’s Manual to Accompany Understanding Current Procedural Terminology and HCPCS Coding Systems Sixth Edition M ARY J O B OWIE , MS, BS, AAS, RHIA, RHIT TEXTBOOK GUIDE iii TABLE OF CONTENTS INTRODUCTION 1 SECTION I: GETTING STARTED 2 SECTION II: CHAPTER LESSON PLANS AND ANSWER KEYS 4 Chapter 1: Introduction to Current Procedural Terminology 4 Chapter 2: Modifiers 8 Chapter 3: Evaluation and Management 12 Chapter 4: Anesthesia 17 Chapter 5: Surgery and the Integumentary System 21 Chapter 6: Musculoskeletal System 26 Chapter 7: Respiratory System 31 Chapter 8: Cardiovascular System 36 Chapter 9: Hemic and Lymphatic Systems 41 Chapter 10: Mediastinum and Diaphragm 44 Chapter 11: Digestive System 46 Chapter 12: Urinary System 51 Chapter 13: Male Genital System 55 Chapter 14: Female Genital System 58 Chapter 15: Maternity Care and Delivery 62 Chapter 16: Endocrine System 65 Chapter 17: Nervous System 67 Chapter 18: Eye and Ocular Adnexa 70 Chapter 19: Auditory System and Operating Microscope 73 Chapter 20: Radiolog y 76 Chapter 21: Pathology and Laboratory 81 Chapter 22: Medicine 83 Chapter 23: HCPCS Codes 87 SECTION III: ANSWER KEY FOR APPENDIX VII CASE STUDIES 92 INTRODUCTION This instructor’s manual is organized into two sections. SECTION I Getting Started This section contains a semester plan that is used for a 15-week semester and a course outline that can be modified and given to students on the first day of class. SECTION II Chapter Lesson Plans and Answer Keys This section contains a lesson plan for each chapter that includes lecture topics, an overview of the chapter, chapter objectives, and the answers to the exercises and Chapter Review. The authors suggest that students complete the exercises contained in the chapters as homework. The Chapter Reviews and coding cases should be completed as part of laboratory time. SECTION III Answer Key for Appendix VII Case Studies This section contains the answer key for the case studies found in the core text, Appendix VII. Section I Getting Started This section contains a semester plan and a course outline. The semester plan is intended to be used as a guide to organize the course content. The course outline can be used to develop a course syllabus that can be updated according to your specific class needs. SEMESTER PLAN This plan is for 45 hours of lecture and 30 hours of lab time. The lecture time assumes 30 minutes to 1 hour for testing on each chapter. The instructor’s Microsoft PowerPoint presentation that accompanies this manual should be used. As homework assignments for each chapter in the following list, students should complete the exercises found within the textbook chapters and review the Internet links found at the end of the chapters. The lab assignments to be used include the coding assignments and case studies found at the end of the chapters in the core book. The students also should be instructed to complete the Chapter Review at the end of each chapter. The Chapter Reviews can be completed as homework assignments or as lab assignments. Lecture Hours Lab Hours Chapter 1 Introduction to Current Procedural Terminology 3 1 Chapter 2 Modifiers 3 2 Chapter 3 Evaluation and Management 3 2 Chapter 4 Anesthesia 3 2 Chapter 5 Surgery and the Integumentary System 2 2 Chapter 6 Musculoskeletal System 2 2 Chapter 7 Respiratory System 2 2 Chapter 8 Cardiovascular System 2 2 Chapter 9 Hemic and Lymphatic Systems 1 0.5 Chapter 10 Mediastinum and Diaphragm 1 0.5 Chapter 11 Digestive System 2 2 Chapter 12 Urinary System 2 1 Chapter 13 Male Genital System 1.5 1 Chapter 14 Female Genital System 1.5 1 Chapter 15 Maternity Care and Delivery 2 1 Chapter 16 Endocrine System 1.5 1 Chapter 17 Nervous System 1.5 1 Chapter 18 Eye and Ocular Adnexa 1.5 1 Chapter 19 Auditory System and Operating Microscope 1.5 1 Chapter 20 Radiology 2 1 Chapter 21 Pathology and Laboratory 2 1 Chapter 22 Medicine 2 1 Chapter 23 HCPCS Codes 1 1 TOTAL HOURS 44 30 Section I ■ Getting Started 