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Introduction to CPT®

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The Current Procedural Terminology (CPT®)

Copyrighted and maintained by American Medical Association (AMA)
Used with other codes sets to report healthcare services performed in the United States
Established as an indexing/coding system to standardize terminology among physicians and other providers

Note: Page numbers listed in red throughout this presentation refer to the page number in the CPT Professional Codebook published by the AMA

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The Current Procedural Terminology (CPT®)

Copyrighted and maintained by American Medical Association (AMA)
Used with other codes sets to report healthcare services performed in the United States
Established as an indexing/coding system to standardize terminology among physicians and other providers

Note: Page numbers listed in red throughout this presentation refer to the page number in the CPT Professional Codebook published by the AMA

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The Current Procedural Terminology, or CPT®, coding manual is a compilation of guidelines, codes, and descriptions to report health care services performed by health care providers in the United States. The CPT® code set is copyrighted and maintained by American Medical Association (AMA) and is used with other code sets established by the Department of Health & Human Services and other federally-named entities for health care reporting and reimbursement.

The first CPT® code set was developed and published by the AMA in 1966, and was established as an indexing or coding system to standardize terminology among physicians and other providers.

In 1983, the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services, or CMS) adopted CPT® and its own Healthcare Common Procedure Coding System, HCPCS, Level II, mandating these code sets be for use in all Medicare billings. These code sets largely standardized reporting of medical services, equipment, and supplies.

Medicaid agencies and commercial health plans soon adopted the code sets and began to require CPT® and HCPCS Level II codes for reporting health care services for reimbursement.

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Introduction to CPT®

Instructions for use of the CPT ^® codebook (Page xii)

Unlisted procedure
Parenthetical notes
Accuracy and quality of coding

Related guidelines
Parenthetical instructions
Other coding resources

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Introduction to CPT®

The CPT® code set includes three categories of medical nomenclature with descriptors.

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Category I

Category II

Category III

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Category I CPT® Codes

Five-digit numerical code, eg 12345
Over 7,000 service codes, plus titles and modifiers
Reviewed and updated annually
Mandatory to report for services and reimbursement

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Category I CPT® Codes

The CPT® coding manual divides Category I CPT® codes into six main section titles:

Evaluation and Management (99201–99499)
Anesthesiology (00100-01999)
Surgery (10021-69990)
Radiology (70010-79999)
Pathology and Laboratory (80047-89398)
Medicine (90281-99199, 99500-99607)

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Category I CPT® Codes

Section titles have subsections divided by anatomic location, procedure, condition, or descriptor subheadings.

The subheadings, structured by CPT® conventions, may list alternate coding suggestions in parenthetical instructions.

Example (Page 72):

Section: Surgery (10021-69990)
Subsection: Integumentary System
Subheading: Skin, Subcutaneous and Accessory Structures
Category: Debridement

(For dermabrasions, see 15780 – 15783)
(For nail debridement, see 11720-11721)
(For burn(s), see 16000-16035)
(For pressure ulcers, see 15920-15999)

Alternate coding suggestions

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Category I CPT® Codes

Specific guidelines presented at the beginning of each section identify correct coding protocols.

Example (Page 193):

Section, Surgery

Subsection: Cardiovascular System (33010-37799)

Guideline:

Selective vascular catheterizations should be coded to include introduction and all lesser order selective catheterizations used in the approach (e.g., the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries).

Additional second and/or third order arterial catheterizations within the same family of arteries supplied by a single first order artery should b e expressed by 36218 or 36248. Additional first order or higher catheterizations in t vascular families supplied by a first order vessel different from a previously selected and coded family should be separately coded using the conventions described above.

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Category II CPT® Codes (Page 667)

Alphanumeric format, with the letter “F” in the last position, eg, 0001F
Optional “performance measurement” tracking codes
Physician Quality Reporting System (PQRS)
Example:

A physician counsels a patient regarding prescribed Statin therapy for coronary artery disease.
Report:

4013F Statin therapy prescribed or currently being taken (CAD)
Appropriate level office visit code (99201–99215).

