Professional Documents
Culture Documents
2006 Edition
Copyright ©2006 by the American Health Information Management Association. All rights
reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise,
without the prior written permission of the publisher.
The Web sites listed in this book were current and valid as of the date of publication. However,
Web page addresses and the information on them may change or disappear at any time and for
any number of reasons. The user is encouraged to perform his or her own general Web searches
to locate any site addresses listed here that are no longer valid.
Portions of this volume were originally published in Clinical Coding Workout 2006, AHIMA
product number AC201506.
ISBN 1-58426-152-8
AHIMA Product Number AC200606
Claire Blondeau, Project Editor
Melanie Endicott, MBA/HCM, RHIA, CCS, Reviewer
Elizabeth Lund, Editorial Assistant
Melissa Ulbricht, Editorial/Production Coordinator
Ann Zeisset, RHIT, CCS, CCS-P, Technical Reviewer
Ken Zielske, Publications Director
www.ahima.org
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Chapter 3 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Chapter 4 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
iii
Gail I. Smith, MA, RHIA, CCS-P, is an associate professor and director of the health informa-
tion management program at the University of Cincinnati in Cincinnati, Ohio. She has been
an HIM professional and educator for more than thirty years. Prior to joining the faculty at the
University of Cincinnati, she was director of a health information technology associate degree
program and was health information manager in a multihospital healthcare system.
Ms. Smith also is a coding consultant and a frequent presenter at conferences through-
out the United States. An active member of the American Health Information Management
Association (AHIMA), she has served on the board of directors and several of AHIMA’s com-
mittees and task forces.
Ms. Smith received a bachelor of science degree in health information management from
The Ohio State University in Columbus and a master of arts degree in education from The
College of Mt. St. Joseph in Cincinnati.
This workbook provides basic training and practice in the application of procedural codes from
the Current Procedural Terminology (CPT) and the Healthcare Procedural Coding System
(HCPCS). CPT is published by the American Medical Association (AMA). Updated annually
on January 1, CPT is a proprietary terminology created and maintained by the AMA. Its pur-
pose is to provide a uniform language for describing and reporting the professional services
provided by physicians. HCPCS is maintained by the Centers for Medicare and Medicaid
Services (CMS). Its purpose is to provide a system for reporting the medical services provided
to Medicare beneficiaries. HCPCS is made up of two parts: Level I is composed entirely of
the current version of CPT; HCPCS Level II provides codes to represent medical services that
are not covered by the CPT system, for example, medical supplies and services performed by
healthcare professionals who are not physicians.
Like previous editions, the 2006 edition of Basic CPT/HCPCS Coding is intended for
students who have limited knowledge of, or experience in, CPT/HCPCS coding, and also as a
resource and review guide for professionals. The instructional materials in this workbook are
not specific to any particular practice setting, and they apply to both hospital-based and office-
based coding. The exercises provide hands-on experience in coding some of the more common
procedures and services provided by physicians and other healthcare professionals.
Many healthcare facilities and providers develop their own systematic methods for assign-
ing CPT codes to frequently performed diagnostic procedures. For this reason, this workbook
provides only minimal practice in assigning CPT/HCPCS codes for diagnostic procedures.
The CPT/HCPCS coding process requires coders to apply analytic skills in combination
with a practical knowledge of medical science. To become effective coders, students must be
able to apply their knowledge of medical terminology, anatomy and physiology, pathophysiol-
ogy, pharmacology, and medical–surgical techniques. This workbook assumes that students
will already have a basic understanding of these subject areas.
The primary objectives of this workbook include the following:
• To provide a basic introduction to the format of CPT codes as well as CPT coding
conventions
• To demonstrate different ways to locate CPT codes through the use of the codebook’s
index
• To identify ways to ensure accurate code assignment through the application of coding
guidelines from the AMA and CMS
• To deliniate the documentation necessary for code assignment
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viii
The Web sites listed in appendix A and elsewhere in this workbook were current and valid
as of November 1, 2005. However, Web addresses and the information on Web sites may
change or disappear at any time and for any number of reasons. Students and educators are
encouraged to perform their own Web searches to locate the current addresses of any sites that
can no longer be found under the addresses provided in this workbook.
