1. PART THREE Chapter 6 CPT Basics INTRODUCTION TO CPT McGraw-Hill/Irwin
Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

2. LEARNING OUTCOMES Explain the purpose of the CPT code set.
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LEARNING OUTCOMES
After studying this chapter, you should be able to:
Explain the purpose of the CPT code set.
Identify the medical settings in which CPT is used.
Describe the content and organization of CPT.
Identify the symbols, format and punctuation used in CPT.
Discuss the purpose and use of CPT modifiers, distinguishing among CPT professional, HCPCS, and facility modifiers.
Recognize the importance of using current codes and discuss ways to stay up to date.
Compare and contrast the ICD-9-CM and CPT code sets.
List CPT coding resources and references.
Recognize when an unlisted code is needed, and identify the purpose and parts of a special report.
List the nine steps to properly assign CPT codes and to correctly select and append modifiers.

3. KEY TERMS Add-on code descriptor 837P facility modifier
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KEY TERMS
Add-on code descriptor
837P facility modifier
American Medical Association fee-for-service
Capitation fee schedule
Category I code HCPCS Level 1 code
Category II code HCPCS Level II code
Category III code HCPCS Modifier
CMS HCPCS (Healthcare
Code-range Common Procedure Coding System)
Cross-walk modifier
Current Procedural payment-for-performance Terminology (CPT) (P4P)

4. KEY TERMS CPT Modifier postoperative period
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KEY TERMS
CPT Modifier postoperative period
Primary procedure professional services
Resource-based relative secondary procedure value system (RBRVS)
Section guidelines semicolon
Separate procedure significant procedure
Special report surgical package
Unlisted code usual fee

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DESCRIPTION OF CPT
CPT is a coding nomenclature that allows medical procedures to be transformed to numbers
CPT is based on professional services provided by healthcare providers such as physician, nurse practitioners and physician assistants
CPT services include office visits, surgery, laboratory, radiology, pathology, anesthesia and medical procedures

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CPT BACKGROUND
CPT was developed by the American Medical Association (AMA) in 1966.
CPT is still currently maintained by the AMA
CPT code sets
HCPCS level I
CPT codes maintained by AMA
HCPCS level II
HCPCS codes maintained by Federal Government

7. PURPOSE OF CPT Reimburse physician services
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PURPOSE OF CPT
Reimburse physician services
Trending services provided nationally
Future coding and reimbursement planning
Benchmarking facilities, costs and services
Measuring quality of care and patient outcomes nationally

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ALL CPT CODES MUST BE:
Commonly performed by physicians across the nation
Consistent with mainstream medical practice
Approved by the AMA CPT Editorial Board

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ORGANIZATION OF CPT
Each code is followed by a unique code descriptor explaining the service
More than 8,000 unique CPT codes
CPT codes are 5 digits long
CPT manual includes parenthetical notes

10. INTRODUCTION TO CPT Category I codes are permanent codes
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INTRODUCTION TO CPT
Category I codes are permanent codes
6 Sections of Category I codes-each with a set of guidelines at the section beginning
Evaluation and Management (E/M)
Anesthesia
Surgery
Radiology
Pathology/Laboratory
Medicine

11. EVALUATION AND MANAGEMENT SECTION
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EVALUATION AND MANAGEMENT SECTION
Code Ranges
Cover physician services that are performed to determine the best course for patient care

12. ANESTHESIA SECTION Code Ranges 00100 – 01999
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ANESTHESIA SECTION
Code Ranges – 01999
Used to report anesthesia services performed or supervised by a physician
Codes include routine anesthesia care
Pre-op, intra-op, post-op

13. SURGERY SECTION Largest section in the CPT book
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SURGERY SECTION
Largest section in the CPT book
Code ranges – 69990
Divided by body systems
Integumentary, musculoskeletal, respiratory, digestive, cardiology, urinary, male/female, nervous, auditory/ocular
Codes are for a surgical package
Pre-op, intra-op, post-op

14. RADIOLOGY SECTION Code Ranges 70010 – 79999
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RADIOLOGY SECTION
Code Ranges – 79999
Used to report radiological services performed or supervised by a physician
Codes are selected based on the body part and number/type of view