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Category II CPT® Codes

Due to the constant expansion of identifiable measures for quality patient care, the AMA lists criteria on their website:

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt/category-ii-codes.shtml

Physician Quality Reporting Initiative (PQRS)

http://www.cms.gov/PQRS/

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Category III CPT® Codes (Page 687)

Temporary codes
Alphanumeric structure, with a “T” in the last position, eg, 1234T
Can be reported alone, without an additional Category I code
Example:

0262T Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach

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Category III CPT® Codes

Updated twice a year

January 1
July 1

Implemented six months after

Updates are published on AMA’s website: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt/category-iii-codes.page

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Category III CPT® Codes

If a Category III code is available,

this code must be reported

instead of a Category I unlisted code

(Page 687)

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The CPT® Codebook

CPT® Sections
Section Guidelines
Section Table of Contents
Notes
Category II codes (0001F – 9007F)
Category III codes (0019T – 0380T)
Appendices A-O
Alphabetic Index

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CPT® Guidelines

Referenced in the introduction of each section and subsection of the CPT® manual

Applicable to the section being referenced

Define the information necessary for choosing the correct code

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CPT® Conventions and Iconography

Used throughout the CPT® manual and include:

Indentations
Code symbols - iconology
Parenthetical instructions

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CPT® Conventions and Iconography

Example (Page 72):

11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface.

+ 11001 each additional 10% of the body surface (List separately in addition to code for primary procedure)

(Use 11001 in conjunction with 11000)

Indentation

Iconography (Symbol)

Parenthetical Instruction

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CPT® Conventions and Iconography

; The semicolon and the conventional use of indentions

The use of the semicolon divides the description of a code into two parts:

The “stand-alone” code or the “common portion of the procedure” code descriptor.
The indented descriptor is dependent on the preceding “stand-alone” code

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CPT® Conventions and Iconography

Example (Page 56):

00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise specified

00162 radical surgery

00164 biopsy, soft tissue

Interpreted:

00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise specified.

00162 Anesthesia for procedures on nose and accessory sinuses; radical surgery

00164 Anesthesia for procedures on nose and accessory sinuses; biopsy, soft tissue

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CPT® Conventions and Iconography

+ The “add-on” code symbol - Add-on codes are never reported alone

Example (Page 279):

+43283 Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)

(Use 43283 in conjunction with 43280, 43281, 43282)

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CPT® Conventions and Iconography

● The red circle - new procedure code

Example (Page 71):

10035 Placement of soft tissue localization device(s) (eg. Clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion

The (blue) triangle - code revision

Example (Page 405):

65855 Trabeculoplasty by laser surgery

Appendix B (Page 716):

65855 Trabeculoplasty by laser surgery, 1 or more sessions (defined treatment series)

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CPT® Conventions and Iconography

  The facing triangles - indicate new and revised text other than the procedure descriptors

Example (Page 303):

47135 Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age

(47136 has been deleted. To report, use 47399)

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CPT® Conventions and Iconography

⦸ The circle with a line through it - exempt from the use of modifier 51

Example (Page 623):

⦸ 93612 Intraventricular pacing

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CPT® Conventions and Iconography

• The bulls eye - includes moderate sedation

Example (Page 271):

• 43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

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CPT® Conventions and Iconography

The lightening bolt symbol - codes for vaccines that are pending FDA approval.

Example (Page 579):

90668 Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use

AMA CPT® “Category I Vaccine Codes” website:

www.ama-assn.org

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CPT® Conventions and Iconography

# The number symbol – Resequenced, out of numerical order

Example (Page 302):

46947 Code is out of numerical sequence. See 46700-46947

# 46947 Hemorrhoidopexy (for prolapsing internal hemorrhoids) by stapling

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CPT® Code Basics

Review medical documentation thoroughly and gather additional reports
Reference the alphabetical index for a CPT® numerical code and/or code range.

Condition
Procedure or service
Anatomic site
Synonyms, eponyms and abbreviations

Review the numerical code and/or code range for specific descriptions
Follow CPT® Guidelines, Conventions and Iconology

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CPT® Code Basics

Index (Page 921):

Ovary�Biopsy………………..49321, 58900

Numeric Section (Page 359):

Section: Surgery
Subsection: Female Genital System (56405-58999)
Subheading: Ovary (58800-58960)
Category: Excision (58900-58960)
58900 Biopsy of ovary, unilateral or bilateral (separate procedure)

CPT Changes: An Insider's View 2000
CPT^® Assistant Nov 99:29

(For laparoscopic biopsy of the ovary or fallopian tube, use 49321)

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Separate Procedure

Example (Page 359):

58900 Biopsy of ovary, unilateral or bilateral (separate procedure)

58920 Wedge resection or bisection of ovary, unilateral or bilateral

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National Correct Coding Initiative (CCI)

Implemented by CMS
Promotes correct coding methodologies
Controls the improper assignment of codes that results in inappropriate reimbursement
Procedure to procedure (PTP) edits

