Medical coding has different facilities. To be perfect in all facilities is quite difficult. Their will be multiple coders, who can code outpatient charts but very few will be perfect in inpatient coding department. Similarly, if a coder from radiology department to told to code an Emergency department, he or she will not be confident to find the right procedure code.

The point I am trying to make it that, their are many mistakes coders do while coding, which leads to reporting wrong CPT or diagnosis code. So, today I would just like to share my experience about how we can avoid those mistakes and improve your coding skills and knowledge.

Table of Contents

Read both Header and Technique of the Exam

Every medical charts has both header and technique of the procedure performed. To reach out to the correct procedure code, the header and technique should match. Most of the times the medical coders only check the header and start coding the procedure or CPT code, which is totally wrong. Their may be reports with discrepancy with header and technique.

For example, in radiology medical charts the header says ” CT Brain with IV (intravenous) Contrast” but the technique of the exam, has not documentation of contrast. We have separate CPT code for CT brain with contrast (70460) and without contrast (70450), hence here the report should be queried. Do not assign a CPT code just by going through the header of the exam.

Another example is about Nuclear Medicine exams, like bone scan, thyroid scan, Pulmonary ventilation and perfusion scan. In Nuclear medicine exam, the radiology coder should properly check the pharmaceutical or radioactive agents injected for the exam. Most of the times the HCPCS code as well as the Procedure code is coded wrong for these exams. To know more about these exam you can refer the below post

Bone Scan Coding guide

Pulmonary ventilation and perfusion Coding guide

Thyroid oral and IV administration CPT codes

Avoid Sequencing Error while coding Multiple CPT codes

Sequencing error is very common in ICD 10 as well as CPT codes. This happen because the medical coder has less knowledge about the primary or main exam performed in the medical reports. Even in ICD 10, the medical coder should know about the importance of primary diagnosis, for proper reimbursement.

The main exam or primary procedure can be easily found out if we understand the procedure performed by the physician. I would just share my experience for coding primary procedures. Just follow below tips.

Always code the main Surgery Procedure code (10000 -60000) first followed by any imaging guidance codes (70000 series)
In ED facility, always codes the ED CPT codes (99281-99285) first followed by any surgery or OP exam performed.
Do not add any Add-on code primary
If their are two surgery performed in a medical report, then look for the RVU values of these procedures and code the highest RVU value CPT code as primary.

Use X{EPSU} or 59 modifiers Carefully with CPT codes

Use of X{EPSU} or 59 modifier is very confusing if you are coding multiple high RVU codes. The reimbursement get affected if we do not assign properly modifiers. Their are many errors done by coder in Outpatient department by coders for assigning wrong codes. I will share the most common error I have seen done by coders.

In Radiology, when you code a MRI and MRA head for same day for same patient, the coder need to assign a 59 modifier to MRI exam. Similarly, if you are coding a CT and CTA exam for same site for same patient on same day, a 59 or X-{EPSU} should be assigned to CT exam CPT codes. These small errors can be easily avoided by the medical coders.

Also, there are procedures where a procedure can be inclusive or a part of another procedure. In such condition only the major procedure is coded and the inclusive procedure is not reported. For example, when a modified barium swallow (CPT code 74230) is performed along with a Barium Swallow Exam (CPT code 74220), then only CPT code 74230 should be reported, because barium swallow in totally inclusive into the modified barium swallow exam.

Also, do check about the repeat CPT codes used for different sites, because in such scenarios, XS modifier is used. For example, for coding duplex venous scan procedure for extremities, we have only two CPT code 93970 and 93971. When both both upper and lower extremities exam is performed we have to code procedure code 93970 twice, with adding XS modifier to any CPT code. XS modifier defines the another exam is done on different structure or site.

Even while coding vascular procedure or vascular families, do use X-{EPSU} modifiers carefully. Since, we have many vascular families, the use of same CPT code happen frequently and hence use of X-{EPSU} becomes essential.

Limited versus Complete Exam CPT codes Errors

Now, coming to again procedure codes, the simple radiology CPT codes can be very confusing sometimes. For example ,the limited and complete exam procedure codes for abdomen and renal exam has been very confusing for long time.

For compete Ultrasound abdomen exam (CPT code 76700), the report should document the eight organs (spleen, liver, gallbladder, common bile duct (CBD), Inferior vena cava (IVC) , kidneys, aorta & pancreas. Most of the time the medical coders, go with header Complete abdomen Ultrasound, without checking the eight organs in the medical report. If the document does not support the complete exam, we should either code it limited US abdomen (76705) or raise a query.

These silly errors has been very common by medical coders, which can be avoided.

Even for code Complete renal ultrasound (76770), the presence of two kidneys, urinary bladder and a renal diagnosis should be documented. But, here also coders miss to check the documentation and code a limited US renal exam (76775) as complete.

Not Reading the notes and Guidelines

Many times the medical coders missed the read the notes given below CPT codes. The notes below the CPT codes are very important because they guide us for coding any two CPT or procedure code together or not. Also, you will get any information about the Add-on codes used along with CPT codes.

There are many important guidelines which you should always remember. Mainly for surgery coders, they should always check the use guidelines of coding any surgery code. For example, some the procedure require use of imaging guidance which should be reported along with the main procedures. If you missed it, the payment will directly get affected for the procedures. Hence do read the notes and guidelines carefully before reporting any procedure code.