The certified coding specialist (CCS) and CCS-P (physician-based) certification exam includes a number of multiple choice questions and coding scenarios. In addition to being required to determine correct code assignment, you will be expected to know the structure of the different coding classification systems and how and when they are used. This column will focus on the structure and use of the categories within the CPT coding system.
CPT was developed and copyrighted by the American Medical Association (AMA) in 1966 and an update is published 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. CPT is divided into three categories of codes.
Category I: Procedures that are consistent with contemporary medical practice and are widely performed.
Category II: Supplementary tracking codes that can be used for performance measures.
Category III: Temporary codes for emerging technology, services and procedures.
It is important to become familiar with each category and how the codes will be used. It is also important to know when codes from another system, such as HCPCS Level II, are required.
Category I Codes
Category I codes are the five-digit numeric codes included in the main body of CPT. Category I is the section that coders usually identify with when talking about CPT. These codes represent procedures that are consistent with contemporary medical practice and are widely performed. Codes assigned to this category have met certain criteria including:
Procedure or service approved by the Food and Drug Administration (FDA)
Procedure or service commonly performed by health care professionals nationwide
Procedure or service's clinical efficacy is proven and documented
Category I codes are used by physicians and by most outpatient providers when reporting a significant portion of their services and procedures. Category I codes are updated annually and are broken down into six sections.
1. Evaluation and Management
5. Pathology and Laboratory
Examples of Category I codes include:
99253 Initial inpatient consultation
11770 Excision of pilonidal cyst or sinus; simple
33512 Coronary artery bypass, vein only, four coronary venous grafts
62270 Spinal puncture, lumbar, diagnostic
76498 Unlisted diagnostic radiographic procedures
78205 Liver imaging (SPECT)
86900 Blood typing, ABO
93010 Electrocardiogram, routine ECG with at least 12 leads; tracing only without interpretation or report
Category II Codes
Category II codes are supplemental tracking codes that are intended to be used for performance measurement. In compliance with ongoing changes being made because of HIPAA regulations, these codes provide a method for reporting performance measures. The Category II codes are intended to facilitate the collection of information about the quality of care delivered by coding a number of services or test results that support performance measures. These performance measures have been agreed upon as contributing to good patient care.
The Category II Codes are alphanumeric and consist of four digits followed by the alpha character 'F.' The use of these codes is optional and are not a substitute for Category I codes.
CPT Category II codes will be arranged according to the following categories:
Composite Measures 0001F
Patient Management 0500F-0503F
Patient History 1000F-1002F
Physical Examination 2000F
Diagnostic/Screening Processes or Results 3000F
Therapeutic, Preventive or Other Interventions 4000F-4011F
Follow-up or Other Outcomes 5000F
Patient Safety 6000F
Only the composite measures category includes codes right now. Cur-rently there are 11 Category II codes. They are:
1. 0001F Blood pressure measured
2. 0002F Tobacco use, smoking, assessed
3. 0003F Tobacco use, non-smoking,
4. 0004F Tobacco use cessation intervention, counseling
5. 0005F Tobacco use cessation intervention, pharmacologic therapy
6. 0006F Statin therapy, prescribed
7. 0007F Beta-blocker therapy, prescribed
8. 0008F Ace inhibitor therapy, prescribed
9. 0009F Anginal symptoms and level of activity, assessed
10. 0010F Anginal symptoms and level of activity, assessed using a standardized instrument.
11. 0011F Oral anti-platelet therapy, prescribed (e.g., aspirin, clopidogrel/Plavix, or a combination of aspirin and dipyridamole/Aggrenox)
The use of the Category II codes is expected to decrease the time spent abstracting a record. They are also intended to decrease the time spent by physicians and other health professionals on chart review to verify that the measures were preformed. For example, if you are trying to track the use of statin therapy in your practice, reporting code 00067F, Statin therapy, prescribed, will allow you to do this through your coding or billing rather than through chart review.
These codes may typically describe services that are included in an evaluation and management (E/M) service. Therefore the Category II CPT codes will not have relative value units (RVUs). The services are embedded within the E/M code in which the aggregate service has already been valued. Category II codes are not recognized by the OCE in hospital outpatient billing of Medicare patients. They may be used for internal tracking and reporting, however it is important that these codes not be included on Medicare OPPS claims.
The tracking codes are reviewed by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel. The PMAG comprises performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement.
The Category II codes are released annually as part of the general CPT code set and are published twice a year, Jan.1 and July 1, on the AMA Web site. The most current listing of CPT II codes can be found on the AMA Web site at http://www.ama-assn.org/ama/pub/category/10616.html. The information on the Web site lists the revised, new or deleted codes, the performance measurement set to which the code belongs, and the release and implementation dates. It is important to note here that all 11 current Category II codes are being deleted effective Jan. 1, 2005 and will be replaced by 14 codes for tracking similar and additional performance measures.