Medicare publishes CCI:

http://www.cms.hhs.gov/NationalCorrectCodInitEd/

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Column1/Column 2 Edits
Column 1	Column 2	* = In existence prior to 1996	Effective Date	Deletion Date�*=no data	Modifier 0=not allowed�1=allowed�9=not applicable	PTP Edit Rationale
11042	0213T		20100701	*	0	Misuse of column two code with column one code
11042	0216T		20100701	*	0	Anesthesia service included in surgical procedure
11042	0228T		20100701	*	0	Anesthesia service included in surgical procedure
11042	0230T		20100701	*	0	Anesthesia service included in surgical procedure
11042	10030		20140101	*	1	Standards of medical/surgical practice
11042	10060		19960101	*	1	Standards of medical/surgical practice
11042	11000		19960101	*	1	Standards of medical/surgical practice
11042	11001		19960101	19960101	9	Standards of medical/surgical practice
11042	11010		19980101	*	1	Mutually exclusive procedures
11042	11011		19990401	*	1	Mutually exclusive procedures
11042	11040	*	19960101	*	1	HCPCS/CPT procedure code definition
11042	11041	*	19960101	*	1	HCPCS/CPT procedure code definition

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Sequencing

Based on RBRVS

Physician Work
Practice Expense
Professional Liability/Malpractice Insurance

Highest RBRVS listed first.

www.cms.hhs.gov/PhysicianFee-Sched/

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CPT® Assistant

Articles answering everyday coding questions
CCI bundling information
E/M billing guidance
Current code use and interpretation
Case studies demonstrating practical application of codes
Anatomical illustration charts and graphs for quick reference
Information for appealing insurance denials
Information to validate code usage when audited

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CPT® Appendices

Appendix A (Page 709) - Modifiers categorized as:

Modifiers applicable to CPT® codes
Anesthesia Physical Status Modifiers
CPT® Level I Modifiers approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use
Level II (HCPCS/National) Modifiers

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CPT® Appendices

Appendix B (Page 715) - changes and additions to the CPT^® codes from the previous year

Appendix C (Page 722) - clinical E/M examples for different specialties

Appendix D (Page 747)– Add-on Codes

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CPT® Appendices

Appendix E (Page 748) – Exempt from the use of modifier 51 (multiple procedures)

Appendix F (Page 749) – Exempt from the use of Modifier 63 (procedures performed on infants less than 4kg)

Appendix G (Page 750) – Include Moderate (Conscious) Sedation

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CPT® Appendices

Appendix H (Page 752)– Alphabetic Index of Performance Measures by Clinical Condition or Topic

Available only on the AMA website
www.ama-assn.org.

Appendix I (Page 752) – Genetic Testing Code Modifiers

Removed with deletion of molecular pathology stacking codes.

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CPT® Appendices

Appendix J (Page 753) - Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves

Assigns each sensory, motor, and mixed nerve with its appropriate nerve conduction study code
Table containing maximum number of studies

Appendix K (Page 756) - Product Pending FDA Approval

Identified throughout the CPT^® codebook with a lightening bolt symbol
For updated vaccine approvals by the FDA, visit the AMA CPT® Category I Vaccine Code information on their website: � www.ama-assn.org/ama/pub/category/10902.html

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CPT® Appendices

Appendix L (Page 757)- Vascular Families

Based on the assumption that a vascular catheterization has a starting point of the aorta
Illustrates vascular “families” that emerge from the aorta using brackets to identify the order of vessels.

Appendix M (Page 760)- Renumbered CPT Codes – Citations Crosswalk

Crosswalks citations for CPT Assistant references for deleted codes.
Essential when referencing citations regarding coding for specific procedures.

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CPT® Appendices

Appendix N (Page 766)- Summary of Re-sequenced CPT® Codes This listing is a summary of CPT® codes not appearing in numeric sequence. This allows for existing codes to be relocated to an appropriate location.

Appendix O (Page 767) - Multianalyte Assays with Algorithmic Analyses -

This is a listing of administrative codes for Multianalyte Assays with Algorithmic Analyses (MAAA) procedures. These are typically unique to a single clinical laboratory or manufacturer.

