DRG Coding Advisor: Expert offers guidance for using category 3 CPT codes

Medicare clamps down on use of unlisted codes’

With 10% or more changes to the more than 8,000 Current Procedural Terminology (CPT) codes each year, health care coders may find themselves intimidated by the prospect of learning what’s new and what has changed.

"This year 950 changes were made to the CPT text itself in all different areas," says Celeste Kirschner, manager at PricewaterhouseCoopers of Chicago. Kirschner is a health care consultant who provides business advisory services for health care organizations. Kirschner is an expert on CPT codes and spent 16 years as the director of CPT with the American Medical Association in Chicago.

Also, there were 269 codes that were deleted in 2002, and coders may find that the code they have been using no longer is valid, Kirschner says.

"But it’s not always the code change itself that necessarily is important," Kirschner says.

Even the guidelines and introduction to CPT changes can affect the way coders select a particular CPT code. "There were a couple of sentences added to the CPT text that were very important because they changed the philosophy of coding for some procedures," Kirschner says.

For example, the introduction to the CPT text refers to coders not selecting a code that merely approximates a code provided if the code they’re trying to describe doesn’t exist, Kirschner explains.

"If the code doesn’t exist, you must use the unlisted code," she says. "In the past, people have been reluctant to use unlisted codes because of the documentation required, but this gives instructions to us to not use the next closest thing, even though we think it might come close to describing a service."

Kirschner outlines some other changes in coding practices:

  • Documentation requirements: Audits of physicians at teaching hospitals have changed many health care systems’ documentation practices, Kirschner says.

"Services were being provided that were not complying with Medicare regulations. While residents were providing the services, attending physicians were billing for them even when they were not in the hospital at the time the services were provided," she explains. "The documentation that goes along with teaching hospitals, as a result of these investigations, really started bringing home to people that they have to follow the rules."

Another cause for documentation changes was the implementation of Medicare documentation guidelines for evaluation and management services for physicians, Kirschner says.

"This brought to light a lot of deficiencies in documentation when folks started having the level of service they reported downcoded because they didn’t have adequate documentation in the record to support what they said they were providing," Kirschner says.

"Those were the two biggest changes in modifying behavior, and while it’s not 100% at this time, people have been paying a lot more attention to it than they have in previous years," Kirschner says.

  • Category 3 CPT codes: These are codes for new and emerging technology, and the coding takes a different path than traditional coding for CPTs.

"These are a temporary set of codes for services that do not meet the requirements for a Category 1 CPT code, such as approval from the Food and Drug Administration [FDA], or FDA approval is anticipated very shortly," Kirschner says.

While category 3 codes are there for data-collection purposes so people can demonstrate that the service is well-established in the medical community, the insurance industry has been largely unsure about what to do with these codes, Kirschner says.

"The federal government in the Federal Register says they don’t exclude category 3 codes, and that it’s on a case-by-case basis," Kirschner says. "They’ll look and see if they want to cover it, making individual determinations about what the payment will be. So just because it has a CPT code, it doesn’t mean you’ll get paid for it."

  • Unlisted codes: When there is no code that precisely identifies a procedure, the coder now must assign an unlisted code to that service, and this will means submitting additional documentation.

"If it’s an operative procedure, most people would submit an operative report, and that’s a document that they’re already producing anyway," Kirschner says. "Where an operative report is not generated, then what you would do is one of two things: either submit a copy of the day’s progress or clinical notes, or submit a written explanation of the procedure."

If the service didn’t have a category 3 code, the coder would submit a statement on what the service was and what the documentation was. It’s then up to the payer to decide whether it is covered under the patient’s contract or whether it is a contract exclusion, Kirschner says. "There’s no standard way to say whether this is always covered."

Coders will need to obtain the physician’s notes and make certain this unlisted code doesn’t fall through the cracks without appropriate documentation.

"If the coder normally files electronically, then depending on the computer system and process, there usually is a way to have a paper claim printed that can be mailed with the documentation," Kirschner says.

Since Medicare changed the philosophy behind using unlisted codes for physician services, HIM departments should expect to see an increase in the number of unlisted procedure codes that are being used.

"In a community-based facility, you’ll probably see less of it because you won’t have as many people developing new procedures in that environment as you would in an institution affiliated with a university," Kirschner says.

  • Pediatric surgery changes: This is one of the more interesting CPT changes because it will require coders to determine an infant patient’s age from conception, instead of just from birth.

"In the pediatric surgery area there were some new codes for hernia repair, and the most important is in surgery for premature infants," Kirschner says.

The changes to coding for these procedures reflects the new reality that premature infants are surviving at greater rates than in the past, so they are undergoing surgical procedures that are much more complex than they would be if the child was a 2-year-old, Kirschner explains.

Check medical records for maternal history

"So how do we capture and describe the level of complexity that is happening with perinatal procedures?" Kirschner asks. "One concept that was introduced this year is fairly complex: It’s the concept of post-conceptual age, basing the age of the infant on the date of conception rather than the date of birth."

Coders will need to know this precise date because it will affect the code. So coders will need to check the medical records for the maternal history, which usually will state the estimated date of conception.

"It might be on the medical chart, or they might have to go back and ask for it from a pediatric surgeon or specialist," Kirschner says.

Here are some examples of how the coding for certain procedures differs according to post-conceptual age:

CPT 49491: This is repair of initial inguinal hernia for a pre-term infant less than 37 weeks gestation at birth, performed from 35 weeks up to 50 weeks post-conceptual age; incarcerated or strangulated.

CPT 49492: This is repair of initial inguinal hernia for a pre-term infant less than 37 weeks gestation at birth, performed from birth up to 50 weeks post-conceptual age, with or without hydrocelectomy; reducible.

CPT 49495: This is repair of initial inguinal hernia for an infant under age six months or a pre-term infant over 50 weeks post-conceptual age and under six months from date of birth at the time of surgery; incarcerated or strangulated.

CPT 49496: This is repair of initial inguinal hernia for full-term infant, under age six months or pre-term infant over 50 weeks post-conceptual age and under six months from date of birth at the time of surgery; with or without hydrocelectomy; reducible.

For coders who need assistance in calculating gestational age, there is a web site with information on this at http://members.aol.com/winston/index.htm.