CPT: Surgery Coding Guidelines - AHIMA

1 CPT: Surgery Coding Guidelines Audio Seminar/Webinar February 8, 2007. Practical Tools for Seminar Learning Copyright 2007 American Health Information Management Association. All rights reserved. Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program.

2 CPT five digit codes, nomenclature, and other data are copyright 2006. American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA. assumes no liability for the data contained herein. As a provider of continuing education, the American Health Information Management Association ( AHIMA ) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: 1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation.

3 2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and 3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. AHIMA 2007 Audio Seminar Series i Faculty Susan Von Kirchoff, MEd, RHIA, CCS, CCS-P. Ms. Kirchoff has seen all sides of the healthcare environment from teacher, to coder, to COO and Assistant CEO, to Vice President of Operations for YPRO Corporation. Susan has conducted seminars nationally and presented at many AHIMA state conventions, including New York, Illinois, Louisiana, Missouri, Texas and Florida.

4 She has also been a guest speaker for HFMA in regards to compliance, Coding , documentation, audits and billing. Ms. Kirchoff is currently President-Elect for Arkansas HIMA. Linda S. Welch, RHIT, CCS. Ms. Welch is Senior Manager for YPRO Corporation; she has audited and provided education for over 20 years. Linda is knowledgeable in all aspects of outpatient Coding , including revenue and chargemaster codes in addition to HIM and Physician office Coding . Ms. Welch has been past-president for the Northern Indiana HIMA. AHIMA 2007 Audio Seminar Series ii Table of Contents Disclaimer .. i Faculty ..ii Objectives .. 1. CPT Surgery Guidelines History of 2. Rationale for CPT Surgery 2. Polling Question.

5 3. Guidance for CPT Surgery .. 3. Documentation 4. Integral Surgery Services .. 5. Integral Surgical Approach .. 5. Unbundling .. 6. Polling Question .. 7. Fragmented 7. Unbundling for Related Services .. 8. Breakout Unbundling .. 8. Downcode Unbundling .. 9. Unbundling 9. Polling Question ..10. Surgical Package Case Study ..11. Global Surgical Package ..12. Polling Question ..12. Billing during Global Surgical Modifiers Polling Question ..15. NCCI Edits ..16. Separate Procedure ..17. Add-on Codes ..17. Example ..18. Polling Question ..18. Multiple Approaches for Surgery ..19. Extensive Approach ..19. Sequential Sources of Information ..21. Appendix ..24. CE Certificate Instructions AHIMA 2007 Audio Seminar Series.

6 CPT: Surgery Coding Guidelines Notes/Comments/Questions Objectives Review CPT Surgery Guidelines Review CPT Surgical Package Surgical Follow Up Care Discuss Modifier Usage Documentation Requirements for CPT. Surgery Practice CPT Surgery Case Scenarios 1. CPT Surgery Guidelines The Guidelines for the use of CPT codes are found as introductory notes at the beginning of a section or subsection, or as cross-references following specific codes or series of codes. Although the information contained in these Guidelines is important when using the CPT. codes, changes to the Guidelines often are overlooked. 2. AHIMA 2007 Audio Seminar Series 1. CPT Codes Copyright 2006 by AMA. All Rights Reserved.

7 CPT: Surgery Coding Guidelines Notes/Comments/Questions History of CPT. CPT is current procedural terminology , and was developed by the American Medical Association in 1966. January 1, 2007 effective update for CPT. The most recent version of CPT, contains 8,611. codes and descriptors. 3. Rationale for CPT Surgery Guidance CPT codes define medical and surgical procedures performed on patients. Some procedure codes are very specific defining a single service ( CPT code 93000. (electrocardiogram) while other codes define procedures consisting of many services ( CPT code 58263 (vaginal hysterectomy with removal of tube(s) and ovary(s) and repair of enterocele). 4. AHIMA 2007 Audio Seminar Series 2.))

8 CPT Codes Copyright 2006 by AMA. All Rights Reserved . CPT: Surgery Coding Guidelines Notes/Comments/Questions Polling Question How frequently is the National Correct Coding Initiative updated? *1 Annually *2 Bi-Annual *3 Quarterly *4 Monthly 5. Guidance for CPT Surgery NCCI- National Correct Coding Initiative was developed by CMS to promote correct Coding methodologies Initially intended for Part B Claims National Correct Coding Policy Manual, Physician Version , Updated January, April, July and October each year. 6. AHIMA 2007 Audio Seminar Series 3. CPT Codes Copyright 2006 by AMA. All Rights Reserved . CPT: Surgery Coding Guidelines Notes/Comments/Questions Guidance for CPT Surgery cont.

9 Procedures should be reported with the HCPCS/CPT codes that most comprehensively describe the services performed. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. 7. Documentation Requirements CPT Surgery Operative report Technique and approach Open vs. closed, aspiration, percutaneous, etc Screening vs. diagnostic vs. therapeutic Location- Right, left, bilateral, distal, proximal,etc. 8. AHIMA 2007 Audio Seminar Series 4. CPT Codes Copyright 2006 by AMA. All Rights Reserved . CPT: Surgery Coding Guidelines Notes/Comments/Questions Integral Surgery Services Some services are integral to large numbers of procedures.

10 Cleansing, shaving and prepping of skin Draping and positioning of patient Insertion of intravenous access for medication administration Sedative administration by the physician performing a procedure Local, topical or regional anesthesia administered by the physician performing the procedure 9. Integral Surgical Approach Including identification of anatomical landmarks, incision, evaluation of the surgical field, simple debridement of traumatized tissue, lysis of simple adhesions, isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve,and muscles including stimulation for identification or monitoring surgical cultures 10. AHIMA 2007 Audio Seminar Series 5.