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HCPCS Level II�(Healthcare Common Procedure Coding System)

Level I HCPCS is CPT®

Maintained by AMA
Identify services and procedures

Level II HCPCS

Maintained by CMS
Identify products, supplies, and services not included in CPT®

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HCPCS Level II

A Codes ~ Transportation Services, Med/Surg Supplies, Admin
B Codes ~ Enteral and Parenteral Therapy
C Codes ~ Pass-Through Items
E Codes ~ Durable Medical Equipment
G Codes ~ Procedures/Professional Services
H Codes ~ Alcohol and Drug Abuse Treatment Services
J Codes ~ Drugs Admin Other Than Oral Method/Chemotherapy Drugs
K Codes ~ DME Supplies
L Codes ~ Orthotic/Prosthetic Procedures
M Codes ~ Medical Services
P Codes ~ Lab/Path
Q Codes ~ Temporary Codes
R Codes ~ Diagnostic Radiology
S Codes ~ Temporary National Codes (Non-Medicare)
T Codes ~ Nat’l Codes for State Medicaid Agencies
V Codes ~ Vision/Hearing Services

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HCPCS Level II

Types of Level II Codes

Permanent National Codes maintained by the CMS HCPCS Workgroup

Responsible for additions, deletions, revisions
Updated annually

Temporary National Codes maintained by the CMS HCPCS Workgroup

Responsible for additions, deletions, revisions
Updated quarterly

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HCPCS Level II

C Codes

Outpatient Prospective Payment System - Pass-Through Items

Hospital Outpatient Departments and Ambulatory Surgical Centers

Not reported for physician coding

Example: C1819 Surgical tissue localization and excision device (implantable)

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HCPCS Level II

Dental Codes

Current Dental Terminology or CDT®
Separate category of national codes
Used for billing dental procedures and supplies
Copyright by the American Dental Association
Additions, deletions and revisions made by the ADA

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HCPCS Level II

E Codes

Durable Medical Equipment

DMEPOS Provider

Physician - prescription

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HCPCS Level II

G Codes

Procedures/Professional Services
Modifying definition

Example:

G0412 – G0415 – unilateral or bilateral

27215 – 27218 – unilateral only

CPT® Codebook:

27215

27216

27217

27218

HCPCS Codebook:

G0412

G0413

G0414

G0415

For Medicare,

see G0412-G0415

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HCPCS Level II

G Codes

Physician Quality Reporting System (PQRS)

Performance Measures

G8395 – G8977

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HCPCS Level II

H codes

Used by State Medicaid Agencies
Identify Mental Health Services

Alcohol Treatment Services
Drug Treatment Services

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HCPCS Level II

J Codes

Drugs administered

Example: J0561 Injection, penicillin g benzathine, 100,000 units

2,400,000 U Penicilin G Benzathine – reported as J0561 x 24

* Watch Quantity*

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HCPCS Level II

S Codes

Temporary Codes

Not for Medicare claims

Medicare

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HCPCS Level II

Coding Conventions

Bullet indicates new code

Triangle indicates code description has been revised

Color Coded Symbols

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HCPCS Level II

Format:

Alphabetic Index

Tabular List

Divided into different alpha-numeric sections

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HCPCS Level II

Appendices:

Level II modifiers

May be used with some CPT® codes, i.e., LT/RT

Table of Drugs and Biologicals

Names of Drugs, dosage, delivery method

Medicare References
Abbreviation and Acronyms
Place of Service Codes

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HCPCS Level II Modifiers

Two alpha characters:�Example: RT – right� LT - left

One alpha and one numeric character:�Example: F1 – Left hand, second digit� F2 – Left hand, third digit� F3 – Left hand, fourth digit� F4 – Left hand, fifth digit

Left Hand

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HCPCS Level II Table of Drugs and Biologicals

Alphabetized by drug name
Dose/Unit
Route of administration
Code

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Discarded Drugs/Medicine

MCM, Pub 100-4, Chapter 17, Subsection 100.2.9

Modifier JW - Drug amount discarded/not administered to any patient
Example: code J0595 is for a 1mg vial; patient given 0.5mg

J0595 x 0.5 mg
J0595-JW x 0.5 mg (this is for the discarded medication)

JW is not to be used:

Discarded amounts from a multi-dose vial (MDV)
Remaining amount is used on another patient instead of discarded.

