Assigning medical codes, module 1

INFORMATION SHEET # 2

LO2: Assign codes for procedures and services

Objective:
Upon completion of this topic participants should be able to identify and assign
codes for different medical procedures and services.

Part 1: CURRENT PROCEDURAL TERMINOLOGY

The Current Procedural Terminology (CPT), published and developed by the American
Medical Association (AMA) in 1966, provides a system for standardizing the categorization
of the types of services to patients by physicians. CPT generally applies to the services
provided to patients who are not covered by the federal Medicare program. The CPT was
adopted for application to the Medicare reimbursement system in 1983. Since that time,
CPT has been widely used as the standard for outpatient and ambulatory care procedural
coding and reimbursement.

The information represented by CPT codes is also used for several purposes other than
reimbursement, including:

 Trending and planning outpatient and ambulatory services
 Benchmarking activities that compare and contrast the services provided by similar
 non–acute care programs
 Assessing and improving the quality of patient services

The CPT codebooks include several additional appendixes and an index of procedures.
CPT codebooks and codes are updated annually, with additions, revisions, and deletions
becoming effective on January 1 of each year. A new edition of the CPT codebook is
published annually, and the new edition should be purchased every year to ensure accurate
coding. Healthcare providers are expected to begin using the newest edition for encounters
on January 1,and there is no longer a grace period during which claims based on out-of-
date codes will be accepted.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 50

INFORMATION SHEET # 2

WHAT DOES A CPT CODE LOOK LIKE?

A CPT code is a five digit alphanumeric code with no decimal marks. Most CPT codes
consist of 5 numbers. Some are used frequently like 99213 or 99214 (for general check
ups). Some CPT codes may have a letter at the end of them, using 4 numbers and one
letter.

WHERE TO FIND CPT CODES

1. As we leave a doctor's appointment, check out of the hospital, or any other medical
facility, we are handed paperwork that, to the professionals, is a numeric summary of
the services they provided to us. The five character codes are usually CPT codes.

There are other codes on that paperwork, too. Some may be ICD codes, which may
have numbers or letters and usually have decimal points. If you are curious about
codes with decimal points, check out ICD Codes

If you use Medicare, those codes will be called HCPCS codes but for patient
purposes, the codes are the same.

2. When we receive a bill from the doctor, before or after it has been sent to our payer
(insurance or Medicare), it will have a list of services. Next to each service will be a
5-digit code. That's the CPT code.

3. When we receive an EOB, Explanation of Benefits, from our payer (insurance,
Medicare or others), then it will show how much of each service was paid for on our
behalf. Like the doctor's bill, each service will be aligned with its CPT code.

WHERE PROVIDERS ARE USING CPT CODES

1. CPT codes directly affect a provider's income. As such, they are very particular
about how coding is done, and spend huge sums of money each year in the
management of billing and coding. Medical coding is its own career, and can be very
lucrative for the right person.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 51

INFORMATION SHEET # 2

2. After we leave the doctor's office, the billing and coding people submit to our payers
a list of the services they provided to us. This may be done by postal mail or fax, but
more and more, doctors and facilities are using electronic means to store and
transfer this information.

HOW TO MATCH CPT CODES TO THE SERVICES THEY REPRESENT

If you have paperwork that has a CPT code on it, and you want to figure out what that code
represents, you can do so in a number of ways:

1. Do a CPT code search on the American Medical Association website for free. This is
a new capability and allows patients to search for a CPT code, or use a keyword to
see what the associated CPT code might be.

2. Contact your doctor's office and ask them to help you match CPT codes and
services.

3. Contact your payer's billing personnel and ask them to help you.

PART 2: CPT CATEGORIES

CPT category I codes

The CPT codebook includes a general introduction followed by six main sections that
together make up the list of Category I CPT codes:

Codes for Evaluation and Management: 99201-99499

 (99201 - 99215) Office/Outpatient Services
 (99217 - 99220) Hospital Observation Services
 (99221 - 99239) Hospital inpatient services
 (99241 - 99255) Consultations
 (99281 - 99288) Emergency department services
 (99291 - 99292) Critical Care Services
 (99304 - 99318) Nursing facility services

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 52

INFORMATION SHEET # 2

 (99324 - 99337) Domiciliary, rest home (boarding home) or custodial services
 (99339 - 99340) Domiciliary, rest home (assisted living facility), or home care
plan oversight services
 (99341 - 99350) Home services
 (99354 - 99360) Prolonged services
 (99363 - 99368) Case management services
 (99374 - 99380) Care plan oversight services
 (99381 - 99429) Preventive medicine services

 (99441 - 99444) Non-face-to-face physician services
 (99450 - 99456) Special evaluation and management services
 (99460 - 99465) Newborn care services
 (99466 - 99480) Inpatient neonatal intensive, and pediatric/neonatal critical care
services