3 COURSE OUTLINE This outline can be used to organize your class content and to prepare a course syllabus for your students. Course Name: Insert name of course established by your school. Course Number: Insert course number. Course Format: ____ hours of lecture and ____ hours of laboratory per week. Prerequisites: List prerequisites established by your school. Semester: Insert current semester. Course Objectives: At the conclusion of this course, the student will be able to: 1. Explain the format and organization of CPT. 2. Describe the sections found in CPT. 3. Describe the procedural codes found in CPT. 4. Explain the procedures associated with the various procedural codes found in CPT. 5. Assign CPT procedural phrases. 6. Assign CPT procedural codes to case studies. Textbook: Bowie, Mary Jo, Understanding Procedural Coding: A Worktext , 6th ed., Clifton Park, NY: Cengage Learning, 2019 . Division of Subject Matter Date to Be Completed (List dates according to school calendar.) Chapter 1 Introduction to Current Procedural Terminology Chapter 2 Modifiers Chapter 3 Evaluation and Management Chapter 4 Anesthesia Chapter 5 Surgery and the Integumentary System Chapter 6 Musculoskeletal System Chapter 7 Respiratory System Chapter 8 Cardiovascular System Chapter 9 Hemic and Lymphatic Systems Chapter 10 Mediastinum and Diaphragm Chapter 11 Digestive System Chapter 12 Urinary System Chapter 13 Male Genital System Chapter 14 Female Genital System Chapter 15 Maternity Care and Delivery Chapter 16 Endocrine System Chapter 17 Nervous System Chapter 18 Eye and Ocular Adnexa Chapter 19 Auditory System and Operating Microscope Chapter 20 Radiology Chapter 21 Pathology and Laboratory Chapter 22 Medicine Chapter 23 HCPCS Codes Section II Chapter Lesson Plans and Answer Keys CHAPTER 1 INTRODUCTION TO CURRENT PROCEDURAL TERMINOLOGY LESSON PLAN Time: 2–3 hours instructor preparation 3 hours in-class lecture time 1 hour in-class lab time (if lab component is part of course) Topics: History of Current Procedural Terminology The Structure and Design of CPT CPT as Part of HCPCS Overview: This chapter presents an overview, the development, and the format of CPT. It further discusses the symbols used in CPT and the process of locating codes. The main sections are introduced. Level I and Level II codes that are found in HCPCS are also discussed. OBJECTIVES 1. Discuss the purpose of Current Procedural Terminology (CPT). 2. Explain the development of CPT. 3. Summarize the format of CPT. 4. Discuss the symbols used in CPT. 5. Understand how to locate a CPT code. 6. Outline the six main sections of CPT. 7. Differentiate among Level I and Level II codes in HCPCS. Chapter 1 ■ Introduction to Current Procedural Terminology 5 EXERCISE ANSWERS 1.1 – Check Your Understanding Code Section/Subsection 1. 70300 Radiology/Diagnostic Radiology (Diagnostic Imaging) 2. 60220 Surgery/Endocrine System 3. 26034 Surgery/Musculoskeletal System 4. 88036 Pathology & Laboratory—Anatomic Pathology 5. 43651 Surgery/Digestive System 6. 38115 Surgery/Hemic and Lymphatic Systems 7. 99304 Evaluation and Management/Nursing Facility Services 8. 97010 Medicine/Physical Medicine and Rehabilitation 9. 77021 Radiology/Radiologic Guidance 10. 65112 Surgery/Eye and Ocular Adnexa 11. 90371 Medicine/Immune Globulins, Serum, or Recombinant Products 12. 99203 Evaluation and Management/Office or Other Outpatient Services 13. 10160 Surgery/Integumentary System 14. 33120 Surgery/Cardiovascular System 15. 50100 Surgery/Urinary System 16. 21811 Surgery/Musculoskeletal System 17. 66184 Surgery/Eye and Ocular Adnexa 18. 52441 Surgery/Urinary System 19. 61000 Surgery/Nervous System 20. 