Use is at the discretion of local Medicare Administrative Contractors (MACs)

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HCPCS Level II

Clinical Trials and Medicare Coverage

Health-related research studies performed on humans
Q1 – Routine clinical service provided in a clinical research study that is in an approved clinical research study
Z00.6 Encounter for examination for normal comparison and control in clinical research program
D4 – Form Locator Fields 39-41 along with 8-digit clinical trial number

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HCPCS Level II

Finding a Code

Lanoxin, 0.5mg IM

Table of Drugs and Biologicals(Appendix A)

LANOXIN, SEE DIGOXIN
DIGOXIN, 0.5 MG, IM or IV, J1160

J1160 – Injection, digoxin, up to 0.5 mg� DRUGS: LANOXIN, DIGOXIN, LANOXIN INJ

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HCPCS Level II

Finding a Code

Alphabetic Index - Orthopedic Shoes

Tabular List - L3204 – Orthopedic shoe, hightop with supinator or pronator, infant

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HCPCS Level II - Conclusion

Fewer codes than CPT® and ICD-10-CM
Smaller textbook

Care still needs to be taken when making a code selection

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CPT® Global Surgical Package

Includes a standard package of preoperative, intraoperative, and postoperative services

Payer policies may vary

May be furnished in any service location

For example, a hospital, an ambulatory surgical center (ASC), or physician office

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CPT® Global Surgical Package�(Found in the CPT® Surgery Guidelines)

Included in the surgery package and not separately billable:

Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
Evaluation and Management (E/M) service(s) subsequent to the decision for surgery, on the day before and/or day of surgery (including history and physical)
Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals
Writing orders
Evaluating the patient in the postanesthesia recovery area
Typical postoperative follow-up care

Inclusive

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CMS Global Surgical Package

Major Surgery: Has a preoperative period of 1 day with 90 days for the postoperative period.

Minor Surgery: The preoperative period is the day of the procedure with a postoperative period of either 0 or 10 days depending on the procedure.

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CMS Global Surgical Package

PFS Relative Value File

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Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

HCPCS	DESCRIPTION	GLOB DAYS	PRE OP	INTRA OP	POST OP
26010	Drainage of finger abscess	10	0.1	0.8	0.1
26011	Drainage of finger abscess	10	0.1	0.8	0.1
26020	Drain hand tendon sheath	90	0.1	0.69	0.21
26025	Drainage of palm bursa	90	0.1	0.69	0.21
26030	Drainage of palm bursas	90	0.1	0.69	0.21
26034	Treat hand bone lesion	90	0.1	0.69	0.21
26035	Decompress fingers/hand	90	0.1	0.69	0.21
26037	Decompress fingers/hand	90	0.1	0.69	0.21

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CMS Global Surgical Package

MMM and XXX

Global concept does not apply

YYY

Subject to individual pricing

ZZZ

Always included in the global period

Global period days for Medicare patients may be accessed on the CMS website:

http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp

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Global Package Modifiers

54 Surgical care only
55 Postoperative management only
56 Preoperative management only

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HCPCS	DESCRIPTION	GLOB DAYS	PRE OP	INTRA OP	POST OP
26010	Drainage of finger abscess	10	0.1	0.8	0.1
26020	Decompress hand tendon sheath	90	0.1	0.69	0.21

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Global Package Modifiers

24 Unrelated E/M by the same physician or other qualified health care professional during a postoperative period

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Example:

January 22 – Patient is seen for an injury to right index finger. The patient’s finger is amputated at the DIP joint.

March 15 – Patient is seen by the same physician for a right leg infection.

Because the March 15 visit was unrelated to the finger amputation surgery, modifier 24 is appended to the evaluation and management service for the leg infection problem.

January 22 – 26951

March 15 – 99213-24

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Global Package Modifiers

25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

Minor procedure with E/M
Global days = 0-10

Example:

A patient visits the family doctor for chest pain. The provider performs a complete work up of the chest pain and also removes a lesion on the patient’s arm. The procedure of removing the lesion is separately identifiable from the office visit.

99213-25, 11400

Modifier 25 is appended to the office visit. Modifier 25 can only be appended to evaluation and management codes.

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Global Package Modifiers

57 Decision for surgery

E/M on day before or day of a major procedure
Global days = 90

Example:

A patient visits the emergency department with acute right lower quadrant abdominal pain that increases with cough and motion. The provider determines the patient has acute appendicitis and decides to immediately perform an appendectomy.

99284-57, 44950

Because the decision for surgery was made during that office visit, and the visit falls within the preoperative global period, modifier 57 is appended to the evaluation and management code.

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Global Package Modifiers

58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period

78 Unplanned return to the operating/ procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period

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Global Package Modifiers

58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period

Example:

March 2 – Breast Biopsy

March 6 – Modified radical mastectomy

Add modifier 58 to the modified radical mastectomy

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Global Package Modifiers

78 Unplanned return to the operating/ procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

Example:

January – Gastric bypass (90 day global period)

March – Incisional hernia on the bypass incision, taken back to the operating room for incisional hernia repair.