AHIMA provides supplementary materials for educators who use this workbook in their
classes. Materials include lesson plans, keys to practice exercises in appendix C, PowerPoint
slides, and other educational resources. All answer keys are available to instructors in online
format from the individual book page in the AHIMA Bookstore (imis.ahima.org/orders), and
also are posted on the AHIMA Assembly on Education Community of Practice (AOE CoP)
Web site. Instructors who are AHIMA members can sign up for this private community by
clicking on the help icon within the CoP home page and requesting additional information on
becoming an AOE CoP member. An instructor who is not an AHIMA member or a member
who is not an instructor may contact the publisher at publications@ahima.org.
ix
xi
Several medical terminologies and classification systems are used to document and report
information related to healthcare services in the United States. The International Classifica-
tion of Diseases, Clinical Modification, currently in its ninth revision (ICD-9-CM), is used
to describe and report the illnesses, conditions, and injuries of patients who require medical
services. ICD-9-CM is made up of a series of numerical and alphanumerical codes and code
descriptions that represent very specific illnesses and injuries.
Similarly, the services provided by physicians and other healthcare professionals are
described and reported by using terminologies and classification systems. The International
Classification of Diseases, Clinical Modification, provides a system for coding medical pro-
cedures performed in the inpatient departments of hospitals, but two other systems apply to
the services provided by physicians and other medical providers in hospital-based outpatient
departments, physicians’ offices, and other ambulatory settings: the Current Procedural Ter-
minology and the Healthcare Common Procedure Coding System.
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 pub-
lished 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.
CPT Category I
The CPT codebook includes a general introduction followed by six main sections that together
make up the list of Category I CPT codes:
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 subsec-
tions 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 integumen-
tary 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.
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.
Updated Category III codes are released semiannually via the AMA’s CPT Web site. The com-
plete 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.
Most of the two-character modifiers for Category I codes are numerical. (Chapter 3 of this
workbook includes a list of the CPT modifiers in CPT 2006.) 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:
(Chapter 2 of this workbook provides additional guidelines for applying CPT codes, and chap-
ter 3 discusses modifiers in more detail.)
division of the U.S. Department of Health and Human Services that administers the Medicare
program and the federal portion of the Medicaid 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 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 ser-
vices not included in CPT.
HCPCS Level I
Copyrighted and published by the AMA, Level I of HCPCS consists of five-digit Category I
CPT codes. Level I HCPCS codes are used by physicians to report services such as hospital
visits, surgical procedures, radiological procedures, supervisory services, and other medical
services. Hospitals also use Level I codes to report hospital-based outpatient services, such as
laboratory and radiological procedures and ambulatory surgeries, to Medicare and other third-
party payers. Level I codes represent approximately 80 percent of the HCPCS codes submitted
for reimbursement each year.
HCPCS Level II
Known as the National Codes, HCPCS Level II codes were developed by CMS for use in
reporting medical services not covered in CPT. Level II codes are provided for injectable
drugs, ambulance services, prosthetic devices, and selected provider services.
Level II codes are made up of five characters: The first character is a capital Arabic letter,
and the following four characters are numbers. Examples of HCPCS Level II codes include
the following:
Like Level I (CPT) codes, HCPCS Level II codes are updated annually on January 1. A
list of current Level II codes can be requested from the U.S. Government Printing Office or
any local Medicare carrier. Several commercial publishing companies distribute the National
Codes in book form, which is more user-friendly than the government-issued lists owing to
the addition of enhancements such as indexes and cross-references. 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/. (HCPCS
Level II codes are discussed in more detail in chapter 10 of this workbook.)
To ensure complete and accurate coding, healthcare providers must update or replace
their ICD-9-CM codebooks as new codes are implemented and existing codes are amended or
deleted. In addition, encoders and other coding software must also be updated at least yearly.
