Why should I care about coding?
Assigning the correct code to a procedure or service is an essential skill for everyone who bills Medicare and non-Medicare payers. Not only does correct coding keep the auditors away, but it also ensures the maximum allowable reimbursement for the services provided. Physicians who up-code or over code their services risk facing fraud and abuse charges if they are discovered. Upcoding or over coding occurs when the physician reports a higher level code than the service or procedure is assigned in CPT. Physicians who down-code or under code services lose rightfully earned revenue. Instead, for compliance and financial reasons, physicians and coders should strive to accurately code the services provided.

Step 1 – Do You Have a Current CPT Manual?
The first step to appropriate coding is to ensure you are using the current year’s CPT manual. The American Medical Association (AMA) makes changes to CPT every year and if you do not have the most current manual you could be missing out on revenue by reporting codes that no longer exist or you may risk compliance problems. You can purchase the CPT manual from the AMA at www.amabookstore.com or by phone at (800) 621-8335. CPT books can also be purchased from other vendors such as Ingenix.

Step 2 – How to Locate the Appropriate Code
CPT has a table of contents located at the front of the book that tells users where each specialty’s codes are located. ASGE members typically use codes from the endoscopy sections of the Digestive System/Surgery chapter, but they also use codes from the gastroenterology section of the Medicine chapter and the Evaluation and Management chapter. It is important to recognize that the listing of a service or procedure and its code number in a specific section of the CPT Manual does not restrict its use to a specific specialty group. Any procedure in any section of the CPT Manual may be used to designate the services rendered by any qualified physician or other qualified healthcare professional. Any physician may report any procedure from any section of the book as long as the CPT code descriptor corresponds with the service provided. If you are looking for a specific service or procedure, go to the index. However, never assign a CPT code by using the index only. Always check the full descriptor for the CPT code listed in the index to make sure it describes the service or procedure you performed before reporting the code.

Step 3 – Special Guidelines and Instructions
Before assigning a CPT code, it is important to know about the extra guidance and instructions that are part of CPT but do not appear in the individual CPT codes. The AMA offers general instructions on using CPT in the book’s Introduction, specialty-specific instructions at the beginning of each chapter, family-specific instructions before certain procedures or services in a section, and code-specific instructions beneath some codes. One of the most important instructions in the Introduction tells users to select the CPT code that accurately describes the service provided. Never report a code that merely approximates the service. If no CPT code exists, report the unlisted services code from the appropriate section. These codes typically are located at the end of each section and end with the number 9. For example, code 91299 Unlisted diagnostic gastroenterology procedure.

The AMA provides guidelines at the beginning of each section that contain special instructions, definitions, and subsection information. For example, the guidelines section at the beginning of the Surgery section provides the definition of the surgical package, instructions on where to find related services in the Evaluation and Management and Medicine sections, and a listing of each subsection’s code families as well as other information. Skipping the information in the guidelines section may cause miscoding a service.

In addition to the section guidelines, the AMA also places instructional paragraphs at the beginning of certain subsections within each section. These paragraphs provide additional information about the services of particular code families. While the language of each CPT code defines the service, the instructional paragraphs can provide additional guidance on how to report the codes or definitions of the services in the section. For example, under the Esophagus section of the Digestive System/Surgery chapter, there is an instructional paragraph that precedes the Endoscopy families (43200-43272). A sentence in the paragraph reminds users that surgical endoscopy always includes diagnostic endoscopy.

Code-specific instructions are listed in parenthesis beneath the code. These instructions typically involve whether or not a code can be reported in conjunction with other codes, but they can also point users to other codes that might be more appropriate. For example, a parenthetical notation beneath code 43242 for upper GI endoscopy with ultrasound FNA/biopsy directs users to code 43238 if the procedure performed involves transendoscopic FNA/biopsy limited to the esophagus.

Step 4 – Deciphering CPT Format and Symbols
If each code were listed with its full descriptor, the book would be too large to carry so the AMA created a formatting system of code families to conserve space. A code family is identified by a “parent code” that appears flush to the left margin with one or more codes related to the parent indented beneath. The parent code is the only code in the family that contains the full descriptor and only the portion of the code to the left of the semicolon applies to the indented codes. Therefore, to correctly read the indented codes you must refer to the portion of the parent code to the left of the semicolon and add it to the codes indented beneath it. For example:

45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

45303 with dilation (eg, balloon, guidewire, bougie)

Code 45303 actually reads, “Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guidewire, bougie).” It is important to note that just because two or more codes are part of a family does not necessarily mean that they cannot be reported together if both procedures are performed.