Category III Codes
Category III codes represent temporary codes for new and emerging technologies. They have been created to allow for data collection and utilization tracking for new procedures or services. Category III codes are different from Category I CPT codes in that they identify services that may not be performed by many health care professionals across the country, do not have FDA approval, nor does the service/procedure have proven clinical efficacy. To be eligible for a Category III code, the procedure or service must be involved in ongoing or planned research. The rationale behind these codes is to help researchers track emerging technology and services to substantiate widespread usage and clinical efficacy. In the past, researchers have been hindered by the length and requirements of the current CPT approval process.
The Category III codes are five characters long, with four digits followed by the letter 'T' in the last field (e.g. 0002T). The codes are intended to be temporary and will be retired if the procedure or service is not accepted as a Category I code within five years. In some instances Category III codes may replace temporary local codes (HCPCS Level III) assigned by carriers and intermediaries to describe new procedures or services. If a Category III code is available it must be used instead of the unlisted Category I code. The use of the unlisted code does not offer the opportunity for collection of specific data.
Category III codes were initially released in July 2001 and are included as a separate chapter in CPT following the Category II codes. There are currently 55 Category III codes. The AMA releases new codes twice a year (January and July) on its Web site. The codes released in July are included in the next published edition of CPT. The most current listing of CPT III codes can be found on the AMA Web site at http://www.ama-assn.org/ama/pub/category/3885.html. The information on the Web site lists the revised, new or deleted codes. Fourteen new Category III codes will be implemented effective Jan. 1, 2005.
Early release of these codes is possible because payment for these services is based on the policies of payers and not on a yearly fee schedule. CMS began recognizing a number of the Category III codes as of Jan. 1, 2002, and has designated certain codes as covered.
Examples of Category III codes are as follows:
0005T Transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous; initial vessel
0007T Transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous, radiological supervision and interpretation, each vessel
0012T Arthroscopy knee, surgical, implantation of osteochondral graft(s) for treatment of articular surface defect, autografts
0058T Cryopreservation, reproductive tissue, ovarian
If there is a HCPCS Level II code that also describes the new technology or service identified by a Category III code, then the HCPCS Level II code must be assigned when reporting Medicare claims. For example, Category III code 0019T, Extracorporeal shock wave therapy; involving musculoskeletal system, should not be reported to Medicare. Medicare created two HCPCS Level II codes G0279 Extracorporeal shock wave therapy; involving elbow epicondylitis, and G0280, Extracorporeal shock wave therapy; involving other than elbow epicondylitis or plantar fascitis, that must be reported in place of Category III code 0019T.
CMS had previously granted providers a 90-day grace period for the use of discontinued CPT codes from Jan. 1 through March 31 for claims submitted to Medicare contractors by April 1 of the current year. This grace period gave providers time to become familiar with the new codes and learn about the discontinued codes. During this 90-day grace period, providers could use either the previous or the new HCPCS codes. HIPAA, however, requires the use of medical code sets that are valid at the time the service is provided. Because CPT is an approved HIPAA medical code set, effective Jan. 1, 2005, CMS will no longer allow a 90-day grace period for discontinued codes. The elimination of the grace period applies to the annual CPT-4 update and to any mid-year coding changes. Any codes discontinued mid-year will no longer have a 90-day grace period. All claims with discontinued CPT codes will be returned to the provider (RTP) for dates of service on or after Jan. 1, 2005.
Guidance on the use of CPT was provided in the previous CCS Prep Column titled "Review of the CPT and HCPCS Level II Code Sets." After reviewing this CCS Prep Column it may also be helpful to review the AMA Web sites listed above. After you have completed your review, check yourself with the quiz below.
1. On March 15, 2005, it will be appropriate to bill services provided on Jan. 15, 2005, using either 2004 or 2005 CPT Codes because of the grace period.
2. Codes for new technology may be reported using the following codes:
a) CPT Category I codes, CPT Category III codes and HCPCS Level II codes
b) CPT Category I codes and CPT Category III codes
c) CPT Category III codes
d) CPT Category III codes and HCPCS Level II codes
3. CPT Category II codes may be used for reporting quality indicators to Medicare for hospital OPPS claims.
4. The following agencies are responsible for maintaining CPT codes:
b) CMS and AMA
d) CMS, AMA, American Hospital Association (AHA) n
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, 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.
Answers to CCS PREP!: 1. b: False. Effective Jan. 1, 2005 the previous three-month grace period for reporting CPT codes will be eliminated. Effective Jan. 1, 2005, all claims must include codes that are valid at the time the service is provided; 2. d: Both CPT Category III codes and HCPCS Level II codes are available and may be used for reporting new and emerging technologies; 3. b: False. CPT Category II codes are not recognized by the OCE in hospital outpatient billing of Medicare patients. They may be used for internal tracking and reporting however it is important that these codes not be included on Medicare OPPS claims. Providers should check with other payers to determine if they will accept CPT Category III codes; 4. c: The AMA is responsible for updating and maintaining CPT codes.