CPT Coding in Oral Medicine

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CPT® - Current Procedural Terminology®

Medical Code Set (00000-99999)

• Established as an indexing/coding system to standardize terminology among physicians and other providers

• Used with other codes to report healthcare services performed in the United States

• Copyrighted and maintained by the American Medical Association through the CPT Editorial Panel

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CPT Categories

• The CPT code set includes three categories of medical nomenclature with descriptors

• Five digit numerical code

• Over 7,000 service codes, plus titles and modifiers

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Objectives of CPT Coding

• Provider

- To prepare a standardized “bill” for services given to a patient

• Payer

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The CPT Coding Manual

• CPT Sections • Section Guidelines • Table of Contents • Notes • Category II codes (0001F-7025F) • Category III codes (0019T-0318T) • Appendices A-O

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CPT Codes

• Examples:

• 99203 – physical exam (E/M code) • 40810 – excision of mouth lesion • 20552 – trigger point injection

• 70355 - orthopantomogram

• 64400 – trigeminal diagnostic nerve block

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Minor surgical procedure with problem oriented

E/M service

The CPT codes for minor surgical procedures include

• preoperative evaluation services such as assessing the site or problem

• explaining the procedure and risks and benefits • obtaining the patient’s consent

The Centers for Medicare & Medicaid Services (CMS)

has clarified that the initial evaluation is always

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Modifiers: Why use them?

Modifiers can be the difference between full

reimbursement and reduced reimbursement – or

denial

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Modifier 24

• CPT suggests using it with an “unrelated evaluation and management service by the same physician during a

postoperative period”

• So if a patient returns to the office within 10 days of the

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Helpful Tip

It is helpful to maintain an easily

accessible list of the global periods

for office-based procedures so you

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Modifier 59

• Modifier 59 is used for “distinct procedural services” that wouldn't otherwise appear to be distinct – that is,

procedures and services that are not normally reported together, but are appropriately reported under the

circumstances

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Modifier 59

• For example, if you perform a destruction of a premalignant lesion (code 17000) on the same day you biopsy another

lesion (code 11100), you will need to append modifier 59 to CPT code 11100 to indicate that the services were performed at different anatomic sites

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Modifier 59

• Private payers often use the CCI as a guide for their own bundling policies

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Modifier 25

• Modifier 25 is used to report a “significant, separately

identifiable evaluation and management service by the same physician on the same day of the procedure or other service” • In some cases when an injection or drug administration code

is reported, modifier 25 is required to distinguish the E/M service from the actual injection

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Using the 25 modifier

When you perform an “Oh, by the way” E/M service at the same visit as a procedure and the E/M service requires

physician work “above and beyond” the physician work

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Helpful Tip

You should consider including the

most common modifiers on your

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Missed Charges

Busy practices can easily miss capturing charges for

many of the services they provide

Lab and other ancillary services are the ones most

often missed, simply because the order may be

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Missed Charges

• Injections are another area where charge capture errors tend to occur

• If your practice is administering injections and providing the

injectable medications, you should be reporting two codes – one for the administration and one for the medication

• The HCPCS codes for the medications include the name and the dosage for each unit of service

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Location and Use of Superbills

• Failure to report an encounter in the emergency department is a sure way to miss getting reimbursed for the service

• Be sure your superbills make it easy for clinicians to capture services based in the hospital and nursing facility, and create a system for ensuring that all superbills are returned your

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Unlisted service or procedure

• A service or procedure may be provided that is not listed in this edition of the CPT codebook

• When reporting such a service, the appropriate “Unlisted Procedure” code may be used to indicate the service,

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Unlisted service or procedure

97139 Unlisted therapeutic procedure (specify) 97039 Unlisted modality

99199 Unlisted special service, procedure or report

97799 Unlisted physical medicine/rehabilitation service or procedure

97110 Therapeutic exercises

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Special Report

• A service that is rarely provided, unusual, variable, or new may require a special report

• Pertinent information should include an adequate definition or description of the nature, extent, and need for the

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Supplied materials

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CPT Code Basics

Review medical documentation thoroughly and gather

additional reports

Reference the alphabetical index for a CPT numerical

code and/or code range

• Condition

• Procedure or service • Anatomic site

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CPT Code Basics

Review the numerical code and/or code range for

specific descriptions

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Resources

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