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INTRODUCTION

OBJECTIVES

Following completion of this chapter, the reader will be able to:

  • Explain what a Current Procedural Terminology CPT code is and the application of CPT codes in physical therapy.

  • Explain what an ICD-10 code is and the application in physical therapy.

  • Describe the relationship between the CPT codes and ICD-10 codes.

  • Compare the relationship between the medical diagnosis and the physical therapy diagnosis (problem).

  • Understand the difference between attended and unattended procedures.

“To be payable, the medical record and the information on the claim form must consistently and accurately report covered therapy services, as documented in the medical record. Documentation must be legible, relevant and sufficient to justify the services billed.”1

CURRENT PROCEDURAL TERMINOLOGY CODES

The Healthcare Common procedure Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT-4), a numeric coding system maintained by the American Medical Association (AMA). The CPT-4 is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals, including physical therapists. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT-4 codes, the level II HCPCS codes were established for submitting claims for these items.2,3

The HCPCS has been selected as the approved coding set for entities covered under the Health Insurance Portability and Accountability Act (HIPAA), for reporting outpatient procedures. The HCPCS is based upon the American Medical Association’s (AMA) “Physicians’ Current Procedural Terminology, Fourth Edition” (CPT-4). It includes three levels of codes and modifiers. Level I contains only the AMA’s CPT-4 codes. This level consists of all numeric codes. Level II contains alpha-numeric codes primarily for items and nonphysician services not included in CPT-4, e.g., ambulance, DME, orthotics, and prosthetics.4

The CPT contains approximately 10,000 codes.2 CPT codes are used in the billing process with International Classification of Disease codes (ICD).2,5

There are three categories for CPT codes:

  • Category 1 is procedures and contemporary medical practices

  • Category 2 is clinical laboratory services

  • Category 3 is emerging technologies, services, and procedures

ICD codes are numeric codes for diseases and pathologies, medical procedures including surgeries, and functionally oriented deficits or conditions.5 ICD-10 (10th revision) code versions are in use for physical medicine and physical therapy procedures.5 The ICD codes were developed by the World Health Organization (WHO) as a ...

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