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

LEARNING OUTCOMES Explain the purpose of the CPT code set. 6-2 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.

KEY TERMS Add-on code descriptor 837P facility modifier 6-3 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-1500 HCPCS (Healthcare Code-range Common Procedure Coding System) Cross-walk modifier Current Procedural payment-for-performance Terminology (CPT) (P4P)

KEY TERMS CPT Modifier postoperative period 6-4 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

6-5 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

6-6 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

PURPOSE OF CPT Reimburse physician services 6-7 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

6-8 ALL CPT CODES MUST BE: Commonly performed by physicians across the nation Consistent with mainstream medical practice Approved by the AMA CPT Editorial Board

6-9 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

INTRODUCTION TO CPT Category I codes are permanent codes 6-10 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

EVALUATION AND MANAGEMENT SECTION 6-11 EVALUATION AND MANAGEMENT SECTION Code Ranges 99201 - 99499 Cover physician services that are performed to determine the best course for patient care

ANESTHESIA SECTION Code Ranges 00100 – 01999 6-12 ANESTHESIA SECTION Code Ranges 00100 – 01999 Used to report anesthesia services performed or supervised by a physician Codes include routine anesthesia care Pre-op, intra-op, post-op

SURGERY SECTION Largest section in the CPT book 6-13 SURGERY SECTION Largest section in the CPT book Code ranges 10021 – 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

RADIOLOGY SECTION Code Ranges 70010 – 79999 6-14 RADIOLOGY SECTION Code Ranges 70010 – 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

PATHOLOGY/LABORATORY SECTION 6-15 PATHOLOGY/LABORATORY SECTION Code Ranges 80048 – 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

MEDICINE SECTION Code Ranges 90281 – 99607 6-16 MEDICINE SECTION Code Ranges 90281 – 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

6-17 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”

CATEGORY III CODES Introduced in 2002 6-18 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

APPENDIXES Appendix A Appendix B Appendix C Appendix D 6-19 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

APPENDIXES CONTINUED Appendix E Appendix F Appendix G Appendix H 6-20 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

APPENDIXES CONTINUED Appendix I Appendix J Appendix K Appendix L 6-21 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

PUNCTUATION AND SYMBOLS 6-22 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

PUNCTUATION AND SYMBOLS CONTINUED 6-23 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

MODIFIERS 2-digit characters added to the end of a CPT code 6-24 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

CPT MODIFIERS Listed in the front cover of the CPT book List of these: 6-25 CPT MODIFIERS Listed in the front cover of the CPT book List of these: 21 -22 -23 -24 -25 -26 -27 -32 -47 -50 51 -52 -53 -54 -55 -56 -57 -58 -59 -62 63 -66 -73 -74 -76 -77 -78 -79 -80 -81 82 -90 -91 -99

FACILITY MODIFIERS There are 13 approved facility modifiers 6-26 FACILITY MODIFIERS There are 13 approved facility modifiers Some of these are the same of the CPT modifiers List of these: 25 -27 -50 -52 -58 -59 -73 74 -76 -77 -78 -79 -91

HCPCS MODIFIERS Are alphanumeric 6-27 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

DESCRIPTION OF MODIFIERS 6-28 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

DESCRIPTION OF MODIFIERS 6-29 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 - 73 - discontinued out-patient hospital/ambulatory surgery center procedure prior to the administration of anesthesia

DESCRIPTION OF MODIFIERS 6-30 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

DESCRIPTION OF MODIFIERS 6-31 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

DESCRIPTION OF MODIFIERS 6-32 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

DESCRIPTION OF MODIFIERS 6-33 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

6-34 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.

HOW TO ASSIGN CPT CODES AND MODIFIERS 6-35 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

HOW TO ASSIGN CPT CODES AND MODIFIERS 6-36 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

HELPFUL CPT CODING RESOURCES 6-37 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 www.cms.hhs.gov/NationalCorrectCodInitEd www.cms.hhs.gov/center/coverage.asp