15. PATHOLOGY/LABORATORY SECTION
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PATHOLOGY/LABORATORY SECTION
Code Ranges – 89356
Cover services provided by physicians or technician supervised by physicians
Complete procedure includes:
Ordering the test
Taking/handling the sample
Performing the test
Analyzing/reporting on the test results

16. MEDICINE SECTION Code Ranges 90281 – 99607
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MEDICINE SECTION
Code Ranges – 99607
Codes include the many types of evaluation, therapeutic, and diagnostic procedures that physicians/health care providers perform
May be used by procedures done or supervised by a physician of any specialty

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CATEGORY II CODES
Used to track physician performance in measuring and monitoring patient care
Are alphanumeric codes, start with 1 letter then followed by 4 numbers
Improve quality of care but are not “billable”

18. CATEGORY III CODES Introduced in 2002
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CATEGORY III CODES
Introduced in 2002
They are used to report new technology, services or procedures that do not currently have a CPT code assigned
Located directly after the Category II codes
Allow researchers to track emerging technology

19. APPENDIXES Appendix A Appendix B Appendix C Appendix D
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APPENDIXES
Appendix A
Lists/examples of modifiers
Appendix B
Summary of additions/deletions/revisions
Appendix C
Clinical Examples of E/M Codes
Appendix D
Summary of CPT Add-on Codes

20. APPENDIXES CONTINUED Appendix E Appendix F Appendix G Appendix H
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APPENDIXES CONTINUED
Appendix E
Summary of CPT codes exempt from -51
Appendix F
Summary of CPT codes exempt from -63
Appendix G
Summary of CPT codes which include conscious sedation
Appendix H
Alphabetical index of performance measures by clinical condition or topic

21. APPENDIXES CONTINUED Appendix I Appendix J Appendix K Appendix L
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APPENDIXES CONTINUED
Appendix I
Genetic Testing Code Modifiers
Appendix J
Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves
Appendix K
Product Pending FDA Approvement
Appendix L
Vascular Families
Appendix M
Crosswalk to deleted CPT codes

22. PUNCTUATION AND SYMBOLS
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PUNCTUATION AND SYMBOLS
; Semicolon
Divides the common portion of a code descriptor from the unique portion
Bullet
New Code
▲Triangle
Revised code
+ Plus Symbol
Add on code

23. PUNCTUATION AND SYMBOLS CONTINUED
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PUNCTUATION AND SYMBOLS CONTINUED
 Modifier 51 Exempt
Indicates the code cannot be assigned with -51
►◄Facing Triangles
That the code is new or revised since the last year’s edition
 Circled Bullet
That conscious sedation is included in code
 Lightning Bolt
Is for a vaccine pending FDA Approval

24. MODIFIERS 2-digit characters added to the end of a CPT code
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MODIFIERS
2-digit characters added to the end of a CPT code
Used to communicate special circumstances surrounding the assigned code
May increase or decrease the amount of reimbursement
Three types of modifiers
CPT Modifiers
Facility Modifiers
HCPCS Modifiers

25. CPT MODIFIERS Listed in the front cover of the CPT book List of these:
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CPT MODIFIERS
Listed in the front cover of the CPT book
List of these:

26. FACILITY MODIFIERS There are 13 approved facility modifiers
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FACILITY MODIFIERS
There are 13 approved facility modifiers
Some of these are the same of the CPT modifiers
List of these:

27. HCPCS MODIFIERS Are alphanumeric
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HCPCS MODIFIERS
Are alphanumeric
Some are in the front of the CPT book and the remaining are in the HCPCS book
Required when filing claims to government payors
List of these:
Ca -E1 -E2 -E3 -E4 -FA -F1 -F2 -F3 -F4
F5 -F6 -F7 -F8 -F9 -GA -GG -GH -LC
LD -RC -QM -QN -TA -T1 -T2 -T3 -T4
T5 -T6 -T7 -T8 -T9 -TC

