Procedural Coding Basics Flashcards
Common Procedural Terminology (CPT)
● CPT puts procedures into numerical codes.
● Contains 5 numbers and no letters.***
● Updates every January 1st
● Start at the Tabular Index (the back), then the Alphabetic Index (the front)
● Managed by the American Medical Association (AMA)***
● Used for tracking, insurance claims submission, and keeping confidentiality safe.
CPT Codes can be found: FEE SLIP
● In the Encounter Form
● Also known as the Fee Slip.
● It’s a form/document that allows the provider to check off what he/she has done
so they can get paid for their service.
This form then gets sent off to get billed.
● Pathology Reports and Radiology Reports are also included
CPT Coding Index Only (Opposite of ICD-10)
● The Alphabetic Index is located in the back of the book.
● The Tabular Index is located in the front of the back.
E/M codes
● Codes that reflect what the provider does during the time spent with the patient.
● Charges go by the level of medical decision-making (MDM), the level of
knowledge that the physician may have, and if there new or an established
patient.
6 Sections of Tabular Index:
- Evaluation and Management (E/M)
- Anesthesia
- Surgery
- Radiology
- Pathology and Laboratory
- Medicine
Upcoding
- use of a higher-level procedure code than is supported in the*****
documentation of medical necessity. (the use of a higher charge to get more money, but
there is no proof. could be fraudulent)
Downcoding ( losing money)
- use of a lower-level procedure code than is justified. (losing money for
professional courtesy, fraudulent)
Fraud ( billing for a service that was never provided)
- an intentional deception to gain something for your benefit (billing for a service
that was never provided)
ABUSE ( taking advance at a higher level)
- knowingly taking advantage/overcharging at a higher level than was never
needed. (abusing the power to charge them)
CPT Modifiers ( 2 digit numerical code ended of a copy )
● A 2-digit numerical code that is added to the end of a CPT code gives it more
detail.
● Ex: 91234 -50
Conventions
● Symbols used to provide more information about specific codes.
● Explanation of codes located at the bottom of the Tabular Index
New Patient -
- Has not received any professional services from the provider (or another
of the practice’s providers with the same specialty and subspecialty) in the last 3 years
Established Patient -
Has received professional services from the provider (or another
of the practice’s providers with the same specialty and subspecialty) in the last 3 year
POS - Place of Service
● Healthcare facility where the provider delivers care to the patient.
○ Ex: provider’s office, hospital emergency department, skilled nursing
facility, patient’s home
CPT Coding - Surgical Section
Coded for the size of the wound in centimeters
CPT Coding - Pathology and Laboratory Section
- Panel - all tests listed under code selected are performed (blood draw procedure)
- Ex: lipid panel, thyroid panel.
DME - Durable Medical Equipment covered under B Medicare
- Equipment the patient uses at home
- Covered under Medicare part B***
- Includes crutches, wheelchairs, walkers, glucometers, bp cuffs etc.
ON RMA - Bundled Codes
A charge for one prize
Global period
Limited time for bundle codes
○ (ex: limited combo lasting until April 30th)
CPT Code Categories
- Category I
- Includes regular CPT Codes
- (ex: 99215 contains no letter, 5 digits) - Category II
- Also known as HCPCS Codes
- (ex: A8790 contains a letter, 5 code*
- Codes for Durable Medical Equipment (DME)
- Codes that help measure performance
- Codes for medical supplies - Category III
- Codes for Emerging Technology
- (ex: 8763T contains a letter, T, 5 digit)
CPT Modifier
Modifer 50 = bilateral
- Ex: 69210 - one side of the ear
- Ex: 69210-50 - both sides of the ear
Modifer 26
-professional component
- More than one doctor is involved.
Claim Form
● A document that goes to the insurance company to request payment
● Must be error-free, denial will occur if errors are seen
● No one wants claims denied because payment will not be processed
Group Number
● a code assigned to your employer’s insurance plan
Insurance Card
- Make sure to scan BOTH SIDES of the pt’s insurance card
- On the back of the card has numbers (insurance resources)