Codes for Anaesthesia: 00100-01999; 99100-99150

 (00100 - 00222) head
 (00300 - 00352) neck
 (00400 - 00474) thorax
 (00500 - 00580) intrathoracic
 (00600 - 00670) Vertebral column/spine & spinal cord
 (00700 - 00797) upper abdomen
 (00800 - 00882) lower abdomen
 (00902 - 00952) perineum
 (01112 - 01190) pelvis (except hip)
 (01200 - 01274) upper leg (except knee)
 (01320 - 01444) knee & popliteal area
 (01462 - 01522) lower leg (below knee)
 (01610 - 01682) shoulder & axilla
 (01710 - 01782) upper arm & elbow
 (01810 - 01860) forearm, wrist & hand
 (01916 - 01936) radiological procedures
 (01951 - 01953) burn excisions or debridement
 (01958 - 01969) obstetric
 (01990 - 01999) other procedures

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 53

INFORMATION SHEET # 2

Codes for Surgery: 10021-69990
 (10021 - 10022) general
 (10040 - 19499) integumentary system
 (20000 - 29999) musculoskeletal system
 (30000 - 32999) respiratory system
 (33010 - 37799) cardiovascular system
 (38100 - 38999) hemic & lymphatic systems
 (39000 - 39599) mediastinum & diaphragm
 (40490 - 49999) digestive system
 (50010 - 53899) urinary system
 (54000 - 55899) male genital system
 (55920 - 55980) reproductive system & intersex
 (56405 - 58999) female genital system
 (59000 - 59899) maternity care & delivery
 (60000 - 60699) endocrine system
 (61000 - 64999) nervous system
 (65091 - 68899) eye & ocular adnexa
 (69000 - 69979) auditory system

Codes for Radiology: 70010-79999
 (70010 - 76499) diagnostic imaging
 (76506 - 76999) diagnostic ultrasound
 (77001 - 77032) radiologic guidance
 (77051 - 77059) breast mammography
 (77071 - 77084) bone/joint studies
 (77261 - 77799) radiation oncology
 0(78000 - 79999) nuclear medicine

Codes for Pathology & Laboratory: 80047-89398

 (80047 - 80076) organ or disease-oriented panels
 (80100 - 80103) drug testing
 (80150 - 80299) therapeutic drug assays
 (80400 - 80440) evocative/suppression testing
 (80500 - 80502) consultations (clinical pathology)
 (81000 - 81099) urinalysis
 (82000 - 84999) chemistry
 (85002 - 85999) hematology & coagulation
 (86000 - 86849) immunology
 (86850 - 86999) transfusion medicine
microbiology
 (87001 - 87999)

 (88000 - 88099) anatomic pathology (postmortem)

 (88104 - 88199) cytopathology

 (88230 - 88299) cytogenetic studies

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 54

INFORMATION SHEET # 2

 (88300 - 88399) surgical pathology
 (88720 - 88741) in vivo (transcutaneous) lab procedures
 (89049 - 89240) other procedures
 (89250 - 89398) reproductive medicine procedures

Codes for Medicine: 90281-99199; 99500-99607

 (90281 - 90399) immune globulins, Serum (blood)|serum or recombinant prods
 (90465 - 90474) immunization administration for vaccines/toxoids
 (90476 - 90749) vaccines, toxoids
 (90801 - 90899) psychiatry
 (90901 - 90911) biofeedback
 (90935 - 90999) dialysis
 (91000 - 91299) gastroenterology

 (92002 - 92499) ophthalmology
 (92502 - 92700) special otorhinolaryngologic services
 (92950 - 93799) cardiovascular
 (93875 - 93990) noninvasive vascular diagnostic studies
 (94002 - 94799) pulmonary
 (95004 - 95199) allergy & clinical immunology
 (95250 - 95251) endocrinology
 (95803 - 96020) neurology & neuromuscular procedures
 (96101 - 96125) central nervous system assessments/tests (neuro-cognitive,
mental status, speech testing)
 (96150 - 96155) health & behavior assessment/intervention
 (96360 - 96549) hydration, therapeutic, prophylactic, diagnostic injections &
infusions, and chemotherapy & other highly complex drug or
 (96567 - 96571) highly complex biologic agent administration
 (96900 - 96999) photodynamic therapy
 (97001 - 97799) special dermatological procedures
 (97802 - 97804) physical medicine & rehabilitation
 (97810 - 97814) medical nutrition therapy
 (98925 - 98929) acupuncture
 (98940 - 98943) osteopathic manipulative treatment
 (98960 - 98962) chiropractic manipulative treatment
 (98966 - 98969) education & training for patient self-management
 (99000 - 99091) non-face-to-face nonphysician services
 (99100 - 99140) special services, procedures and reports
 (99143 - 99150) qualifying circumstances for anesthesia
 (99170 - 99199) moderate (conscious) sedation
 (99500 - 99602) other services & procedures
 (99605 - 99607) home health procedures/services
medication therapy management services

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 55

INFORMATION SHEET # 2
Sample: MRI CPT CODING GUIDE

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 56

INFORMATION SHEET # 2

Specific coding guidelines are provided for each of the main sections.