Diagnostic Coding
The Central Office on ICD-9-CM maintains the official coding guidelines for diagnostic cod-
ing. The guidelines require ICD-9-CM code assignments to be as specific as possible and to be
supported by health record documentation. The guidelines also require the reporting of as many
codes as necessary to completely describe the patient’s condition. Guidelines also establish the
order in which multiple codes are to be reported. The ICD-9-CM codebook also provides detailed
advice on assigning codes correctly.
Every claim for outpatient services must contain at least one ICD-9-CM code, but care
must be taken to report every applicable code in the sequence specified in the official coding
guidelines. Medicare and most other third-party payers reject claims that report incomplete
ICD-9-CM codes.
A set of Official ICD-9-CM Coding Guidelines for Outpatient Services was developed
in 1990 and revised subsequently in 1995 and 2002. Coders must thoroughly understand and
carefully follow these guidelines. Official ICD-9-CM coding advice is also published by the
American Hospital Association (AHA) in its quarterly publication, Coding Clinic. The official
coding guidelines for ICD-9-CM are available from the Central Office on ICD-9-CM of the
American Hospital Association as well as from the CMS Web site.
The following examples illustrate correct and incorrect code assignments for a patient with
a diagnosis of type II diabetes.
Example:
250.00 Diabetes mellitus without mention Correct
of complication, Type II or unspecified
type, not stated as uncontrolled
250.0 Diabetes mellitus without mention Incorrect
of complication, Type II or unspecified
type, not stated as uncontrolled
250 Diabetes mellitus without mention Incorrect
of complication, Type II or unspecified
type, not stated as uncontrolled
(Basic ICD-9-CM Coding, by Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, pro-
vides a more detailed discussion of the basics of ICD-9-CM coding. The workbook also provides
numerous practice exercises. A new edition of the workbook with updated codes is released by
the American Health Information Management Association every summer.)
Medicare Regulations
The Social Security Act of 1965 and its subsequent amendments establish the federal regula-
tions that govern Medicare. Medicare regulations require the collection of several types of
coded information on reimbursement claims for services provided to Medicare beneficiaries:
Claims Submission
Reimbursement claims for medical services provided to beneficiaries of commercial and
government-sponsored health insurance programs may be submitted in electronic or paper
form. Electronic claims, however, must follow the standards developed by the Accredited Stan-
dards Committee (ASC) and mandated by the Health Insurance Portability and Accountability
Act (HIPAA). ASC Standard X12 applies exclusively to electronic claims.
The CMS-1500 form shown in figure 1.1 is the standard billing document used for physi-
cian claims submitted on paper for Medicare Part B reimbursement. Providers also use this
form for paper claims submitted to many private health insurance companies and Medicaid
agencies. (CMS forms may be accessed on the Web by following the links and instructions at
cms.hhs.gov/providers/edi/edi5.asp.)
Up to four diagnostic codes may be reported in field location 21 of this form; information
on the service or procedure provided is reported in field location 24. Up to six HCPCS codes
may be reported in column D of field location 24; in column E, the diagnostic codes are linked
with the related HCPCS codes by placing a number (1, 2, 3, or 4) to show which diagnostic
code is related to the procedure. Coders must be sure that any association of ICD-9-CM diag-
nostic codes with HCPCS procedure codes is logical and appropriate.
Example: Patient’s chief complaint is lower leg pain. The physician orders a lower
leg x-ray and an EKG. The lower leg pain is linked with the x-ray, but
there is no logical symptom or diagnosis to link with the EKG. Review
of the health record may reveal an existing condition, such as premature
ventricular contractions, or a symptom, such as tachycardia. Documenta-
tion must support the procedure or service provided; otherwise, the claim
will be denied.
Medicare and many commercial third-party payers often establish coverage limits for
certain services. Reimbursement claims for services with coverage limits (for example, inpa-
tient psychiatric care) must include sufficient diagnostic information to support the medical
necessity of the services provided. This diagnostic information is communicated in the form
of ICD-9-CM codes.
