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Medical Coding Definitions

Understanding CPT® Methods

By Patricia Trites; PhD

www.HealthcareFinancials.com

The American Medical Association Physicians’ Current Procedural Terminology manual (commonly known as the CPT® manual) is the recognized coding manual used by healthcare providers to bill third party payers.

CPT Codes

No quantitative values are assigned the CPT® codes contained within the CPT® manual.  Each third party payers determines a value, whether a direct dollar or unit value, for each CPT® code.  Each CPT® code represents a service, procedure, test, or study. 

The CPT® manual attempts to define each of the codes specifically by individual descriptive phrases, and generally utilizing guidelines, rules, and definitions related to code groupings: medical, surgical, pathological, and diagnostic services.  Third party payers develop for internal use additional protocols, guidelines, rules and definitions.

Assigned Values

The value assigned to each CPT® code is based on a determined amount of work, practice expense and risk inherently bundled into the service or procedure.  Each procedure or service is further defined as a body of work made up of multiple lesser components all valued within the main CPT® code. 

Case Example:

As an example, if the surgical lengthening of a leg tendon is the main procedure to performed, it would be assigned a unique CPT® code. Within the tendon lengthening code definition and assigned value would be included (bundled or “packaged”) seemingly obvious lesser procedures available to the surgeon in achieving the ultimate goal of the tendon lengthening. These lesser procedures include the incision itself, retraction of vital structures, tying off small vessels, suturing the tendon in a lengthened position, closing the soft tissue in layers, suturing the skin, application of a dressing, and application of a posterior splint. 

Modifications

While some surgeons in a particular case may not need to tie off small vessels because no vessels interfered with the surgical exposure, or maybe they had to tie off two more vessels than they usually have to do, or they may elect not to apply a posterior splint, or the procedure takes twenty minutes more because a required instrument falls on the floor and needs to be re-sterilized, the overall code value of the tendon lengthening procedure does not change. 

Essentially with the exception of minor modifications, one way or another, the main procedure remains essentially the same. Those minor modifications or variations in technique would be included in what would be called the global surgical description and allowance. Not all potential secondary or minor procedures need to be performed to fully reimburse the primary procedure.

Billing Fragmentation

The fragmentation, breakdown or unbundling of the main or primary procedure through the billing of each secondary procedure is billing abuse at best, intentional double billing at worse. Bundling is also addressed in the Correct Coding Initiative [CCI] issued by the Centers for Medicare and Medicaid Services [CMS]. This is a quarterly publication that lists the procedures and/or services that cannot be billed on the same day for the same patient.

Assessment

Healthcare providers intentionally billing unbundled services may be committing fraud or abuse.

Conclusion

Your thoughts and comments are appreciated.

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Seeking CMO in Iowa

St. Luke’s Hospital

By Sue LeGrand

St. Luke’s Hospital, a prominent and award-winning 560-bed hospital in Cedar Rapids, Iowa is seeking a Chief Medical Officer due to the retirement of their current CMO. St. Luke’s Hospital is part of the Iowa Health System, one of the top 25 integrated delivery systems in the United States.

St. Luke’s was named a Top 100 Heart Hospital and Press Ganey named St. Luke’s a 2007 Success Story for outstanding patient satisfaction results.  Also in 2007, St. Luke’s received the Iowa Recognition for Performance Excellence silver award. This is Iowa’s premier award recognizing high performance management principles.

This CMO opportunity is rich with challenging and attainable priorities.  As part of the President’s Council, the CMO be the liaison with the 400-physician medical staff comprised of employed physicians, private practice physicians, members of the Iowa Health Medical Group and contracted physician groups.

Qualifications include board certification, experience as a physician leader in a hospital environment, quality management, medical staff relations, and an excellent clinical background.

If you are interested in learning more, please reply to this message and attach a copy of your current CV / resume, or contact me below:

Sue LeGrand
800/678-7858 ext. 63458
314/863-3631 Fax
slegrand@cejkasearch.com

CEJKA SEARCH
4 CityPlace, Ste 300
Saint Louis, Missouri 63141
http://www.cejkasearch.com

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