The Category I codes in each of the main sections are further broken down into
subsections and subcategories according to the type of service provided and the body
system or disorder involved. For example, code 76645—Ultrasound, breast(s) (unilateral or
bilateral), B scan and/or real time with image documentation—appears in the radiology
section under the subsection entitled Diagnostic Ultrasound and the subcategory Chest.
Similar procedures are grouped to form ranges of codes. For example, the range of codes
from 19140 through 19240 represents the various types of mastectomy in the subsection
covering the integumentary system in the surgery section. The codes in each of the six
main sections (or Category I) of the CPT codebook are composed of five digits and are
arranged in numerical order within each section.

CPT Supplementary Codes

CPT also provides three types of supplementary codes: Category II codes, Category III
codes, and modifiers. Each of these code sets is listed and explained in a separate section.
The Category II and III sections are placed after the medicine codes in the codebook. The
list of modifiers and the coding guidelines for modifiers are included in appendix A of CPT
2006.

CPT Category II Codes

Category II provides supplementary tracking codes that are designed for use in
performance assessment and quality improvement activities. CPT Category II codes are
composed of five characters: four numbers and an alphabetic fifth character, capital letter F.
Codes 1000F and 1001F, for example, describe a specific aspect of patient history,
specifically, assessments of patient tobacco use. The assignment of Category II CPT codes
is optional. Category II supplementary codes are updated twice each year, on January 1
and July 1.

CPT Category III Codes

CPT Category III includes temporary codes that represent emerging medical technologies,
services, and procedures that have not yet been approved for general by the FDA and so
are not otherwise covered by CPT codes. Level III codes give physicians and other
healthcare providers and researchers a system for documenting the use of unconventional
methods so that their efficacy and outcomes can be tracked. Like CPT Category II codes,
Category III codes are composed of five characters: four numbers and an alphabetic fifth
character, capital letter T.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 56

INFORMATION SHEET # 2

EXAMPLE: Code 0017T represents a procedure for destroying macular drusen by the
application of photocoagulation.

Updated Category III codes are released semiannually via the AMA’s CPT Web site. The
complete list of temporary codes is published annually in the CPT codebooks.

CPT Modifiers

A third set of supplementary codes known as modifiers can be reported along with many of
the Category I CPT codes. The two-character modifier codes are appended to Category I
five-digit CPT codes to report additional information about any unusual circumstances
under which a procedure was performed. The reporting of modifiers is meant to support the
medical necessity of procedures that might not otherwise qualify for reimbursement.

EXAMPLE: Suppose that a surgeon successfully performed a percutaneous transluminal
balloon angioplasty to remove a blockage from a patient’s renal artery, but later that day it
became evident that the artery had become occluded again. If the surgeon who performed
the original procedure were not available, another surgeon on call would repeat the
procedure to remove the blockage. Code 35471 would be reported by the first surgeon to
identify the original angioplasty, and the second surgeon would report 35471–77 to identify
the repeat angioplasty.

Most of the two-character modifiers for Category I codes are numerical. However, there
also are some alphanumeric modifiers to indicate the physical status of patients undergoing
anesthesia. These modifiers begin with a capital letter P, as follows:

P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes

Resources: http:// www.findacode.com/cpt/cpt-code-set.html

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 57

INFORMATION SHEET # 2

PART 3 EVALUATION AND MANAGEMENT GUIDELINES

Medicare and Commercial Insurance
 CMS 1995 and 1997 E/M guidelines -
 http://www.cms.hhs.gov/MLNProducts/downloads
 Use either set
 1997 approved by AMA

Medicaid
 Does not use ‘95 or ‘97 guidelines
 Uses AMA guidelines
 E/M Service Guidelines section in “Instructions for
 selecting a Level of E/M Service

Evaluation and Management Coding

1. Key components
 History

Definitions

 Chief complaint (CC) Reason for the visit

 History of present illness (HPI) Chronological review of condition/complaint

 Review of systems (ROS) Inventory of systems through questions

 Past, Family, Social, History (PFSH)

History

Problem Focused
 Chief Complaint
 Brief HPI
 No ROS
 No PFSH

Expanded Problem Focused
 Chief Complaint
 Brief HPI
 Problem pertinent ROS
 No PFSH

