Coders should be aware of the basic CPT and HCPCS Level II code structure and coding guidelines before sitting for the CCS or CCS-P exam.
The Healthcare Common Procedure Coding System (HCPCS) was created in 1983 by the Center for Medicare and Medicaid Services (CMS) as a uniform method for health care providers and medical suppliers to report professional services, procedures and supplies. HCPCS codes were mandated by CMS for Part B Medicare services in 1983 and for Medicaid services in 1986. In 1987 HCPCS codes became mandatory for reporting Medicare hospital outpatient services. In addition to these federal programs, HCPCS codes may be required by other payers.
When HCPCS codes were initially implemented there were three levels:
Level I or CPT-4 (Current Procedural Terminology)
Level II or HCPCS/National Codes
Level III or Local Codes
CPT and HCPCS Level II codes are two of the HIPAA-approved National Codes Sets mandated for use by Oct. 16, 2002. For those providers and payers who have been granted an extension, they are mandated by Oct. 16, 2003. Level III Local codes will be eliminated by Dec. 31, 2003. All services previously reported using Level III codes will be reported using either CPT or HCPCS Level II codes. Many services previously reported using HCPCS Level III codes are now reported using codes from the S or C code sections of HCPCS Level II.
HCPCS codes are updated annually in January. However, CMS grants a three-month grace period for reporting these new codes through March 31st of each year. CMS will accept new and old HCPCS codes during this grace period. Beginning with claims submitted on April 1st, new codes must be submitted.
CPT was developed and was copyrighted by the American Medical Association (AMA) in 1966 and is updated annually in January. CPT is a listing of five-digit codes that identify services and procedures performed by physicians in any setting and by facilities for services and procedures performed in any outpatient setting. In addition to those provided in the CPT Book, guidelines for using CPT are included in AMA's CPT Assistant publication.
Alphabetic Index: The Alphabetic Index appears in the back of the CPT book. It is organized by main term, which appears in bold print. Subterms are indented under the main term to which they apply.
Main terms include the following:
Anatomical SitesTo code placement of tube into the pancreatic duct, look under pancreatic duct.
Procedure PerformedTo code fallopian tube anastamosis, look up anastamosis.
EponymSee Hartman Procedure.
Condition or Symptom that is being treatedFor repair of hernia, look under hernia repair.
SynonymsWhen you look up hysterolysis, you are instructed to see lysis, adhesions, uterus.
For each index entry, a specific code may be provided. In other cases, however, the coder may be referred to two or more codes or a range of codes. Regardless of the number of codes provided in the index, all codes must be verified in the Tabular Listing for accuracy.
Tabular Listing: The CPT Tabular Listing is organized into six major sections: Evaluation and Management Services; Anesthesiol-ogy; Surgery; Radiology; Pathology and Laboratory; and Medicine.
Each major section includes guidelines relevant to that major section. The procedures and services with their identifying codes are in numerical order within each section. There are many notes throughout the CPT Tabular Listing. Some relate to an entire section, some only to a specific subsection or subheading. It is very important that all notes be reviewed carefully before assigning a code. See the note for Repair (Closure), which begins prior to code 12001.
Indentations and Use of Semicolons: CPT is designed to provide stand-alone descriptions of procedures; however, many of the procedures refer back to a common portion listed in preceding entries. In these cases, the incomplete description is indented under the main entry. The main entry will be followed by a semicolon and is part of all indented entries that follow. See code 29874.
Symbols: CPT codes are updated annually. New codes are identified by a blackened circle, l, placed before the code number. See code 50543. Code revisions that alter the procedure description are indicated with a blackened triangle, s. See codes 11400-11446. Codes indicating procedures performed in addition to the primary procedure are called add-on codes and are identified with a plus sign, +, before the code number. Add-on codes are never reported alone but are listed secondary to the primary procedure. See code 22614.