In addition to CPT formatting, the AMA also conserves space by using symbols. Some symbols alert users to changes to the CPT book. New codes are marked with a circle preceding the code number. If the AMA has changed an existing code’s descriptor, a triangle will appear before the code number. Changes to special guidelines and instructions are marked by an arrow placed before and after the new or revised text.

Other symbols alert users to the status of a CPT code. Add-on codes are marked by a plus sign preceding the code number. This symbol tells the user that the code cannot be reported alone. It must be reported in conjunction with another service. The AMA uses the symbol to identify codes that cannot be used with modifier 51 Multiple procedures.

Symbols beneath a CPT code in the Professional Edition of CPT alerts users that the AMA has reference material with additional information about the service. The available reference resource will appear to the right of the symbol.

Step 5 – CPT Categories
Category I Codes
In the late 1990s CPT began implementing a plan to improve CPT and create two additional code categories for performance measures and emerging technology. The traditional 5-digit CPT codes comprise Category I. The criteria for code assignment to this category remained unchanged. It is very important to understand each of the code sets in order to assign the appropriate code.

Category II – Performance Measures
Category II codes were created to capture performance measurement services in order to alleviate the administrative burden on physicians by decreasing the need for record abstraction and chart review. Use of these codes is optional. The Category II codes are comprised of a 5-character alphanumeric sequence that ends with the letter F. They are published each January 1 and July 1 at the AMA’s website (www.ama-assn.org/go/cpt) and are printed in the CPT book the following year.

Category II codes are used primarily for measurements that are well established or have been developed and tested by national organizations.

0505F Hemodialysis plan of care documented (ESRD)

0507F Peritoneal dialysis plan of care documents (ESRD)

For a complete listing of Category II codes, go to www.ama-assn.org

Category III – Emerging Technology
In CPT 2002 the first set of Category III codes for emerging technology services and procedures was published. Codes in this category do not meet all of the requirements for Category I. The codes are 5-character sets of 4 numbers and the letter T as the 5th character. Category III codes are released each January and July on the AMA’s website (www.ama-assn.org/go/cpt) and are printed in the CPT book the following year.

The AMA created Category III codes to facilitate data collection to substantiate widespread use of a new technology or in the FDA approval process. The codes are retired after 5 years if they have not been approved for Category I status during that time. Use of these codes is mandatory. Check the CPT book and the AMA’s website to be sure you are using the correct category of code for the service performed. If a Category III code exists that accurately describes the service or procedure performed, you must use the Category III code. Never report a Category III code in addition to a Category I code for the same service or procedure. Because the AMA does not value Category III codes, Medicare typically does not reimburse them. Non-Medicare payers may not pay for them either.

There are typically some GI-related procedures assigned to Category III in any given year. For example, these GI-related codes were listed in CPT 2004:

0008T Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with suturing of the esophagogastric junction

0057T Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease. (Note: this code is now Category I code 43257)

Step 6 – Appending Modifiers
Because the descriptor of each code is fixed, modifiers are the only way to provide additional information about a service or procedure. Using the appropriate modifier can avoid inappropriately denied claims and facilitate payment. A complete listing of modifiers is available in Appendix A of the current CPT Manual. The following examples demonstrate how modifiers can add the detail necessary for payers to accurately assess and pay a claim:

What if a procedure is terminated early for the patient’s safety?
Reporting the CPT code with modifier 53 Discontinued Procedure may be appropriate to let the payer know that the physician was not able to complete the procedure. If this modifier is not used, the payer will reimburse the procedure as if it were completed in its entirety and the physician may be liable for the over payment if he or she is ever audited.

What if the same procedure was performed at two different anatomic sites?
Adding modifier 59 Distinct Procedural Service to the second unit of the same CPT code is sometimes appropriate and will inform the payer that the physician did not accidentally report the same service twice. Instead, the procedure was performed on two different anatomic sites and each should be paid. An example is placement of two bile duct stents into left and right biliary ducts at ERCP (43268), whereas two stents in SAME duct would be reported only once.

What if more than one surgical procedure is performed on a patient during a single visit?
Modifier 51 Multiple procedures may be appended to the secondary and subsequent procedures to identify that multiple procedures were performed by the same physician on the same date of service. The typical instance is same-day reporting of a colonoscopy code and an Upper GI Endoscopy service. However, most payers do not require use of this modifier. In fact, CPT coding guidelines for modifier 51 may differ from third-party payer policies. Check with your local third-party payers for their specific reporting guidelines regarding use of modifier 51.

What if, on the same day a patient is scheduled for a surgical procedure, he requires a separate and significant Evaluation and Management service that is above and beyond the typical pre and postoperative care?
Reporting the appropriate E/M code with modifier 25 modifier (Significant Separately Identified Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service will let the payer know that the physician is not trying to unbundle the E/M service from the procedure. The modifier is applied to the E/M code, not to the procedure code.