Detailed
 Chief Complaint
 Extended HPI
 Extended ROS
 Pertinent PFSH

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 58

INFORMATION SHEET # 2

Comprehensive
 Chief Complaint
 Extended HPI
 Complete ROS
 Complete PFSH

History of Present Illness (HPI)
 Location
 Quality
 Severity
 Duration
 Timing
 Context
 Modifying factors
 Associated signs and symptoms

History Example

Expanded Problem Focused
CC Vaginal discharge
HPI Patient is complaining of a white vaginal (location) discharge for the past 2
days (duration)
ROS Negative dysuria no fever
PFSH Patient has had 2 sexual partners in the past 60 days (social)

Detailed
CC Vaginal discharge
HPI New patient is complaining of a white vaginal (location) discharge for the past
2 days (duration). Heavier flow in the AM: No change with Monistat
ROS Patient denies itching (integumentary), burning with urination (genitourinary)
or fever (constitutional).
PFSH Patient has had 2 sexual partners in the past 60 days (social)

 Physical examination

Problem Focused 1 body area/organ system or 1-5 elements

Expanded Problem Focused 2-4 body areas/ organ systems or 6 - 11 elements

Detailed 5-7 body areas/organ systems or 2 elements in

2+areas/systems

Comprehensive 8 organ systems or 2 elements in each of 9

areas/systems

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 59

INFORMATION SHEET # 2

Physical Exam Organ Systems
Body Areas Eyes
ENMT
Head (including face) Cardiovascular
Neck Respiratory
Chest Gastrointestinal
Abdomen Genitourinary
Genitalia, groin, buttocks Musculoskeletal
Back Skin
Each extremity Neurologic
Psychiatric
Lymphatic/Immunology

Physical Exam Example
Expanded Problem Focused
Vaginal Discharge Exam
Constitutional
BP, temp, pulse
Genitourinary
Examination of external genitalia
Examination of cervix
Detailed
Vaginal Discharge Exam
Constitutional
BP, temp, pulse
Genitourinary
Examination of external genitalia
Examination of cervix
Abdominal

 Medical Decision making

Straightforward
 Diagnoses/mgmt options
 Amt./complexity of data (0 -1)
 Risk (minimal)

Low Complexity
 2 Diagnoses/mgmt options
 Amt./complexity of data (2)
 Risk (low)

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 60

INFORMATION SHEET # 2

Moderate Complexity
 3 Diagnoses/mgmt options
 Amt./complexity of data (3)
 Risk (moderate)

High Complexity
 4 Diagnoses/mgmt options
 Amt./complexity of data (4)
 Risk (high)

Decision Making Example
Vaginal Discharge Exam

New problem, additional workup planned
Lab is ordered

Review/order tests in Moderate decision making
Undiagnosed new problem with uncertain prognosis
Prescription drug management -Prescription written

Decision Making level = Moderate
Extensive number Diagnosis/mgmt options
Minimal amount of data to be reviewed
Table of risk - Moderate

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 61

INFORMATION SHEET # 2

CPT Coding

CPT Code CPT Code NEW/EST History Physical Exam Medical
Description (# of Decision
Problem Body Making
New Problem 99201 New Focused
Focused, 10 99202 New Expanded Systems) Straight
min) 99203 New Forward
New - 99204 New Problem
Expanded 99211 Est Focused
(Problem
Focused, 20 99212 Est Expanded Straight
min) 99213 Est Forward
New - Detailed 99214 Est
(Problem 99215 Est Detailed Detailed Low
Focused, 30 Complexity
min.)
New - Comprehensive Comprehensive Moderated
Comprehensive Comp
(Problem
Focused, Minimal Minimal Minimal
45 min.)
Established - Problem Problem Straight
Brief (Problem Focused Focused Forward
Focused 5
min - No Expanded Expanded Straight
Provider Forward
Needed)
Established - Detailed Detailed Low
Brief (Problem Complexity
Focused 10
min.) Comprehensive Comprehensive Moderated
Established - Comp
Expanded
(Problem
Focused 15
min.)
Established -
Detailed
(Problem
Focused
25 min.)
Established -
Comprehensive.
(Problem
Focused 40
min.)