Medicare policies include two types of coverage limits: national coverage decisions and
local coverage determinations (LCD). CMS establishes contractual arrangements with the
private insurance companies (referred to as carriers), intermediaries, and Program Safeguard
Contractors who process Medicare claims in local geographic regions. These contractors are
responsible for making coverage decisions for Medicare beneficiaries, and the contractors base
their decisions on established national coverage requirements for specific medical supplies and
services. For cases that are not covered by existing national policies, contractors may make
local coverage determinations at their own discretion. A list of the Medicare coverage policies
can be found on the CMS Web site. The following policy is an example of a LCD. (It was
accessed on the Web site for the Ohio fiscal intermediary AdminaStar Federal.)
Example: CPT codes 20974 and 20975 for electrical stimulation to aid bone healing
are covered by Medicare only when one of the following ICD-9-CM diag-
nosis codes appears on the claim form:
733.82 Nonunion of Fracture
909.3 Late Effect of Complications of Surgical & Medical Care
V45.4 Postsurgical Arthrodesis Status
The CMS-1450 form, better known as UB-92 (figure 1.2), is used primarily by hospitals
for both outpatient and inpatient services. This form is used to submit claims for Medicare
Part A services. It is also used by other third-party payers to report claims for outpatient and
inpatient services provided by hospitals and ambulatory surgery centers (ASCs).
CARRIER
STAPLE
IN THIS
AREA
( ) Employed Full-Time
Student
Part-Time
Student ( )
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED’S DATE OF BIRTH SEX
MM DD YY
YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 3.
23. PRIOR AUTHORIZATION NUMBER
2. 4.
24. A B C D E F G H I J K
6
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
(For govt. claims, see back)
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS RENDERED (If other than home or office) & PHONE #
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM CMS-1500 (12-90), FORM RRB-1500,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
10
11
Up to nine diagnostic codes can be reported in field locations 67 through 75 and six ICD-
9-CM procedure codes in field locations 80 and 81. HCPCS codes (for outpatient services
including surgery) are reported in field location 44. Required modifiers are appended to the
HCPCS code in this field location. Up to two modifiers may be used to provide additional
information about the HCPCS codes on the claim form for Medicare patients. Field locator 76
is for admitting diagnosis and 77 is for E-code reporting.
1. What organizations are responsible for updating CPT codes and HCPCS Level II codes?
4. Dr. Smith saw a Medicare patient with a diagnosis of rectal abscess in Central Hospital.
She per formed an incision and drainage in the outpatient surgery department.
a. Which coding system(s) would Dr. Smith use to bill for her services?
Diagnosis: ____________________________________________________________________
Procedure: ____________________________________________________________________
b. Which coding system(s) would Central Hospital use to bill for its services?
Diagnosis: ____________________________________________________________________
Procedure: ____________________________________________________________________
c. Which form would Central Hospital use to submit a paper-based claim to Medicare for
payment?
5. Which coding system describes the reason for the patient visit or encounter?
6. A patient was seen in a physician’s office for excision of a 0.5-cm facial nevus (HCPCS Level
I code 11440). The ICD-9-CM diagnostic code for the benign lesion is 216.3. During this
encounter, the physician also evaluated the patient’s hyperglycemia (ICD-9-CM code 790.6)
and chronic simple anemia (ICD-9-CM code 281.9). A three-specimen glucose tolerance test
(HCPCS Level I code 82951) was performed. Using the CMS-1500 form provided in figure 1.3,
link the appropriate ICD-9-CM codes found in block 21 with HCPCS Level I codes found in
block 24D. In column 24E, select the appropriate number (1, 2, or 3) to indicate which diag-
nostic code is related to the procedure.
12
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
216.3 790.6
281.9
01-19 11440
01-19 82951
Chapter 1 Test
Choose or write the appropriate answers.
3. CPT is updated:
a. Annually for the main body of codes and every 6 months for category III codes
b. Annually
c. Every 6 months
d. As often as required by new technology
4. There are six sections to CPT: evaluation and management, anesthesia, surgery, radiology,
laboratory/pathology, and ________________________________________________________.
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