College of Medicine Office of Compliance, Gainesville, Florida
Procedural and Diagnosis Coding Must Be Linked By Medical Necessity
What is a CPT code?
CPT is an acronym for Current Procedural Terminology. CPT codes are published by the American Medical Association, and the fourth edition is the most current. The purpose of the coding system is to provide uniform language that accurately describes medical, surgical, and diagnostic services.
A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. There are approximately 7,800 CPT codes ranging from 00100 through 99499. Two digit modifiers may be appended when appropriate to clarify or modify the description of the procedure.
It is published in two versions - the first is the most common, CPT Physician's Current Procedural Terminology. A second publication is also available - the CPT Physician's Current Procedural Terminology Specially Annotated for Hospitals. The Hospital version contains all the information in the original version with the addition of special Medicare guidelines and notations for identifying criteria applicable to outpatient hospital billing.
The rules for assigning the appropriate code are complex, and so we advise individuals who are determining the appropriate codes receive the proper training and credentials. This would include any office or clinic personnel who play a significant role in coding.
What is an ICD-9 Code?
ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) coding system is used to code signs, symptoms, injuries, diseases, and conditions.
The relationship between ICD-9 (diagnosis) and CPT (procedural) Codes
The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure. Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. For example, a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD-9 826.0, closed fracture of a phalanges of the foot. Such a claim would be quickly identified and rejected.
Where to buy the books
We strongly recommend that individuals in the clinical billing process be provided with the most current edition of the CPT manual. CPT codes are revised annually in November with hundreds of codes added, changed or deleted each year. You need a new book annually. Professional additions, with illustrations are helpful to both new coders and frequent users alike. The most current version of "Physician ICD-9-CM" codes can be identified by the note on the cover "effective through September 30, 2009". Both books can be ordered through the University of Florida Bookstore, or commercial vendors such as Ingenix, the AMA, or the AAPC.
If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at firstname.lastname@example.org.
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