1 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CHAPTER 1 INTRODUCTION TO THE CPT

2 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. MEDICAL CODING Transforms services/procedures/ supplies/drugs into CPT/HCPCS codesTransforms services/procedures/ supplies/drugs into CPT/HCPCS codes Transforms diagnosis and procedures into ICD-9-CM codesTransforms diagnosis and procedures into ICD-9-CM codes

3 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Levels of Service Codes Level I CPT—(Category 1: , Category III: 0016T-0183T), Text, Chapters 1-13Level I CPT—(Category 1: , Category III: 0016T-0183T), Text, Chapters 1-13 Level II HCPCS, National Codes— (A0021-V5364), Text, Chapter 13Level II HCPCS, National Codes— (A0021-V5364), Text, Chapter 13 Level III Local Codes—phased out due to HIPAALevel III Local Codes—phased out due to HIPAA

4 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Diagnosis Codes ICD-9-CM, Volumes 1 & 2ICD-9-CM, Volumes 1 & 2 International Classification of Diseases, 9th Ed., Clinical ModificationInternational Classification of Diseases, 9th Ed., Clinical Modification Text, Chapters 14 and 15Text, Chapters 14 and 15

5 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. ICD-9-CM Classification systemClassification system Explains why service was providedExplains why service was provided Changes diagnoses into codesChanges diagnoses into codes Diabetes becomes 250.XX (highest level of specificity)Diabetes becomes 250.XX (highest level of specificity)

6 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Why Codes? Computers understand numbersComputers understand numbers Specific descriptions attached to each codeSpecific descriptions attached to each code

7 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CPT-4 Developed by the AMA in 1966Developed by the AMA in 1966 Five-digit codesFive-digit codes Updated in November for use January 1Updated in November for use January 1

8 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Examples of Types of CPT Codes MedicalMedical SurgicalSurgical Diagnostic servicesDiagnostic services Anesthesia, etc.Anesthesia, etc. Category II and Category III codes—alpha numericCategory II and Category III codes—alpha numeric –Category II = performance measuring –Category III = emerging technology

9 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CPT Codes Allow For Communication that is both effective and efficientCommunication that is both effective and efficient A mechanism to report a service not described by a specific CPT or Level II codeA mechanism to report a service not described by a specific CPT or Level II code

10 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Consider Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent)Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) OR 50575OR 50575

11 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Codes Are Used to tell third-party payers about services/procedures providedUsed to tell third-party payers about services/procedures provided Often used as basis of paymentOften used as basis of payment

12 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Incorrect Coding Results in providers being paid inappropriatelyResults in providers being paid inappropriately –Either over or underpayment –Decreases cash flow –Liability risk

13 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Codes Are Used By ClinicsClinics HospitalsHospitals Rehabilitation unitsRehabilitation units Ambulance servicesAmbulance services Long-term careLong-term care Wherever health care services are providedWherever health care services are provided

14 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Outpatient Services for Physicians Reported on insurance formReported on insurance form CMS-1500 = universal formCMS-1500 = universal form

15 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CMS-1500 Figure: 1.1

16 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CPT Format Symbols in CPTSymbols in CPT Used to convey informationUsed to convey information Bullseye, moderate (conscious) sedation included (full list in Appendix G, CPT)Bullseye, moderate (conscious) sedation included (full list in Appendix G, CPT) –Example 45391, Colonoscopy with endoscopic ultrasound examination Lightning bolt, pending FDA approvalLightning bolt, pending FDA approval –Example 60662, Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

17 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Bullet = New Code Bullet = New Code Figure: 1.2

18 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. ▲Triangle = Revised Code Figure: 1.3

19 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. ►◄ Right and Left Triangles = Beginning and Ending of Text Change Figure: 1.4

20 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. + Plus = Add-On Code Figure: 1.5

21 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Add-On Code (…Cont’d) Can only be used with another specific codeCan only be used with another specific code Never used aloneNever used alone No reduction for multiple servicesNo reduction for multiple services Full list in Appendix D of CPTFull list in Appendix D of CPT

22 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. =Circle With Line, -51 Cannot Be Used With these Codes =Circle With Line, -51 Cannot Be Used With these Codes CPT Appendix E contains a listing of -51 exempt codesCPT Appendix E contains a listing of -51 exempt codes Services typically exempt from multiple procedure reductionsServices typically exempt from multiple procedure reductions Figure: 1.6

23 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Six CPT Sections (like chapters) 1.Evaluation & Management (E/M) 2.Anesthesia 3.Surgery 4.Radiology 5.Pathology & Laboratory 6.Medicine Category II CodesCategory II Codes Category III CodesCategory III Codes AppendixAppendix IndexIndex

