Healthcare Common Procedure
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Healthcare Common Procedure
Healthcare Common Procedure
Explain the Healthcare Common Procedure Coding System (HCPCS). Why is HCPCS important to the coding world? What can be found when using HCPCS?
Next, code for the following scenario using Encoder Pro:
A woman has come into the physician’s office for a routine pap smear. From her past appointments, there has always been a screening completed for cervical or vaginal cancer as well as a pelvic and clinical breast examination.
Please code for the HCPCS procedure. Also, list your steps for finding the code.
Your complete assignment should be a minimum of two pages in length. Outside sources are not a requirement for this assignment.
QUESTION 2.
1.Procedure code descriptions contain diagnostic information.
True
False
2.NOS stands for not otherwise specified.
True
False
3.Root operation is a device that remains in the body after the completion of a procedure.
True
False
4.The index is the ending point when selecting the code.
True
False
5.The character positioning on the table has little meaning.
True
False
6.NEC stands for not elsewhere classified.
True
False
7.The character meaning for M is the body system, the bursae, and ligaments.
True
False
8.By referencing the main term, a minimum of the three characters will appear in the index.
True
False
9.he Placement section identifier is 4.
True
False
10.The ICD-10-PCS uses seven-letter codes.
True
False
QUESTION 3.
Only Need To Be 100 words
What are the benefits of coders enhancing their terminology knowledge of anatomy and physiology to use ICD-10-CM/PCS? Do you feel that coders need this knowledge in order to become a coding specialist? Why, or why not?
To identify and organize the services inside each APC, we use the Healthcare Common Procedure Coding System (HCPCS), which contains some Current Procedural Terminology (CPT) codes.
CMS’s Healthcare Common Procedure Coding System is known as HCPCS.
The G-Code system has superseded CPT® codes in the Medicare Physician Fee Schedule (MPFS) and the Healthcare Common Procedure Coding System (HCPCS) settings.
Preauthorization is required on a yearly basis for refills of an intrathecal medication delivery system with pharmaceuticals that are not on the closed formulary and are billed using Healthcare Common Procedure Coding System (HCPCS) Level II J codes.
When filing claims to Medicaid, providers should utilize the most appropriate Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for the service provided.
In either situation, the Healthcare Common Procedure Coding System (HCPCS) codes and from and through dates of service are shown on the Form CMS-1500 claim, or the HCPCS code and date of service are shown on the Form CMS-1450 outpatient claim (except for critical access hospital (CAH) claims).
To identify and organize the services under each APC group, CMS employs Healthcare Common Procedure Coding System (HCPCS) codes and descriptions.
1
Clinically, all services and goods in an APC category are comparable and demand similar resources.
The rate for durable medical equipment shall be determined at the Durable Medical Equipment Regional Carrier (DMERC) reimbursement level for those goods that have a national Healthcare Common Procedure Coding System (HCPCS) code.
The Center for Medicare and Medicaid Services (CMS), the American Medical Association (AMA), Current Procedural Terminology (CPT), the Healthcare Common Procedure Coding System (HCPCS), and the International Class of Diseases and Related Health Problems 10th Edition all have coding guidelines that we follow (ICD-10).
To identify and organize the services under each APC group, CMS employs Healthcare Common Procedure Coding System (HCPCS) codes and descriptions.
1
Clinically, all services and goods in an APC category are comparable and demand similar resources.
Codes for Procedures
The medical procedure or service that is being invoiced must be described on a medical bill submitted to an insurer for payment.
Current procedural terminology, or CPT, is a registered trademark of the American Medical Association that is used to express the great majority of operations in the United States.
CPT is owned and maintained by the American Medical Association.
When the (then-new) Medicare program needed a terminology for identifying medical services, the American Medical Association (AMA) released the first version in 1966.
To this day, CMS, which manages the Medicare program for the Department of Health and Human Services, has agreed to use the CPT book as the primary source of codes and descriptors for processing medical claims through a contract with the American Medical Association.
CPT became the terminology that all clinicians, government organizations, and private insurers must use once the HIPAA requirements were implemented in 2003.
The goal of CPT, according to the American Medical Association, is to create “a uniform language that appropriately describes medical, surgical, and diagnostic services, thereby providing an effective mechanism for reliable countrywide communication among physicians, patients, and third parties.”
10
Almost every sort of physician and laboratory service, including cytologic slide preparation and interpretation, has a CPT code.
(For instance, CPT code 10021 defines the technique of doing a FNA without the use of a picture.)
CPT codes are five-digit codes that describe even the most complicated medical operations.
Tell a knowledgeable person that you just completed an 88164, and he or she will immediately recognize that this was a manual screening of a cervical or vaginal smear (not a liquid-based preparation); that Bethesda terminology was used to report the result; and that the procedure only included the so-called “technical” component (staining, coverslipping, CT review, but not a CP’s interpretation).
All of this is based on a five-digit code!