Add modifier 78 to the hernia repair

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Global Package Modifiers

79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period

Example:

January – Amputated DIP joint (finger)

March – Below the knee amputation

Add modifier 79 to the below the knee amputation

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Surgical Modifiers

22 – Increased Procedural Service

50 - Bilateral Procedure

51 - Multiple Procedures

52 - Reduced Services

53 - Discontinued Procedure

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Modifier 22 – Increased Procedural Service

22 Services required to perform the procedure are significantly greater than usually reported with the procedure

Bill with the operative report

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Modifier 22 – Increased Procedural Service

Example:

A patient has a colonoscopy and a polyp is removed. The removal of the polyp causes excessive bleeding and an extra 30 minutes is spent controlling the bleeding.

Modifier 22 is added to the surgical code and the operative report and/or letter must be sent with the claim to the payer, which explains the need for modifier 22..

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Modifier 50 - Bilateral Procedure

Check with payers on how to submit:

One line item with modifier 50�Example: 20610-50

Two line items with modifier 50 on the second code�Example: 20610� 20610-50

Two lines using RT/LT�Example: 20610-RT� 20610-LT

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Modifier 50 - Bilateral Procedure

Pay close attention to code descriptions.

Some codes specify ‘unilateral’ and include a parenthetical statement. �

Example: 50592 – Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency

Some codes say 1 or both. �

Example: 58900 – Biopsy of ovary, unilateral or bilateral (separate procedure)

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Modifier 51 - Multiple Procedures

More than one procedure performed at the same session by the same provider�
Not used on E/M services, Physical Medicine or Rehabilitation Services, the provision of supplies such as vaccines or codes designated as ‘add-on’ codes.�

Example:

Under general anesthesia, an orthopedic surgeon performs a closed treatment of a femoral shaft fracture on the left leg and a closed treatment of a right knee dislocation during the same operative session.

27500-LT and 27552-51-RT.

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Modifier 52 - Reduced Services

Procedure partially reduced at provider discretion
Service not completed in its entirety

Example: �43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device��(For individual component placement, report 43770 with modifier 52)

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Modifier 53 - Discontinued Services

Procedure terminated due to:

Extenuating circumstances
Circumstances threatening the well-being of the patient

Do not use:

Elective cancellation prior to induction of anesthesia

Example:

A patient who is having a surgical procedure and after the administration of general anesthetic exhibits unstable vital signs. At the recommendation of the anesthesiologist the surgeon decides to terminate the procedure.

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Modifier 59 – Distinct Procedural Service

Procedures not normally reported together
Different Session or Patient Encounter
Different Procedure or Surgery
Different Site or Organ System
Separate Incision/Excision
Separate Lesion
Separate Injury

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Modifier 59 – Distinct Procedural Service

CMS provides a subset of modifier 59:

XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter;
XS - Separate Structure, a service that is distinct because it was performed on a separate organ/structure;
XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner; and
XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

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Modifier 59 – Distinct Procedural Service

Example:

A patient had a colonoscopy and a lesion is removed proximal to the splenic flexure. During the same colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure.

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Modifier 63 - Procedures Performed on Infants Less than 4kg

Increased work intensity

Temperature control
Obtaining IV access
Maintenance of homeostasis

Read the “Note” in the description to make sure you’re using the modifier correctly
Note that some procedures such as 31520 include a note in CPT®

(Do not report modifier 63 in conjunction with 31520).

See Appendix F in CPT® for a list of codes exempt from modifier 63

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The Current Procedural Terminology, or CPT®, coding manual is a compilation of guidelines, codes, and descriptions to report health care services performed by health care providers in the United States. The CPT® code set is copyrighted and maintained by American Medical Association (AMA) and is used with other code sets established by the Department of Health & Human Services and other federally-named entities for health care reporting and reimbursement.

The first CPT® code set was developed and published by the AMA in 1966, and was established as an indexing or coding system to standardize terminology among physicians and other providers.

In 1983, the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services, or CMS) adopted CPT® and its own Healthcare Common Procedure Coding System, HCPCS, Level II, mandating these code sets be for use in all Medicare billings. These code sets largely standardized reporting of medical services, equipment, and supplies.

Medicaid agencies and commercial health plans soon adopted the code sets and began to require CPT® and HCPCS Level II codes for reporting health care services for reimbursement.

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Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

Example:

A patient who goes to the Emergency Room with a trauma to the chest. A two-view chest x-ray is taken that shows a pneumothorax. After a chest tube is placed a repeat two-view chest x-ray is taken to verify the placement of the chest tube.