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 62

INFORMATION SHEET # 2

Vaginal Discharge Exam

History - Detailed
Physical Exam –Detailed

Decision Making - Moderate
Contributory Factors –45 minute visit of which 15 is counseling

Code: New Patient –99203

Establish Patient - 99213

2. Contributory factors
 Nature of the presenting problem
 Extent of counseling
 Coordination of care
 Time

E&M Time Component
 Only use when counseling and coordination of care represents greater than 50

percent of time with the patient
 For outpatient services it is face to face with clinician
 Does not have to be continuous time
 Phone time does not count

Documentation

 If not documented, it did not happen
 Must be legible
 Standardize form to meet documentation requirements for ROS and Physical Exam
 Write policy and procedures regarding standard forms and operating processes

Coder’s Challenge

 Appropriately assign procedure codes
 Follow all established guidelines
 Recognize third party reporting requirements
 Do it right the first time

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 63

INFORMATION SHEET # 2
Sample of CPT code on your bill

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 64

LEARNING EXERCISES 2.1

Choose or write the appropriate answers.

1. Which of the following statements is (are) true of CPT codes?
a. They are numeric.
b. They describe nonphysician services.
c. They are updated annually by CMS.
d. All of the above

2. CPT was developed and is maintained by:
a. CMS
b. AMA
c. The Cooperating Parties
d. WHO

3. There are six sections to CPT: evaluation and management, anesthesia, surgery,
radiology, laboratory/pathology, and __________.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 65

OPERATION SHEET #2

LO2 Assign codes for procedures and services

Operation Title: Assigning codes for procedures and services

Purpose: To be able to assign the correct CPT code.

Equipment, Tools and Materials:
1. Computer with internet connection
2. CPT Manual
3. Medical dictionaries
4. Medical forms
5. Mockup/Sample medical documentation

Procedure:

1. Turn on the computer.
2. Connect to the internet.
3. Open your browser.
4. Books for CPT are opened.
5. Manuals and other reference materials should be on

hand.
6. Download sample problems from the internet and

assign CPT codes.

Quality Criteria:

1. Procedures are properly coded and assigned for
timely submission.

2. Validity of the assigned codes must be double
checked.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 66

ASSIGNMENT SHEET #2

LO2. Assign codes for procedure and services

Objectives: To be able to identify and assign codes for different medical procedures and
services.

Students are asked to search the internet for samples of CPT coding system. Exercises
are given every now and then. Samples are shown below:

Suppose that a surgeon successfully performed a percutaneous transluminal balloon
angioplasty to remove a blockage from a patient’s renal artery, but later that day it became
evident that the artery had become occluded again. If the surgeon who performed the
original procedure were not available, another surgeon on call would repeat the procedure
to remove the blockage.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 67

SELF-CHECK #2

LO2. Assign codes for procedure and services

Directions:

A. Code the following using the CPT coding dynamics: E/M codes

1. Initial hospital care C, C, MC ________
2. Telephone conference service 11-20 minutes ________
3. ER department services D, D, MC ________
4. Standby physician services 30 minutes ________
5. Establish patient EPF, EPF, LC ________

B. Using the CPT manual, fill in the blanks with the correct words:

1. For code 99203, the history level is ________, the examination is ________, and the
MDM of ________ complexity.

2. For code 99204, the history level is ________, the examination is ________, and the
MDM complexity is ________.

3. For code 99211, the history level is ________, the examination is ________, and the
MDM complexity is ________.

C. Code the following case for new patients:

A 38-year-old new patient presents for an initial office visit to discuss a surgical
vasectomy for sterilization. The history and examination are detailed and the MDM
is of low complexity.
CPT code: ________

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 68

ANSWER KEY #2

LO2. Assign codes for procedure and services

LEARNING EXERCISES 2.1

Choose or write the appropriate answers.
1. Which of the following statements is (are) true of CPT codes?
a. They are numeric.
b. They describe nonphysician services.
c. They are updated annually by CMS.
d. All of the above

2. CPT was developed and is maintained by:
a. CMS
b. AMA
c. The Cooperating Parties
d. WHO

3. There are six sections to CPT: evaluation and management, anesthesia, surgery,
radiology, laboratory/pathology, and ___Medicine___.

ASSIGNMENT SHEET

Students are asked to search the internet for samples of CPT coding system. Exercises
are given every now and then. Samples are shown below:

Suppose that a surgeon successfully performed a percutaneous transluminal balloon
angioplasty to remove a blockage from a patient’s renal artery, but later that day it became

evident that the artery had become occluded again. If the surgeon who performed the

original procedure were not available, another surgeon on call would repeat the procedure

to remove the blockage.

Answer: Code 35471 would be reported by the first surgeon to identify the original
angioplasty, and the second surgeon would report 35471–77 to identify the

repeat angioplasty.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 69

SELF-CHECK #2 ANSWERS

Directions:

A. Code the following using the CPT coding dynamics: E/M codes

1. Initial hospital care C, C, MC 99222
2. Telephone conference service 11-20 minutes 99442
3. ER department services D, D, MC 99284
4. Standby physician services 30 minutes 99360
5. Establish patient EPF, EPF, LC 99213

B. Using the CPT manual, fill in the blanks with the correct words:

1. For code 99203, the history level is detailed, the examination is detailed, and the
MDM of low complexity.

2. For code 99204, the history level is comprehensive, the examination is
comprehensive, and the MDM complexity is moderate.

