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 the documentation or medical necessity supports, and it’s considered fraud or abuse. Downcoding is the use of a lower-level procedure code than the documentation supports; even though it reduces reimbursement rather than inflating it, it’s still inaccurate coding and can raise the same compliance concerns.
In procedural coding, the coder must always choose the code that most accurately describes the services provided - neither higher nor lower than what the documentation supports.
Modifiers
Modifiers are two-character codes appended to a five-digit CPT code to supply additional information or describe circumstances that altered the procedure or service without changing its basic definition. CPT modifiers are numeric - for instance, modifier -50 adds the detail that a procedure was performed bilaterally, or on both sides of the body, and modifier -80 indicates an assistant surgeon, allowing that surgeon to submit charges for their time. HCPCS Level II also supplies alphanumeric modifiers that are reported alongside CPT codes, most commonly to show which side of the body a 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, one of the lettered appendices the CPT manual uses to organize changes to the original code set (for example, added, deleted, and revised codes) along with special code and modifier lists.
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.
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:
- Analyze and abstract the procedural statement documented in the health record.
- 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
- 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.
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
Abstracting is the skill that ties the rest of this chapter together - it’s how you turn a provider’s documentation into the code that belongs on the claim. The term abstract, used as a verb in this context, is the process of collecting pertinent medical information needed to assign the correct code. Abstracting ensures 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.