59074 Surgery/Maternity Care and Delivery CHAPTER REVIEW ANSWERS True/False 1. False 2. True 3. False 4. False 5. True Fill in the Blank 6. American Medical Association (AMA) 7. Appendix A 8. Six 9. Semicolon 10. Index Chapter 1 ■ Introduction to Current Procedural Terminology 6 Coding Assignments 1. Anesthesia 2. Surgery 3. Pathology and Laboratory 4. Surgery 5. Surgery 6. Medicine 7. Evaluation and Management 8. Radiology 9. Surgery 10. Medicine 11. Surgery 12. Radiology 13. Surgery 14. Pathology and Laboratory 15. Medicine 16. Medicine 17. Pathology and Laboratory 18. Radiology 19. Surgery 20. Medicine Short Answer 1. Unlisted procedure or service: A service may be provided that is not specifically listed in the CPT manual. When this occurs, an unlisted procedure code is used from within a specific subsection of the CPT manual. 2. Add-on codes are codes that are listed as secondary to a main procedure code and are used in conjunction with the main code. Add-on codes are not to be reported alone. 3. Modifiers are two-digit codes that are appended to a CPT code to enhance or further describe a service provided. 4. A special report may be required by some third-party payers when an unusual, variable, or new service is provided. Information contained in the special report includes a description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service. 5. The Alphabetical Reference Index is an expanded alphabetical index that includes listings by the name of the procedure and anatomic site. Eponyms and other designations are also included in the index. 6. The section numbers and their sequences are as follows: Evaluation and Management 99201 – 99499 Anesthesia 00100 – 01999, 99100 – 99140 Surgery 10021 – 69990 Radiology (including Nuclear Medicine and Diagnostic Ultrasound) 70010 – 79999 Pathology and Laboratory 80047 – 89398, 0001U–0071U Medicine (except Anesthesia) 90281 – 99199, 99500 – 99607 Chapter 1 ■ Introduction to Current Procedural Terminology 7 7. Code Answer 11047 yes 60540 no 36100 no 63082 yes 81416 yes 8. Code Answer 99201 no 20975 yes 97535 no 93618 yes 36620 yes CHAPTER 2 MODIFIERS LESSON PLAN Time: 2–3 hours instructor preparation 3 hours in-class lecture time 2 hours in-class lab time (if lab component is part of course) Topics: Definition and Purposes of Modifiers Use of Modifiers for Various Procedures and Service Locations Modifiers Used for Hospital Outpatient Services CPT Level I Modifiers HCPCS Level II Modifiers Overview: This chapter discusses the use of modifiers in the CPT and HCPCS coding systems. The modifiers are defined, and examples are given to illustrate their use. HCPCS Level II modifiers are also introduced. OBJECTIVES 1. Explain the use of CPT modifiers. 2. Define the various modifiers used. 3. Describe the modifiers used for hospital outpatient services. 4. Identify and assign CPT modifiers. EXERCISE ANSWERS 2.1 – Check Your Understanding 1. ND 2. US, GW 3. 56, QT 4. AA, 47 5. 51, 59 2.2 – Pricing and Statistical/Informational Modifiers 1. Pricing 2. Statistical/informational 3. Pricing 4. Pricing 5. Statistical/informational 6. Statistical/informational Chapter 2 ■ Modifiers 9 7. Statistical/informational 8. Pricing 9. Statistical/informational 10. Statistical/informational 2.3 – Modifiers Used for Ambulatory Surgery Center Hospital Outpatient Claims 1. No 2. Yes 3. No 4. Yes 5. No 6. No 7. Yes 8. Yes 9. Yes 10. Yes 11. Yes 12. No 13. Yes 14. Yes 15. Yes CHAPTER REVIEW ANSWERS Fill in the Blank 1. Two 2. Appendix A 3. 24d 4. Informational 5. Multiple 6. Preoperative 7. 32 8. 54 9. 80 10. Outside laboratory Identify the Modifier 1. 62 2. 23 3. 22 4. 52 5. 55 Chapter 2 ■ Modifiers 10 6. To report the professional component of a code 7. Modifier 47 is used only by physicians or surgeons when regional or general anesthesia is provided by the same physician or surgeon who is completing a procedure or service. 8. 50 9. 56 10. Modifier 76 is used to indicate that it was necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. Modifier 77 is used when a physician or other qualified health care professional needs to indicate that a basic procedure or service performed by another physician or other qualified health care professional had to be repeated. 11. 