28. DESCRIPTION OF MODIFIERS
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DESCRIPTION OF MODIFIERS
-21 – prolonged evaluation and management services
-22 – unusual (increased) procedural services
-23 – unusual anesthesia
-24 – unrelated evaluation and management service by the same physician during a postoperative period
-25 – significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
-26 – professional component
-27 – multiple outpatient hospital E/M encounters on the same date
-32 – mandated services
-47 – anesthesia by surgeon
50 – bilateral procedure
51 – multiple procedures

29. DESCRIPTION OF MODIFIERS
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DESCRIPTION OF MODIFIERS
-52 – reduced services
-53 – discounted procedure
-54 – surgical care only
-55 – postoperative management only
-56 – preoperative management only
-57 – decision for surgery
-58 – staged or related procedure or service by the same physician during the postop period
-59 – distinct procedural service
-62 – two surgeons
-63 – procedure performed on infants less than 4 kg
-66 – surgical team
discontinued out-patient hospital/ambulatory surgery center procedure prior to the administration of anesthesia

30. DESCRIPTION OF MODIFIERS
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DESCRIPTION OF MODIFIERS
-74 - discontinued out-patient hospital/ambulatory surgery center procedure after administration of anesthesia
-76 – repeat procedure by same physician
-77 – repeat procedure by another physician
-78 – return to the operating room for a related procedure during the postoperative period
-79 – unrelated procedure or service by the same physician during the postoperative period
-80 – assistant surgeon
-81 – minimum assistant surgeon
-82 assistant surgeon (when qualified resident surgeon not available)
- 90 – reference (outside) laboratory
-91 – repeat clinical diagnostic laboratory test
-99 – multiple modifiers

31. DESCRIPTION OF MODIFIERS
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DESCRIPTION OF MODIFIERS
-E1 – upper left, eyelid
-E2 – lower left, eyelid
-E3 – upper right, eyelid
-E4 – lower right, eyelid
F1 – left hand, second digit
-F2 – left hand, third digit
-F3 – left hand, fourth digit
-F4 – left hand, fifth digit
-F5 – right hand, thumb
-F6 – right hand, second digit
-F7 – right hand, third digit
-F8 – right hand fourth digit
-F9 – right hand fifth digit
- FA – left hand, thumb

32. DESCRIPTION OF MODIFIERS
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DESCRIPTION OF MODIFIERS
-GG – performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
-GH – diagnostic mammogram converted from screening mammogram on same day
-LC – left circumflex coronary artery
-LD – left anterior descending coronary artery
-LT – left side
-QM – ambulance service provided under arrangement by a provider of services
-QN – Ambulance service furnished directly by a provider of services
-RC – right coronary artery
-RT – right side

33. DESCRIPTION OF MODIFIERS
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DESCRIPTION OF MODIFIERS
-T1 – left foot, second digit
-T2 – left foot, third digit
-T3 – left foot, fourth digit
-T4 – left foot, fifth digit
-T6 – right foot, great toe
-T7 – right foot, second digit
-T8 – right foot, third digit
-T9 – right foot, fifth digit
-TA – left foot, great toe

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CPT UPDATES
New, deleted and changed CPT codes are updated yearly, in October by the AMA and go into effect in January of the following year.
Category III codes are updated twice a year, July 1 and January 1.

35. HOW TO ASSIGN CPT CODES AND MODIFIERS
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HOW TO ASSIGN CPT CODES AND MODIFIERS
Step 1: review the complete medical documentation
Step 2: Abstract the medical procedures that should be coded
Step 3: Identify the main terms and related terms
Step 4: Locate the terms in the CPT index
Step 5: Review the codes, descriptors and notes

36. HOW TO ASSIGN CPT CODES AND MODIFIERS
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HOW TO ASSIGN CPT CODES AND MODIFIERS
Step 6: Verify the code against the documentation
Step 7: Assign codes for all significant services
Step 8: Assign modifiers, if appropriate
Step 9: Check all possibilities before final code assignment

37. HELPFUL CPT CODING RESOURCES
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HELPFUL CPT CODING RESOURCES
Medical Dictionary
Anatomy & Physiology Text
Current ICD-9-CM, CPT, and HCPCS codebooks
Physician’s Desk Reference
Merck Manual
Contractor’s Provider Manual
Subscription to AHA Coding Clinic
Subscription to AMA Coding Assistant