In conjunction with Medicare’s Resource-Based Relative Value System, CPT codes are used to determine facility (“technical”) and physician (“professional”) reimbursements (RBRVS).
The RBRVS is a system for evaluating the relative value of medical services across all disciplines, based on effort, practice costs, and other considerations.
The RBRVS creates a relative value unit (RVU) for each current medical operation in this way.
A medical treatment or procedure’s money value is derived by its composite relative weight multiplied by a dollar conversion factor defined nationwide (by CMS).
CMS publishes the RVUs and conversion factor for physician services in the Federal Register every year.
In 2007, the conversion factor was $37.8975.
To determine the particular authorized fee for any given procedure and region, other geographic cost-of-living adjustments and other considerations are also applied, thus the process is not as easy as multiplying an RVU by the conversion factor.
(Expanding on the detailed formula is beyond the scope of this chapter.)
CMS’s website, www.cms.hhs.gov, has a lookup system for permitted charges.
HCPCS codes are a separate set of codes used to describe medications, supplies, and certain other services not covered by CPT.
HCPCS codes have five digits like CPT codes, but the first is a letter and the rest are numbers (e.g., G0123).
The CMS, not the AMA, is in charge of the HCPCS codes.
A national body made up of representatives from CMS, the BlueCross BlueShield Association, and America’s Health Insurance Plans is in charge of maintaining and upgrading them.
Only a few HCPCS codes, those for standard and high-risk Pap exams for Medicare beneficiaries, are of importance to cytologists.
Modifiers are required for some CPT and HCPCS codes to avoid filing a bogus claim and to ensure fast payment by payers.
Although a comprehensive explanation of modifiers is beyond the scope of this chapter, familiarity with the notion is essential.
A few often used cytology case modifiers are worth mentioning.
Modifier 26 of the CPT.
In pathology, this is the most often used.
It means that only the professional component of the service provided by the physician is being billed.
Modifier 52 for CPT.
This modifier suggests a service that is less extensive than usual.
The evaluation of a slide that was evaluated by the ThinPrep Imaging System but rejected for technical reasons is a nice example in cytology.
The automated screening code 88175 can still be billed, but with modifier 52. (i.e., 8817552).
Modifier 59 of the CPT.
A “distinct procedure,” such as a different specimen (e.g., washing versus brushing) or anatomic region, is denoted by modifier 59.
When two or more codes are considered mutually exclusive or duplicative, payors frequently need this modifier.
To avoid having the former charge disallowed, it’s common to report 8810459 for a direct smear bronchial brushing with 88108 for a cytospin bronchial washing.
GC HCPCS Modifier
When a resident or fellow actively participates in performing the underlying medical service, teaching physicians must add modifier GC to CPT and HCPCS codes on Medicare claims.
The qualifier specifies that the teaching physician performed the “critical” element of the treatment personally and is thus entitled to billing for it.
GA, GY, and GZ are HCPCS modifiers.
When billing Medicare, these modifiers are used to Pap test HCPCS codes.
They clarify whether the laboratory has the right (or not) to bill the Medicare beneficiary for the charge if the contractor denies it.
HCPCS Modifier TC is a type of HCPCS Modifier.
The facility technical component of the service being invoiced is denoted by this modification, which is the inverse of the CPT 26 modifier.
It’s worth mentioning a few points about process codes:
1
It is not a covered service just because a code is printed in CPT or HCPCS.
The United States Congress, state governments, and commercial insurers make coverage decisions.
Participation agreements you enter into with managed care firms and commercial insurers may also impose coverage limits.
2
The American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) sometimes disagree on the scope and meaning of CPT codes.
Historically, the American Medical Association (AMA) was the exclusive source of CPT code recommendations for everyone, including Medicare.
Medicare established the National Correct Coding Initiative in 1996. (NCCI).
The AMA and CMS have varied in ways that influence a number of pathology-related operation codes since then.
“AMA-CPT regulations” and “Medicare-CPT rules” are the results.
The nongynecologic cytology procedure codes 88104 (direct smears) and 88108 (direct smears) are two examples (cytospin).
According to Medicare, it is not medically essential to employ both types of preparations for one nongynecologic cytology specimen, thus you can only bill 88108 to them, even though you examined both.
The AMA, on the other hand, deems both procedures chargeable, even if they are performed on the same specimen.
What is the best way to cope with such inconsistencies?
If you’re billing a Medicare carrier or fiscal intermediary, you should follow CMS rules (“render unto Caesar…”).
If CMS policy requires you to follow Medicare CPT policies for Medicaid, TriCare, Medicare Advantage, or commercial insurer accounts, you should do so.
If they don’t, follow their specific recommendations (if any), or if the insurer doesn’t specify a CPT authority, follow the AMA regulations.
3
Only the most recent edition of the CPT codebook should be used.
Every year, the so-called “Category I” CPT codes, which account for 99 percent of the codes you’ll need, are changed on January 1st, and some adjustments to pathology codes are made.
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