Your PCC system supports the American Medical Association’s CPT II code specification, a subset of the standard CPT codes used for procedures.
CPT II codes, commonly used for Medicare billing, report performance measures and can show how well offices are meeting quality measures (PQRI – Physician Quality Reporting Initiative). They are not like regular procedure codes, and they have no associated price. They identify a condition and the clinical component for assessment of that condition.
Should You Participate?: Some insurance carriers may offer pay-for-performance bonuses to practices that use CPT II codes. You can enroll in these programs with your insurance carriers, use the codes during checkout and billing, and payors will then evaluate whether clinical improvement was achieved and send you an incentive bonus.
Procedure Code Guidance: The procedure code recommendations in this article are intended only as examples. You should consult the AMA’s CPT Coding Guide and work with your insurance payers to verify what codes you should use on claims. Your practice updates and maintains your procedure list, codes, and prices in the Procedures table in the Table Editor on your PCC system.
Coding with CPT II, an Overview
Providers use ICD-9/ICD-10 diagnosis codes to indicate patient conditions. They use CPT codes to record the office visit and clinical procedures. The provider may use CPT II in addition to CPT codes in order to indicate how diagnoses and treatment relate. Some CPT II codes are redundant with ICD-9 codes.
There may be extenuating circumstances for why particular care is not performed. If you report those circumstances using CPT II codes with special modifiers (1P, 2P, etc.) you can remain in compliance with a carrier’s Pay for Performance goals. This may happen when a family refuses care, for example.
Only a small subset of the total CPT II codes are of interest to pediatricians. The most common relate to Asthma and Pharyngitis. The table below lists common pediatric CPT II codes. Note that new PQRI measurs and CPT II codes are added regularly.
|4015F||Use this code for patients diagnosed with asthma to indicate whether or not they were prescribed long-term medication or acceptable alternative treatment.|
|1005F||Use this code for patients diagnosed with asthma to indicate whether the patient was evaluated for frequency (numeric) of daytime and nocturnal asthma symptoms.|
|4120F||Use this code for patients diagnosed with URI (Upper Respiratory Infection) or Pharyngitis who were prescribed antibiotics on or within 3 days of visit.|
|4124F||Use this code for patients diagnosed with URI (Upper Respiratory Infection) or Pharyngitis who were *NOT *prescribed antibiotics on or within 3 days of visit.|
|3210F||Use this code for patients diagnosed with pharyngitis who received a group A strep test.|
|4130F||Use this code for patients diagnosed with Acute Otitis Externa who were prescribed topical preparations|
|1116F||Use this code for patients diagnosed with Acute Otitis Externa who were assessed for Auricular or periauricular pain.|
|4132F||Use this code for patients diagnosed with Acute Otitis Externa who were *not* prescribed Systemic antimicrobial therapy.|
|4131F||Use this code for patients diagnosed with Acute Otitis Externa who were prescribed Systemic antimicrobial therapy.|
|2035F||Use this code for patients diagnosed with OME (Otitis Media with Effusion) who had assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry.|
|3230F||Use this code for patients diagnosed with OME (Otitis Media with Effusion) to indicate documentation of hearing test performed within 6 months prior to tympanostomy tube insertion.|
You can learn more about CPT II by visiting the American Medical Association’s web site about CPT II. Visit http://www.ama-assn.org/ and search for CPT II.
Get Started with CPT II in PCC
Read the procedure below to learn more about CPT II and the steps for PCC system implementation.
Research and Evaluate Your Options
Work with your carriers to understand the guidelines of their CPT II, PQRI and pay-for-performance agreements. Evaluate the additional work your providers, front desk, and billing staff will need to perform to implement CPT II on your encounter forms, charge screens, and during the checkout and billing process.
Sign Up or Enroll
In some cases, you may need to adjust your contract or “opt in” to a carrier’s pay-for-performance program before beginning.
Decide What CPT II Codes to Implement
Study the CPT II codes your carriers accept and develop a plan for the codes your office will use. PCC’s coding expert can answer basic questions, and you can learn more about CPT II from the AMA.
Add CPT II Codes to Your PCC System
Run the Table Editor (ted) and create the CPT II code entries in the Procedures table.
- Assign a $0 price for these new procedure codes. Your carriers may have special guidelines or require a $.01 charge for all procedures, so double-check their coding requirements.
- Assign the accounting type of “Revenue – CPT II”. This will ensure that the codes are cataloged properly during reporting.
Adjust Your Office Workflow and Configuration
Work with your providers and your billers. Teach them how to select the correct CPT II codes along with tradition diagnosis and procedure codes. You may need to adjust your encounter forms and charge screens. Contact PCC Software Support at 800-722-1082 for help.
Post Charges and Use CPT II
Once you begin using CPT II, you will be able to run procedure-based reports and track your posting compliance. You can also check your office’s posting work using the dailycheck program.
Post Pay-for-Performance Bonuses
If your pay-for-performance work results in an incentive payment from an insurance carrier, post that money into a holding account. You may create a holding account and patient named for the insurance company.
For your accounts to balance, PCC recommends you post an adjustment in the Refund program. That adjustment, created in the Procedures table, should also have an accounting type of “Revenue – Non-Service.” Next, post the payment in the Post Payments and Adjustments program (pam). You may wish to create new incentive payment types in the Payments table with the name of the insurance carrier.
Reporting: As CPT II procedures have no revenue, they should not adversely effect your reporting. You can run procedure-based reports to watch CPT II coding trends as with any other code. Posting CPT II codes (which should all have a $0.00 amount) will not affect per-visit reimbursement analysis.