3. For code 99211, the history level is minimal, the examination is minimal, and the
MDM complexity is minimal.

C. Code the following case for new patients:

A 38-year-old new patient presents for an initial office visit to discuss a surgical
vasectomy for sterilization. The history and examination are detailed and the MDM
is of low complexity.

CPT code: 992.03

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 70

INFORMATION SHEET # 3

LO3: Assign codes for supplies, equipment and other services

Objective:
Upon completion of this topic participants should be able to assign codes for
supplies, equipment and other services.

Part 1: HEALTHCARE COMMON PROCEDURE CODING
SYSTEM

In order for medical claims to process correctly, there is a standard of codes used to identify
services and procedures. This system of coding is called the Healthcare Common
Procedure Coding System known as HCPCS and pronounced "hicks picks".

HCPCS codes are regulated by HIPAA and requires all healthcare organizations to use the
standard codes for transactions involving healthcare information. It was designed to
represent the physician and nonphysician services provided to Social Security beneficiaries
under the federal Medicare program.

The purpose of HCPCS as implemented in 1985 was to fulfill the operational needs of the
Medicare reimbursement system. Originally, HCPCS codes applied only to the services
provided by physicians to Medicare patients. Since 1986, however, the federal government
has required that physicians use HCPCS codes to report services provided to Medicaid
patients as well. Moreover, with the passage of the Omnibus Reconciliation Act of 1986,
hospitals are also required to report HCPCS codes on reimbursement claims for ambulatory
surgery services as well as radiology and other diagnostic services provided to Medicare
and Medicaid patients.

HCPCS codes enable providers and suppliers to accurately communicate information about
the services they provide. Analysis of HCPCS data also helps Medicare carriers to establish
financial controls that prevent expense escalation. Finally, the information from coded
claims facilitates uniform application of Medicare and Medicaid coverage and
reimbursement policies.

HCPCS Codes are numbers assigned to every task and service a medical practitioner may
provide to a Medicare patient including medical, surgical and diagnostic services. Since
everyone uses the same codes to mean the same thing, they ensure uniformity. For
example, no matter what doctor a Medicare patient visits for an allergy injection (code
95115) that doctor will be paid by

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 71

INFORMATION SHEET # 3

Medicare the same amount another doctor in that same geographic region would be.

Some examples of HCPCS / CPT Codes:
 99214 may be used for a physical
 90658 indicates a flu shot
 12002 may be used to stitch up a one-inch cut on a patient's arm

HCPCS includes two separate levels of codes. Level I is based on the current edition of
CPT. Level II is made up of the National Codes that represent the medical supplies and
services not included in CPT.

HCPCS Level I
Consists of CPT codes. CPT or Current Procedural Terminology codes are made up of 5
digit numbers and managed by the American Medical Association (AMA). CPT codes are
used to identify medical services and procedures ordered by physicians or other licensed
professionals.

HCPCS Level II

are alpha numeric codes consisting of one alphabetical letter followed by four numbers and
are managed by The Centers for Medicare and Medicaid Services (CMS). These codes
identify non-physician services such as ambulance services, durable medical equipment
and pharmacy. Examples of HCPCS Level II codes include the following:

 A4550 Surgical trays
 E1625 Water softening system, for hemodialysis
 J0475 Injection, baclofen, 10 mg
 L3260 Ambulatory surgical boot, each

Both Level I (CPT) codes, HCPCS Level II codes are updated periodically due to new
codes being developed for new procedures and current codes being revised or discarded.
A list of current Level II codes can be requested from the U.S. Government Printing Office
or any local Medicare carrier. In addition, an electronic file containing the most current
version of the HCPCS Level II codes can be downloaded from the CMS Web site at
Utilities/Miscellaneous, www.cms.gov/providers/pufdownload/.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 72

INFORMATION SHEET # 3

Some HCPCS codes required the use of modifiers. They consist of two digit number, two
letters or alphanumeric characters. HCPCS code modifiers provide additional information
about the service or procedure performed.

Modifiers are used to identify the area of the body where a procedure was performed,
multiple procedures in the same session, or indicate a procedure was started but
discontinued.

Providers should be aware of the HCPCS code guidelines for each insurer especially when
billing Medicare and Medicaid claims. Medicare and Medicaid usually have more stringent
guidelines than other insurers.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 73

INFORMATION SHEET # 3

PART 2: UNDERSTANDING HCPCS CODES AND HOW TO LOOK FOR
THEM

Patients can find HCPCS/CPT Codes in a number of places. As you leave the doctor's
office, you are handed a review of your appointment which may have a long list of possible
services your doctor provided, with some of them circled. The associated numbers, usually
five digits, are the codes.

