CPT 2002 Introduction Contains Major Change
Published on Tue Jan 01, 2002
Radiology coders must pay close attention to language changes in the front matter of CPT 2002, according to Michael Beebe of the AMA. He notes that the modification represents a "subtle but major change" in how radiologists and coders report services that are not precisely described by an existing code. Beebe provided this information during the AMA's CPT 2002 Coding Symposium in Chicago, Nov. 15 and 16, 2001.
Instructions about coding these services may be found in the introduction section of the CPT 2002 manual (page x), under the heading "Instructions for Use of CPT." The new directions read (revisions appear in italics):
"Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT Code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code. In surgery, it may be an operation; in medicine, a diagnostic or therapeutic procedure; in radiology, a radiograph. Other additional procedures performed or pertinent special services are also listed. When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record.
"It is important to recognize that the listing of a service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional."
Emphasis on Unlisted-Procedure, Category III Codes
In the past, these directions simply noted that coders should "select the name of the procedure or service that most accurately identifies the service performed," and gave no further instructions to use unlisted-procedure codes. Beebe notes that this change to the introductory material is important and the AMA's primary objective in making the change is to help prevent miscoding of new services. To accommodate this shift in policy, additional unlisted-procedure codes have been added to various sections and subsections of CPT , and more are anticipated.
The following report illustrates when an unlisted service is the most appropriate code to report:
A percutaneous cholangiogram with insertion of ring biliary drainage catheter was performed on July 26. On Aug. 2 the following report was dictated:
Removal of ring biliary drainage catheter and insertion of two gianturco coils. The ring biliary drainage catheter was still in place in the right upper quadrant of the abdomen. The guide wire was placed [...]
