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HCFA to change 87,000 CPT coding combinations

From the December 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Sharon Mikolanis

Approximately 87,000 new current procedural terminology (CPT) coding combinations will go into effect Jan. 1, 1996. The new codes are part of a policy manual intended to promote correct CPT coding for services provided to Medicare beneficiaries and to help physicians properly code services for reimbursement.

These new coding combinations, for which the College is obtaining the final recommendations, will replace all editing done in the past few years by the CPT panel and others and will be revised quarterly. Codes that were added, deleted or revised in 1995 will be reviewed separately.

AdminaStar Federal, an Indiana-based Medicare carrier under contract with HCFA, began developing the manual for the current CPT system in August 1994. In December 1994, specialty societies representing physicians and other health professionals who use CPT codes reviewed AdminaStar's draft policy, which contained 94,000 proposed coding combinations. The College was one of three thousand respondents to offer comments by the March 13, 1995, due date.

Societies disputed approximately 6,700 of the 94,000 proposed coding combinations. After extensive review, AdminaStar agreed with the public comments concerning 5,700 of the proposed coding combinations. The fate of the remaining 1,000 coding combinations is uncertain.

Staff at HCFA and a group of carrier medical directors will evaluate these recommendations and respond by June 1996.

Here are some of the key provisions of the correct coding policy:

  • Codes representing services or procedures that, based on CPT definitions or standard medical practice, cannot or would not be done during the same session by the same provider on the same patient must not be submitted together. These services or procedures are considered mutually exclusive.
  • When CPT descriptors designate several procedures of increasing complexity, only the code describing the most complex of these procedures should be submitted.
  • CPT descriptors that identify procedures only done on men or women should be coded for a patient of the appropriate gender (e.g., hysterectomy/females).
  • A panel of laboratory tests, when ordered, should be coded by the panel or grouping, not by the individual test.
  • Diagnostic procedures done at the same session that establish the decision to perform the more comprehensive service may be separately submitted.
  • In instances where several attempts to perform procedures are unsuccessful, only the procedure successfully accomplished should be submitted. This policy is limited to certain types of procedures that are unsuccessful and that mandate a more comprehensive procedure.

A new CPT modifier known as the -GB modifier will also be available Jan. 1, 1996. This modifier indicates that a procedure or service is distinct from other services billed on the same date. The service may represent a different session or patient encounter, different procedure or surgery, different anatomical site, separate lesion or separate injury or area of surgery in extensive injuries. If another CPT modifier--for example, -LT, -RT, -25 or -51--accurately describes the service rendered, then it should be used instead of the -GB modifier. HCFA provided some examples of appropriate use of the new modifier:

Example: Most fractures are caused by trauma. Therefore, other injuries may also be associated with the fracture, many of which require debridement involving skin, subcutaneous tissue, muscle and/or bone. If debridement is necessary solely because of the fracture--for example, with open fractures--the CPT codes describing debridement are not separately payable. If debridement is necessary because of associated trauma, the codes describing it are separately payable. Thee medical record must reflectthis situation, and the CPT code should be submitted with the -GB modifier.

Example: With chemotherapy administration, infusion of fluids such as saline or dextrose solutions may be necessary to maintain line patency or to flush lines between administration of different agents given at the same session. These types of infusions should not be separately billed. If fluid administration is medically necessary for therapeutic reasons during transfusion or chemotherapy--for example, for hydration or protection of renal function--then this procedure could be billed separately using the -GB modifier because the procedure is medically necessary.

Sharon Mikolanis is Associate for Payment Policy in ACP's Washington, D.C., office.

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