CPT coding basics and documentation

At the beginning of each section and some subsections are coding guidelines. These guidelines add definitions and descriptions needed to interpret and report the procedures and services in that section or subsection. Coding guidelines enhance the coder’s understanding of when and under what circumstances specific codes may be used. It is important to thoroughly read and apply the coding guidelines provided. Because coding guidelines are updated every year in October and are effective every January, it is also important to reread the guidelines after every new edition is released. Selecting a code without reading the guidelines usually leads to selection of the wrong code. Not only will this result in possibly delayed or denied reimbursement, but also, continued inappropriate code selection can be considered fraud or abuse and can result in serious civil or criminal penalties.

Terms related to inaccurate coding are upcoding and downcoding. Upcoding is the use of a higher-level procedure code than is supported in the documentation or medical necessity. A documentation example would be using Evaluation and Management (E/M) code 99213 (medically appropriate history and/or examination and low level of medical decision making) when the documentation supports 99212 (medically appropriate history and/or examination and straightforward level of medical decision making). As mentioned in the diagnostic coding chapter, diagnosis and procedure codes are linked on the claim. For example, a patient undergoes a rhinoplasty for cosmetic reasons, but the diagnosis code for a deviated septum is submitted. A deviated septum would be considered medically necessary and could be paid by the insurance company. It is likely that the insurance company would request the records for this procedure and see in the documentation that the patient requested a cosmetic rhinoplasty. These examples would be considered fraud.

Downcoding is the use of a lower-level procedure code than is justified. This also can be damaging to the healthcare facility because it would result in lower reimbursement.

In procedural coding, the coder must always choose the code that most accurately describes the services provided.

Modifiers

Category I code modifiers are two-digit, numeric codes that report or indicate specific criteria, a specific condition, or a special circumstance. Category II code modifiers are alphanumeric. Category I or Category II modifiers are used with CPT codes to indicate that a service or procedure performed was altered by specific circumstances. Modifiers are included with the five-digit CPT code to supply additional information or to describe extenuating circumstances that affected the procedure or service. For instance, modifier –50 adds the detail that a procedure was performed bilaterally, or on both sides of the body. When assistant surgeons are needed for surgical procedures, modifier –80 should be used. This allows assistant surgeons to submit charges for their time. Modifiers can also show which side of the body a medical procedure was performed on. For example, the code 19100–RT indicates that the right breast was biopsied. A list of modifiers can be found in the CPT coding manual in Appendix A.

CPT conventions

Conventions, or special symbols, are used to provide additional information about specific codes. Let’s look at a skin graft procedure for a wound that is 50 sq cm:

• Code 15271, Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
• Code +15272, each additional 25 sq cm wound surface area, or part thereof

To accurately code for this skin graft, two codes would be used: 15271 and 15272.

In the Tabular List in most CPT manuals, the legend explaining the meanings of the convention symbols is found at the bottom of each page.

Appendices

The CPT coding manual uses appendices to organize changes to the original code set. There are 18 appendices in 2022.

Steps for efficient CPT procedural coding

The CPT coding process, which includes use of the Alphabetic Index and the Tabular List, applies to all sections of the CPT manual, except for the E/M and Anesthesia sections.

To start the procedural coding process, you must first determine the procedures or services that were provided. This is accomplished with two basic steps:

1. Analyze and abstract the procedural statement documented in the health record.
2. Compare it with the encounter form, operative report, or other documentation to ensure that all services and procedures have been recorded.

Documentation for CPT coding

Medical records used for procedural coding can include any or all of the following:

• Encounter form (Figure 17.3)
• History and physical report (H&P)
• Progress notes
• Discharge summary
• Operative report
• Pathology report
• Anesthesia record
• Radiology report

When you compare the documentation to the codes, make sure all the elements of the description match substantially, with nothing added or missing. For example, review CPT codes 21315 and 21320. Both codes describe the closed treatment of a nasal bone fracture. However, 21315 indicates that there is no stabilization, and 21320 indicates that there is stabilization. The coder reviews the procedures and then assigns the CPT code with the description that most closely resembles the documentation.

Some providers have CPT and ICD-10-CM codes printed on their encounter forms; however, these codes should be treated only as a reference. Medical coders must also review the health record carefully, abstracting all the procedures and services rendered during an encounter. For example, a provider may have circled the procedure for a preventive health visit for a 4-year-old on the encounter form but forget to record the injections provided during the encounter. When the medical assistant reviews the patient’s electronic health record (EHR), the provider’s notes state routine injections were administered. If the medical assistant had not reviewed the EHR, the clinic would have lost reimbursement because the claim would not have included all the CPT codes for the visit. Encounter forms should be updated annually to ensure that code additions, changes, and revisions are current.

Abstracting

The term abstract, used as a verb in this context, is the process of collecting pertinent medical information needed to assign the correct code. Abstractingensures that all medical procedures and services are identified, and none are omitted. The abstracted data is then broken down into main terms and modifying terms. A main term is usually the primary procedure or service performed, and a modifying term further defines or adds information to the main term. Next, the main and modifying terms are used to find the code or code ranges in the Alphabetic Index. Last, the code selected is confirmed by reviewing the guidelines, notes, and conventions in the Tabular List to verify that the most accurate code has been chosen.