Report 71020 and 71020-76.

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Now that you have some history, let’s move on to the format of your CPT® book. Much of this information comes from the Introduction Section of CPT®. While I won’t go over all the information in this section, I do want to touch on a few of the subjects. I’d suggest you take the time to thoroughly read the Introduction on your own.

Now, turn with me to the introduction in your CPT® codebook. The introduction is often overlooked, but there is important information for you to refer to.

First, under Instructions for Use of the CPT® Codebook, your second sentence explains, do not select a CPT® code that merely approximates the service provided. Instead an unlisted procedure code should be used.

<pop-up box:

“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 provide. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.”

CPT Professional – Page xii>

The fifth paragraph indicates the importance of reading the parenthetical instructions surrounding the CPT® codes. The parenthetical instructions are intended to prevent significant errors, but are not all inclusive.

The same paragraph in this section reminds us of the importance of accuracy and quality of coding by also referring to the parenthetical instructions related guidelines, AMA CPT® Assistant, and other coding resources. This is an added reminder of how important it is to know and teach through the guidelines. This is all-important information for you to remember as you venture into the world of coding.

<pop-up box:

“When reporting codes for services provided, it is important to assure the accuracy and quality of coding through verification of the intent of the code by use of the related guidelines, parenthetic instructions, and coding resources, including CPT Assistant and other publications resulting from collaborative efforts of the American Medical Association with the medical specialty societies (ie, Clinical Examples in Radiology).”>

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Modifier 77 - Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional

Example:

A patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG.

The second EKG is reported with modifier 77.

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Multiple Surgeon Modifiers

62 – Two Surgeons

Work together as primary surgeons
Perform distinct parts of a procedure
Dictate op report of their distinct part
Each will submit the same code and append modifier 62�

66 – Surgical Team

Highly complex procedures
Require differently specialties
Modifier 66 appended to procedures coded by the surgical team

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Assistant Surgeon Modifiers

80 – Assistant Surgeon

Assistant surgeon present for entire or substantial portion of the operation
Reports the same surgical procedure with modifier 80 appended

81 – Minimum Assistant Surgeon

Circumstances present that require the services of an asst surgeon for a short time. Minimal assistance.
Reports the same surgical procedure with modifier 81 appended

82 – Assistant Surgeon (when qualified resident surgeon not available)

Used in a teaching hospital that employs residents
No residents available and another surgeon is used

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Ancillary Modifiers

Global – a procedure containing both a technical and a professional component

Modifier 26 – Professional Component

Modifier TC – Technical Component

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Each Main Section title has subsections divided by anatomic location, procedure, condition, or descriptor subheadings. The subheadings, structured by CPT® conventions, may list alternate coding suggestions in parenthetical instructions.

Pause this recording while you look for the subsection for Debridement in your CPT® codebook. Press play when you are ready to continue. <pause> We will look at the Debridement subsection on the first page, after the Integumentary System Table of Contents. Press play when you have found this section.

In this example, the section is Surgery, the subsection is the Integumentary System, the subheading is Skin, Subcutaneous and Accessory Structures. The category is Debridement. Under debridement, you will see a paragraph of guidelines, followed by alternate coding suggestions for dermabrasions, nail debridement, burns, and pressure ulcers. The alternate coding suggestions are there to aid in helping you locate the correct code.

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Ancillary Modifiers

Example:

A patient comes to the office with wheezing and congestion. The physician takes a 2-view chest X-ray using his or her own equipment and sends it out to be read by a radiologist. The office reports 71020-TC for the use of the equipment (technical).

The radiologist reports 71020-26 for his/her interpretation and report (professional service).
If the office performs the X-ray and also office physician performs the interpretation and report, code 71020 – without any modifiers – to indicate the global service…both the technical and professional components

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Laboratory Modifiers

90 – Reference (Outside) Laboratory

Used to bill for lab services purchased from an outside lab

91 – Repeat Clinical Diagnostic Lab Test

Not used to confirm results
Not used to repeat a test due to equipment malfunction

92 – Alternative Lab Platform Testing

Single use
HIV testing

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Category II CPT® codes are recognized by their alphanumeric format, with the letter “F” in the last position, for example, 0001F. They are located near the back of the CPT® codebook after the Medicine Section. Locate the Category II codes, they are found by going to the section labeled Category II, toward the back of the book. <pause>

Category II CPT® codes are reported in addition to evaluation and management services or clinical service CPT® Category I codes. They are optional “performance measurement” tracking codes designed to facilitate data collection by the AMA and CMS regarding quality of care. They are also used for the Physician Quality Reporting System (PQRS) to provide outcome measurements for certain medical conditions.

