6 Essential Coding Rules Everyone Needs to Know
6 Essential Coding Rules Everyone Needs to Know

February 20, 2019

Current Procedural Terminology® (CPT) is a coding system that physicians and other providers use to bill for their services. While typically not taught in medical school, residency or other formal education arenas, providers are still expected to know how to properly code for services provided.
Here are six basic coding rules that apply to all specialties and that every provider, manager, billing, and coding staff must follow. Understanding the basics will help providers code accurately and reduce the risk of an audit or insurance company takeback or refund.

1. Do not report multiple CPT codes when a single comprehensive code describes these procedures. Doing so is called “unbundling.”

For example, there are codes that describe a tonsillectomy and adenoidectomy performed at the same operative session (42820-42821). It is considered “unbundling” if two separate codes are reported – one for the tonsillectomy (42825-42826) and one for the adenoidectomy (42830-42836).
Another example is use of the exploratory laparotomy code, 49000. An exploratory laparotomy is included in all other laparotomy codes; therefore, 49000 would not be separately reported. To do so is considered “unbundling” because the more comprehensive code includes the exploratory laparotomy.
2. Avoid “upcoding.” Do not report a “higher” code when a “lower” code is more accurate.
“Upcoding” oftentimes occurs when reporting Evaluation and Management (E/M) codes for office and hospital non-surgical services. If the documentation supports 99203 (new patient visit, level 3), it is considered “upcoding” if the provider codes the service as a higher level such as 99204 (new patient visit, level 4).

3. Remember that there are services integral to a CPT code. Refer to CPT guidelines and your physician specialty publications for more information.

CPT guidelines are not very specific about the services integral to a surgical procedure code. From an intraoperative standpoint, CPT states only the “local infiltration, metacarpal/metatarsal/digital block or topical anesthesia” is included. The assumption is that services normally performed as part of a single CPT code would not be separately coded.
The lack of specificity in CPT has led several physician specialty societies to publish their own guidelines for members and coders.
A good example is performing a lumbar discectomy with use of fluoroscopy for disc space localization. The American Academy of Orthopaedic Surgeons’ Code-X, as well as the American Association of Neurological Surgeons Guide to Coding, state that fluoroscopy is included in all open surgical procedure codes and not separately reported as shown in the table below.
63030 Lumbar discectomy
63030 Lumbar discectomy
76000 Fluoroscopy

4. Access or exposure (e.g., approach), is included in all surgical CPT codes with one exception.

CPT codes describe complete procedures. The incision/exposure/approach to the level of the pathology is included in all surgical procedure codes and should not be separately coded. The American Academy of Orthopaedic Surgeons’ Code-X and the American Association of Neurological Surgeon’s Guide to Coding are examples of how physician specialty societies have specifically defined that the access or approach to the procedure is included in the CPT code.
For example, the endoscopic intranasal approach to a pituitary tumor is included in 62165 (endoscopic transnasal excision of a pituitary tumor). When the otolaryngologist performs the endoscopic intranasal approach for the neurosurgeon to excise the pituitary tumor, then each surgeon reports the same CPT code with modifier 62 (Two Surgeons). The exposure/approach is included in 62165, a stand-alone CPT code, and should not be separately reported with component codes as shown in the table below.
Endoscopic pituitary tumor removal (co-surgery modifier)
62165 Endoscopic pituitary tumor removal billed by neurosurgery
30520 Septoplasty
31287 Sphenoidotomy
Another example is in spine surgery. The approach, or access, to the spine is included in all open spine surgical CPT codes. For example, the retroperitoneal approach is included in 22558 (anterior lumbar interbody fusion) because the procedure could not be accomplished without it. Therefore, when the vascular or general surgeon performs the approach – which is included in 22558 – the code is appended with modifier 62 and reported by both the approach and spine surgeons. It is not accurate for the approach surgeon to report a code such as an exploratory laparotomy (49000).
One exception: the skull base surgery codes (61580-61616) are separated into approach (61580-61598) and definitive procedure (61600-61616) for the resection and closure.

5. The usual closure is included in all surgical procedure CPT codes.

What is the “usual” closure? Well, that depends on the surgical procedure code. All surgical codes include the direct, or primary, closure where the wound edges of the operative tract created by the surgeon are closed primarily at the same operative session.
In general, my simple rule applies: if you open it, you’re supposed to close it.
Some codes may have language that closure is not included. In those instances, closure is typically not performed because the operative wound size is small such as in 41110 (excision of lesion of tongue without closure).
The excision of benign (114xx) and malignant (116xx) skin lesion codes includes a simple, or single layer, closure. If the closure qualifies for an intermediate (12031-12057) or complex (13100-13153) closure, it may be separately reported with the skin lesion excision code.

6. A “scout” endoscopy, diagnostic service, or exploratory procedure is included in a definitive CPT code performed at the same operative session.

Another of my simple rules is, if you are coding for cutting it out, you would not code for diagnosing or finding it.
For example, if you are doing a laryngectomy (31360), then the scout laryngoscopy to assess extent of disease and landmarks (31525) performed at the same operative session is included in the laryngectomy code and not separately reported.
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