500, 88305
9. For removal of more than one lesion in an area of skin, you add up the total centimeters for the lesions, and assign one code from the appropriate section.
10. Patient is admitted for laparoscopic orchiopexy for intra-abdominal testis. Anesthesia is administered and the surgeon begins the abdominal incision to place the scope. At that time, the patient experiences significant tachycardia. The surgeon decides to discontinue the procedure.
b.) 54692-52, 00928
c.) No code necessary as procedure was terminated
11. Which HCPCS level II modifier is used to indicate right foot, second digit?
a.) ? T2
b.) ? T6
c.) ? RT
12. What does status indicator T of the Ambulatory Payment Classification system imply?
a.) Significant Non-discounted procedure when multiple procedures
b.) Significant Discounted procedure when multiple procedures
c.) Significant Non-covered procedure when multiple procedures
13. Pena procedure, urethroplasty, vaginoplasty and formation of a double barrel colostomy. Proximal colon used for graft.
a.) 46746, 44320
b.) 44320, 57292, 53450
14. Which modifier is needed for the HOPPS on an emergency room case when reporting both a CPT surgery code and evaluation and management code in most cases?
15. Surgeon A performs a surgical procedure early in the morning. Later that day, the patient experiences complications, and Surgeon B repeats the entire procedure. What level I modifier would Surgeon B append to the surgical CPT code?
a.) ? 77
b.) ? 22
c.) ? 51
16. HCPCS Level II "E" codes represent:
a.) durable medical equipment
b.) temporary procedure and services codes prior to inclusion in CPT
c.) temporary medical and surgical supplies
17. Surgical procedures identified as "unilateral or bilateral" e.g., 52290, must not be used with level I modifier ? 50?
18. For the inpatient DRG payment system, updates to DRGs occur once per year, every October. How often do updates to the APC payment system occur?
19. The patient has a Fasanella-Servat repair of blepharoptosis of the left eye.
c.) 15823-LT, 67908-LT-51
20. A female patient had a sling operation performed. Sutures were brought through the sling and tied by the physician. A cystoscopy was then performed to ascertain that the procedure was complete. The procedure is being billed on the hospital outpatient facility side.
a.) 57288, 52000-59
We hope this short quiz assists you in preparation for taking the CCS or CCS-P examinations. Remember that Part I of the CCS exam consists of 60 multiple-choice questions (1 hour), testing both inpatient and ambulatory care (ICD-9-CM). Part I of the CCS-P exam consist of 60 multiple-choice questions (90 minutes), testing physician based coding (ICD-9-CM diagnosis only, CPT and HCPCS Level II procedure coding across all specialties).
"CPT only © 2000 American Medical Association. All Rights Reserved."
Pat Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing contract coding and coding compliance review services for hospitals. The corporate office is headquartered in Pawley's Island, SC.
1. b.) Unbundling. Code 71100 includes code 71010; 2. c.) 29826 and 29909-51 are both assigned. CPT does not consider the excision of the distal clavicle an incidental component of code 29826. See CPT 2001 Symposium Q and A section, tab 14, page 4; 3. b.) Comprehensive code edit for 70000-79999; 4. b.) G0105. This is a temporary code for high-risk colonoscopy screenings for 2001; 5. c.) 11406, 12032 (no need for modifier. Codes in ranges 11400 to 11646 are to have modifiers. This is because of the multi-site nature of the codes. See HCFA Transmittal A-99-41, A-00-09); 6. c.) Botox; 7. c.) 73100-RT-26; 8. c.) 88305; 9. b.) False. Only laceration repairs by suture utilize the "add the length of repairs and assign one code" rule; 10. a.) 54692-74 (instructions for quiz state to not coded anesthesia. Modifier ?52 does not apply); 11. b.) ?T6; 12. b.) Discounted procedure.; 13. c.) 46746. To code them all out would be unbundling; 14. c.) ?25. This is used per HCFA Transmittal A-00-40 7/20/2000; 15. a.) ? 77; 16. a.) DME; 17. a.) true; 18. a.) quarterly; 19. a.)67908-LT; 20. b.) 57288. The cystoscopy (separate procecure) was only done to confirm completion so it is not reported. See CPT Assistant October 2000, page 24.