Separate Procedure: The CPT book defines separate procedures as those "commonly carried out as an integral component of a total service or procedure." In most instances, if the term "separate procedure" is listed in the code description, it does not need a separate code. However, these codes may be reported if they are performed independently and are not immediately related to other services. For example, they may represent a different session, separate incision, different site or organ, or separate injury. In some instances, especially when a CCI edit is invoked, it may be necessary to append modifier -59 to the code with the "separate procedure" designation to indicate that the procedure is not considered a component of the more comprehensive procedure. If there is another modifier that better describes the circumstances, use that modifier instead.
Unlisted Procedure or Service: There are many procedures and services not identified with a specific CPT code. Therefore, a number of codes have been designated in CPT to report unlisted services. Unlisted procedure codes are reported when a code describing a service or procedure is not found. The guidelines for each section in CPT contain the unlisted procedure codes for that section. These codes usually end with "99." See code 17999. Many payers require a copy of the operative report or procedure note to describe the exact procedure when an unlisted code is reported.
CPT Category III Codes
Category III codes are temporary codes for emerging technology, services and procedures. Category III codes are five-digit codes that consist of four numbers followed by the letter "T." Category III codes may or may not eventually become permanent CPT (also called Category I) codes. If a Category III code is available, this code must be reported instead of the CPT (Category I) unlisted code. Category III codes are updated semi-annually.
HCPCS Level IINational Codes
Most often when people refer to HCPCS codes, they are referring to Level II codes. Level II codes are published and updated annually by CMS with input from the HCPCS National Panel, which includes representatives from the Blue Cross/Blue Shield Association, the Health Insurance Association of America and CMS. In addition to the annual update, CMS may add, delete or revise codes on a quarterly basis. Visit the CMS Web site at http://www.cms.hhs.gov/medicare/hcpcs for more information on HCPCS Level II codes and a list of changes made since Jan. 1, 2003.
HCPCS Level II codes are used for reporting and billing non-physician services, such as ambulance services, durable medical equipment and specific supplies. They are also used to report services not identified in CPT. HCPCS Level II codes are alpha-numeric and consist of one alphabetic character (a letter between A and V), followed by four digits.
HCPCS Level II codes are organized into 17 sections. Sample sections include:
Durable Medical Equipment: E codes E0100-E9999
Drugs Administered Other Than Oral Method: J codes J0000-J8999
A number of sections are for temporary codes and include:
Outpatient PPS C CodesC1000-C9999
CMS Procedures/Professional Service G codesG0000-G9999
CMS National Q CodesQ0000-Q9999
Non-Medicare National S CodesS0000-S9999
The D codes, which include dental procedure codes D0000-D9999, represent a separate category of codes from the Current Dental Terminology (CDT-4) code set, which is copyrighted and updated by the American Dental Association.
It is important to note here that for OPPS, if there are both a CPT and HCPCS Level II code for the service provided, CMS requires that the HCPCS Level II code be used. For example, use temporary HCPCS Level II code Q0081 instead of CPT code 90780 for infusion therapy for hospital services.
Both CPT and HCPCS Level II code sets contain modifiers. Modifiers in CPT are two numeric codes. Modifiers in HCPCS Level II are alphabetic or alpha-numeric. For more information on modifiers, please refer to the CCS Prep column "Assigning CPT and HCPCS Modifiers for Hospital-Based Out-patient Service" at: www.health-information.advanceweb.com/Editorial/Content/editorial.aspx?CC =15674.
Another CMS Web site that you may find helpful is dedicated to Medicare's National Correct Coding Initiative (CCI): www.cms.hhs.gov/medlearn/ncci.asp#CCI%20and%20OCE%20Edits
CMS developed the CCI to eliminate improper coding. CCI edits are pairs of CPT or HCPCS Level II codes that are not separately payable, except under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service.
Take some time now to review guidelines in the CPT and HCPCS Level II manuals. It may also be helpful to review the CMS Web sites listed above and to read the previous CCS Prep column on modifiers. After you have completed your review, check yourself with the quiz below.