You can see the example here regarding a category II code for a physician who counsels a patient regarding prescribed Statin therapy for coronary artery disease. Statin Therapy is used to help a patient lower their LDL cholesterol measurement. The code is 4013F. The appropriate level of evaluation and management is also reported with this code.

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Anesthesia Modifiers

23 - Unusual Anesthesia

47 – Anesthesia by Surgeon

Physical Status Modifiers

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HCPCS Level II�(Healthcare Common Procedure Coding System)

Level I HCPCS is CPT®

Maintained by AMA
Identify services and procedures

Level II HCPCS

Maintained by CMS
Identify products, supplies, and services not included in CPT®

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HCPCS Level II

A Codes ~ Transportation Services, Med/Surg Supplies, Admin
B Codes ~ Enteral and Parenteral Therapy
C Codes ~ Pass-Through Items
D Codes ~ Dental Procedures – Listed after V codes
E Codes ~ Durable Medical Equipment
G Codes ~ Procedures/Professional Services
H Codes ~ Alcohol and Drug Abuse Treatment Services
J Codes ~ Drugs Admin Other Than Oral Method/Chemotherapy Drugs
K Codes ~ DME Supplies
L Codes ~ Orthotic/Prosthetic Procedures
M Codes ~ Medical Services
P Codes ~ Lab/Path
Q Codes ~ Temporary Codes
R Codes ~ Diagnostic Radiology
S Codes ~ Temporary National Codes (Non-Medicare)
T Codes ~ Nat’l Codes for State Medicaid Agencies
V Codes ~ Vision/Hearing Services

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HCPCS Level II

Types of Level II Codes

Permanent National Codes maintained by the CMS HCPCS Workgroup

Responsible for additions, deletions, revisions
Updated annually

Temporary National Codes maintained by the CMS HCPCS Workgroup

Responsible for additions, deletions, revisions
Updated quarterly

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HCPCS Level II

Types of Temporary Codes

G codes

Professional health care procedures/services with no CPT ® codes
Example:

G0412 – G0415 – unilateral or bilateral
27215 – 27218 – unilateral only, use modifier 50 for bilateral

H codes

Used by State Medicaid Agencies for mental health services such as alcohol and drug treatment services

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HCPCS Level II

Dental Codes

Current Dental Terminology or CDT®
Separate category of national codes
Used for billing dental procedures and supplies
Copyright by the American Dental Association
Additions, deletions and revisions made by the ADA

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HCPCS Level II

Coding Conventions

Bullet indicates new code

Triangle indicates code description has been revised

X with line through code and code description means code has been deleted

Color Coded Symbols

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HCPCS Level II

Format:

Alphabetic Index

Tabular Index

Divided into different alpha-numeric sections

Table of Contents

List of alpha sections with code ranges and page numbers

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HCPCS Level II

Appendices:

Table of Drugs and Biologicals

Names of Drugs, dosage, delivery method, J code

HCPCS modifiers

May be used with some CPT® codes, i.e., LT/RT

List of Abbreviations
Place of Service
Type of Service
Medically Unlikely Edits (MUEs) Including Hospital Outpatient Services
PQRS Table with HCPCS Code Numerator and Corresponding Denominator
General Correct Coding Policies
Column 1 and Column 2 Correct Coding Edits
Publication 100 References

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HCPCS Level II Modifiers

Two alpha characters:�Example: RT – right� LT - left

One alpha and one numeric character:�Example: F1 – Left hand, second digit� F2 – Left hand, third digit� F3 – Left hand, fourth digit� F4 – Left hand, fifth digit

Left Hand

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HCPCS Level II Table of Drugs and Biologicals

Alphabetized by drug name
Dose/Unit
Route of administration
Code(s)

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HCPCS Level II

Finding a Code

Dilantin 50mg IM

Table of Drugs and Biologicals (Appendix 1)

J1165 – Injection, phenytoin sodium, per 50 mg� Use this code for Dilantin.

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HCPCS Level II

Finding a Code

Orthopedic Shoes

Two ways to find it

Table of Contents
Alphabetic Index

L3204 - High-top orthopedic shoe with pronator for an infant

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HCPCS

Fewer codes than CPT® and ICD-9-CM
Smaller textbook

Care still needs to be taken when making a code selection

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