53 12. 57 13. 66 14. 80 15. 26 16. G2 17. F8 18. GM 19. 81 20. 91 Case Studies Case 1—Modifier 25 Rationale: An Evaluation and Management (E/M) code (99213) and a procedure code (OMT-98925) for the same day require a modifier to identify that two separate and distinct services were performed. Modifier 25 is reported with the E/M code. Case 2—Modifier 53 Rationale: Because of the extenuating circumstances of the drop in blood pressure, the doctor felt that it was in the patient’s best interest to stop the procedure. Case 3—Modifier 55 Rationale: Modifier 55 is appended to the code to report that the provider is completing postoperative management only. Case 4—Modifier 63 Rationale: When a procedure is completed and the patient is a newborn and weighs less than 4 kg, modifier 63 is appended to the procedure code. Case 5—33475-80 Rationale: Modifier 80 is appended to the procedure code to report that the provider is the assistant surgeon for the case. Case 6—Modifier 57 Rationale: Modifier 57 denotes that the decision for surgery was made. Case 7—Modifier 32 Rationale: When a service occurs because the service is mandated, modifier 32 is appended to the basic procedure code. Chapter 2 ■ Modifiers 11 Case 8—Modifier 26 Rationale: Modifier 26 is appended to the code to report that the provider completed the professional component of the procedure. Case 9—No, both should report 32854-66 Rationale: Because the providers worked as a team, modifier 66 would be reported by both providers. Case 10—32960-76 Rationale: Modifier 76 would be appended to the procedure code to denote that the procedure was repeated. CHAPTER 3 EVALUATION AND MANAGEMENT LESSON PLAN Time: 2–3 hours instructor preparation 3 hours in-class lecture time 2 hours in-class lab time (if lab component is part of course) Topics: Documentation Guidelines for Evaluation and Management Services Overview of the Evaluation and Management Section Evaluation and Management Coding Overview: This chapter discusses Evaluation and Management (E/M) coding. An overview of the codes found in the various subsections of the Evaluation and Management section of the CPT manual are explained. Documentation guidelines that relate to E/M coding are discussed throughout the chapter. OBJECTIVES 1. Explain the purpose of Evaluation and Management (E/M) codes. 2. Identify the documentation needed to justify the selection of a code from the Evaluation and Management section of the CPT manual. 3. Differentiate between a new and an established patient. 4. Define consultation. 5. State the documentation requirements for the selection of a consultation code. 6. Identify the services bundled into critical care service codes. 7. Explain the services that are considered preventive medicine services. 8. Describe the chapter-specific guidelines for Evaluation and Management coding. EXERCISE ANSWERS 3.1 – Subsection and Subcategories of the CPT Evaluation and Management Section 1. Office and other outpatient services; established patient 2. Emergency department services; new or established patient 3. Home services; new patient 4. Hospital inpatient services; hospital discharge services 5. Consultations; inpatient consultation services 6. Hospital observation services; observation care discharge services Chapter 3 ■ Evaluation and Management 13 7. Hospital inpatient services; subsequent hospital care 8. Consultations; office or other outpatient consults 9. Advance Care Planning 10. Prolonged services; physician standby services 3.2 – POS and Evaluation and Management Codes 1. 11 2. 21 3. 12 4. 31 5. 21 6. 31 7. 21 8. 11 9. 11 10. 23 3.3 – Documentation of Patient History 1. 2—Chief complaint 2. 4—Severity 3. 6—Quality 4. 8—Associated signs and symptoms 5. 5—Family history 6. 3—Past history 7. 7—Review of systems 8. 1—Social history 3.4 – Evaluation and Management Coding 1. 99214 2. 99212 3. 99213 4. 99213 5. 99215 3.5 – Hospital Service Codes 1. 99222 2. 99232 3. 99223 4. 99238 5. 99232