1. CPT, HCPCS Level II and HCPCS Level III codes are all HIPAA-approved National Codes Sets.
2. In most cases, which modifier is needed for an emergency room case when reporting both a CPT surgery code and evaluation and management (E/M) code?
3. HCPCS Level II "A" codes represent:
a.)Transportation services, including ambulance
b.)Durable medical equipment
c.)Temporary medical and surgical supplies
4. CPT codes and HCPCS Level II codes are updated by CMS annually.
5. A flexible diagnostic colonoscopy is performed. During the procedure, a polyp is removed from one area and a lesion is removed from another. Both the polyp and the lesion are removed by snare technique. Which of the following would be the appropriate code selection?
a) 45378-59, 45385, 45385-59
b) 45385, 45385-59
d) 45378-59, 45385
6. The same CCI edits are used by CMS for editing both physician and hospital outpatient services.
7. On April 15, 2003, it was appropriate to bill services provided on March 15, 2003, using either 2002 or 2003 HCPCS codes because of the grace period.
8. The patient presents to the ED with multiple lacerations. Simple repairs of a 2 cm laceration of the leg and a 3 cm laceration of the back are performed. Another 3 cm laceration of the back was repaired but first required extensive cleaning to remove gravel before the single layer closure was performed. Which of the following would be the appropriate code selection for the laceration repairs?
b) 12001, 12002-59, 12002-59
c) 12002, 12032
d) 12001, 12002-59, 12032
9. Modifier -52 is used to report the elective cancellation of a procedure that does not require anesthesia because the physician is unavailable.
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 American Hospital Association.
CPT is a registered trademark of the American Medical Association.
Answers to CCS Prep!
1. b: False. HCPCS Level III codes are not included in the HIPAA-approved National Code Sets. They will be eliminated on Dec. 31, 2003.
2. c: Modifier -25 is appended to the ED E/M code. Modifier -25 identifies significant, separately identifiable E/M services on the same day of the procedure or other services. In most instances, patients that come to the ED do not present to have a procedure performed. The patient first needs to be evaluated by a physician.
3. a: HCPCS Level II A codes are used to report transportation services, including ambulance.
4. b: False. HCPCS Level II codes are updated by CMS. CPT codes are not. CPT codes are updated by AMA.
5. c: Only code 45385 is reported. The diagnostic colonoscopy is not coded separately. Notice the separate procedure designation. The diagnostic colonoscopy is included in the code for any definitive procedure performed. 45385 is not reported twice because the description of the code indicates "with removal of tumor(s), polyp(s), or other lesion(s) by snare technique." Therefore, all tumors, polyps or lesions removed using this technique are reported only once.
6. b: False. The CCI edits used by CMS to edit physician and hospital outpatient services are not the same. CMS uses the most current version of CCI edits to edit physician services. The CCI edits used by CMS to edit hospital outpatient services are included in the Outpatient Code Editor (OCE) and is one release behind. Also, the CCI edits included in the OCE do not include the entire CCI table.
7. b: False. On April 15, 2003, it is not appropriate to bill services provided on March 15, 2003, using either 2002 or 2003 HCPCS codes. The three-month grace period is intended to allow providers time to implement the new codes. After April 1st, all claims for services after January 1st must include the new codes.
8. c: Codes 12002 and 12032 are assigned. The length of the leg and back wounds are added together because they are both simple repairs from anatomical sites that are grouped together. Code 12002 is assigned. Even though the second 3 cm laceration of the back was a single layer closure, extensive cleansing and removal of gravel were required before the wound could be sutured. Code 12032 is assigned. Please refer to the note in the beginning of the Integumentary/Repair section for instructions.
9. b: False. A code for the intended procedure with modifier -52 is not assigned if a procedure is electively cancelled because the physician is unavailable. Other services provided to the patient may be billed.