If your appointment requires follow up billing by your doctor for copays or co-insurance,
then the codes may be on those bills.

A wise patient and smart healthcare consumer will use these codes to review medical
billings from practitioners, testing centers, hospitals or other facilities. It's a good way to be
sure your insurance (and your co-pays and co-insurances) are paying only for those
services you received.

If you receive statements from either the doctor or your health insurance and the
HCPCS/CPT codes do not appear, then contact the party who sent them and request a
new statement that does include the codes.

From this HCPCS lookup, you'll find three things: a description of each HCPCS code, the
Relative Value Amount (RVU) and the Geographic Practice Cost (GPCI). When put
together, they become the Physician Fee Schedule.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 74

INFORMATION SHEET # 3

What is a Relative Value Amount (RVU)?

Each HCPCS code is given a value - an amount of money Medicare will pay a hospital or a
physician for that service as an average. Then, cities and other geographic areas are
assigned an RVU - relative value amount - that is a percentage, higher or lower, of the
average HCPCS payment.

Here's how that works: Depending on where you live in, the RVU will be higher or lower
than the average, based on the cost of doing business. So, for example, the cost of doing
business is higher than average in New York City. The average = 1. The RVU for New York
City might be 1.3. In Birmingham, Alabama, which has a much lower cost of doing
business, the RVU might be .75.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 75

INFORMATION SHEET # 3

What is a Geographic Practice Cost Index?

The GPCI is the amount paid for each HCPCS code once the average has been multiplied
by the RVU. It's not a percentage - it's the actual dollar amount. Looking at Code X from
above, the average coast (RVU = 1.0) might be $100. In New York City, where the RVU is
1.3, Code X is worth $130. In Birmingham, Alabama where the RVU is .75, Code X would
be worth $75.

When combined, the code payment amount, the RVU and the GPCI result in physician's
fees for every service or procedure they may provide to you, their patient. It's called the
Physician Fee Schedule.

Remember, the Physician Fee Schedule only tells you what Medicare pays for these
services. If you have private insurance, the amount paid to your doctor or hospital may be
more or less.

When you do a HCPCS lookup, you can learn four things:
1. You can use a HCPCS code to find out what service or procedure it represents.
2. You can use a service or procedure to look up the HCPCS codes that might apply.
3. You can find out how much Medicare pays a doctor and a facility in your area for that
service or procedure (the RVU).
4. You can find out the average amount paid across the US for that code.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 76

INFORMATION SHEET # 3

Steps on how to do your look-up for free:

Step 1: You'll begin on an overview page that describes the material you’re about to
Step 2: look up. Read through the information on the overview page, then click on
START SEARCH.
Step 3: On the next page, you'll find a title that says you are looking up CPT codes.
Step 4: These codes are mostly identical to HCPCS codes, although HCPCS includes
additional codes for devices, ambulance services and durable medical
equipment.

You'll find an End-Use License. In essence it tells you that you may look up
these codes only for your personal information and that you cannot sell them
to anyone else. There is additional legaleese which you should read through.
Click on ACCEPT or DON'T ACCEPT. If you click on DON'T ACCEPT, you
will not be allowed access to the code lookup.
The next page is your search page. First you'll choose the year or portion of a
year that you're looking up the codes for. Next you'll choose the kind of results
you want. If you aren't sure, and you're comparing your own billing paperwork
to pricing, then choose the GPCI for starters. If it turns out not to be what you
want, you can return to look up another value.

You'll also need to choose a specific "carrier" or "locality." These are difficult
to choose from because they are in a strange order. You may need to read
through each possibility because they aren't really alphabetical. For example,
I live in Central NY which isn't listed anywhere near New York. It's listed as
"Rest of New York."

Hit SUBMIT.

Step 5: Input the HCPCS code you are trying to identify on the next page. Then
choose ALL MODIFIERS since that will give you all the information about that
code.

Continue looking up the codes you need. Record the information you need
depending on what you will use them for.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 77

INFORMATION SHEET # 3

References

http:// library.ahima.org/xpedio/groups/public/.../ahima/bok1_009346.pdf
http://www.cicatelli.org/titlex/.../20081218The%20BasicsOfCPTCoding.pdf

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 78

INFORMATION SHEET # 3
Sample of a Hospital Bill wherein CPT and HCPCS are shown

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 79

OPERATION SHEET # 3

LO3 Assign codes for supplies, equipment and other services

Operation Title: Assigning codes for supplies, equipment and other services.

Purpose: To identify and assign codes for supplies, equipment and other
services provided to the patients by their respective
providers/physicians.

Equipment, Tools and Materials:
1. Computer with internet connection
2. HCPCS manual
3. Medical dictionaries
4. Medical forms
5. Mockup/Sample medical documentation

Procedure:

1. Turn on the computer.
2. Connect to the internet.
3. Open your browser.
4. Books for HCPCS are opened.
5. Manuals and other reference materials should be on

hand.
6. Download sample problems from the internet and assign

HCPCS codes.

Quality Criteria:

1. Procedures are properly coded and assigned for timely
submission.

2. Validity of the assigned codes must be double checked.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 80

ASSIGNMENT SHEET #3

LO3. Assign codes for supplies, equipment and other services
Objective: To identify and assign codes for supplies, equipment and other services
provided to the patients by their respective providers/physicians.
Students are asked to search the internet for samples of HCPCS.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 81

SELF-CHECK #3

LO3. Assign codes for supplies, equipment and other services

Directions: Label the following:

CODE THE FOLLOWING:

1. Excision of cyst of the thyroid gland
2. Total thyroid lobectomy – unilateral
3. Excision of recurrent thyroglossal duct cyst
4. Thymectomy, partial, transcervical approach
5. Incision and drainage, infected thyroglossal duct cyst
6. A mother brings her 4-year-old son to the doctor because she found a lump at the

front of his neck. After an ultrasound and a blood test, the doctor diagnoses a
thyroglossal duct cyst and recommends surgery. On the day of surgery, the surgeon
tells the mother that he will perform a Sistrunk operation. Code the diagnosis and
procedure codes on the day of surgery.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 82

ANSWER KEY #3

LO3. Assign codes for supplies, equipment and other services
ASSIGNMENT SHEET
Samples of HCPCS are accessed and browsed through the internet.
SELF-CHECK #3 ANSWERS
LO3 Assign codes for supplies, equipment and other services

CODE THE FOLLOWING:

1. 60200
2. 60220
3. 60281
4. 60520
5. 60000
6. 759.2, 60200

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 83

JOB SHEET

Assigning Medical Codes

Objective:

Upon completion of the job/tasks participants should be able to assign codes for
medical diagnoses, procedures, services, supplies, equipment, and other services.

Materials, Tools and Equipment:

1. ICD-9-CM manual
2. CPT manual
3. HCPCS manual
4. Medical dictionaries
5. Medical forms
6. Mockup/Sample medical documentation
7. Computer with internet connection

Procedure:

1. Identify all the main terms included in the diagnostic statement.
2. Locate each term to be coded in the corresponding manuals (ICD-9-CM, CPT,

and HCPCS).
3. Read all information to get the code that corresponds to the patient’s disease,

condition, procedures, supplies, equipment and other services.
4. Continue coding the diagnostic statement until all the components are fully

identified.
5. Complete the necessary forms needed for medical billing.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 84

PERFORMANCE TEST

Learner's Name Date
Competency: Assign Medical Claims
Test Attempt
1st 2nd 3rd

Directions: OVERALL EVALUATION

CALL INSTRUCTOR, ask Level PERFORMANCE LEVELS
instructor to assess your Achiev
performance in the following 4 - Can perform this skill without supervision and
critical task and performance ed with initiative and adaptability to problem
criteria below situations.
3 - Can perform this skill satisfactorily without
You will be rated based on the assistance or supervision.
overall evaluation on the right 2 - Can perform this skill satisfactorily but requires
side. some assistance and/or supervision.
1 - Can perform parts of this skill satisfactorily, but
requires considerable assistance and/or
supervision.

Instructor will initial level achieved.

PERFORMANCE STANDARDS Yes No N/A
For acceptable achievement, all items should receive a "Yes" or
"N/A" response.

1. Determines Findings/Condition/Diagnoses based on the given
medical report

2. Identifies principal and secondary/additional diagnoses to be
coded based on the given medical report

3. Finds and assigns appropriate diagnoses codes in line with basic
ICD coding steps and guidelines

4. Clarifies unclear/questionable diagnoses with healthcare
providers in line with enterprise procedures

5. Determines procedures and services based on the given
medical report

6. Finds and assigns appropriate procedures and services codes in
line with basic coding steps and guidelines

7. Clarifies unclear/questionable procedures and/or services with
healthcare providers in line with enterprise procedures

8. Determines supplies, equipment and/or other services based on
the given medical report and/or any given supply documentation

9. Finds and assigns appropriate codes for supplies, equipment and
other services in line with basic coding steps and guidelines
10. Clarifies unclear/questionable supplies, equipment and/or other

services with healthcare providers or suppliers in line with
enterprise procedures

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 85