24 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Categorized By SectionsSections SubsectionsSubsections SubheadingsSubheadings CategoriesCategories

25 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Categorized By (…Cont’d) AnatomyAnatomy –Knee or Shoulder ProcedureProcedure –Incision or Excision ConditionCondition –Fracture or Dislocation DescriptionDescription –Cast or Strap Surgical ApproachSurgical Approach –Anterior Cranial Fossa or Middle Cranial Fossa

26 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Categorized By, Example Figure: 1.8 (…Cont’d)

27 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Guidelines Section-specific information begins each sectionSection-specific information begins each section Figure: 1.9

28 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Notes Must-reading located throughout the CPTMust-reading located throughout the CPT Figure: 1.11

29 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Two Types of Codes Stand-alone: Full descriptionStand-alone: Full description Indented: Dependent on preceding stand-aloneIndented: Dependent on preceding stand-alone –Verbiage before the semicolon applies to all indented codes that follow

30 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Types of Codes, Example Figure: 1.13

31 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Semicolon Indicates full description in preceding codeIndicates full description in preceding code You must return to the stand-alone for full descriptionYou must return to the stand-alone for full description

32 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Modifiers Add Information CPT ModifierCPT Modifier Two digitsTwo digits –62 Two surgeons performed a surgical procedure –Each surgeon applies his/her individual skill

33 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Level II HCPCS Modifiers “-AS” Physician’s Assistant“-AS” Physician’s Assistant “-F1” Left hand, second digit“-F1” Left hand, second digit All modifiers used on CPT or HCPCSAll modifiers used on CPT or HCPCS

34 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Example of Modifier Gastrojejunostomy43820 Gastrojejunostomy -62 two surgeons two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payer Example: Medicare requires documentation of medical necessity

35 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Modifier on the CMS-1500 Modifiers are placed in 24D on CMS-1500Modifiers are placed in 24D on CMS-1500

36 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Unlisted Services Codes ending in “99” = “no specific Category I or III code”Codes ending in “99” = “no specific Category I or III code” Used if no more specific codeUsed if no more specific code Written report must accompany submissionWritten report must accompany submission

37 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Written Report Indicates: NatureNature ExtentExtent NeedNeed TimeTime EffortEffort Equipment UsedEquipment Used Photos and medical journal articles if relevantPhotos and medical journal articles if relevant

38 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Category II Codes— Supplemental Tracking Codes Used for performance measurementsUsed for performance measurements Codes collect data concerning quality of care and test(s) requiredCodes collect data concerning quality of care and test(s) required Alphanumeric and end in the letter “F” (1005F)Alphanumeric and end in the letter “F” (1005F) Located after the Medicine section of the CPT manualLocated after the Medicine section of the CPT manual

39 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Category III Codes— New Technology Temporary codes—up to 5 yearsTemporary codes—up to 5 years Identify emerging technology, services, and proceduresIdentify emerging technology, services, and procedures Located after Medicine sectionLocated after Medicine section Alphanumeric (0016T)Alphanumeric (0016T) –May or may not receive future Category I code status

40 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Category I Codes Category I codes (00100–99607)Category I codes (00100–99607) –Approved by AMA and Food and Drug Administration –Proven clinical effectiveness (efficacy)

41 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Category III Codes Category III codes have not been approved and have no proven clinical effectivenessCategory III codes have not been approved and have no proven clinical effectiveness Usage orderUsage order –Use Category III code instead of unlisted code –Use unlisted code if no Category III code

42 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. The Index! Used to locate service/procedure terms and codesUsed to locate service/procedure terms and codes Speeds up code locationSpeeds up code location Like a dictionaryLike a dictionary First entries and last entriesFirst entries and last entries

43 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. CPT Index Figure: 1.17

44 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Presentation of Codes in Index Single code: 38115Single code: Multiple codes: 26645, 26650Multiple codes: 26645, Note comma - Note comma Range of codes: Range of codes: Note hyphen

45 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Location Methods With Examples 1.Service/procedure : repair, excision 2.Anatomic site: medial nerve, elbow 3.Condition or Disease: cleft lip, clot 4.Synonym: toe and interphalangeal joint 5.Eponym: Jones procedure, Heller operation 6.Abbreviation: ECG, PEEP (Pressure Breathing, Positive)

46 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Always Reference indexReference index Locate code in main portion of CPTLocate code in main portion of CPT Read the entire description and any notesRead the entire description and any notes

47 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. “See” in Index Cross-reference termsCross-reference terms –“Look here for code” Index: Stem, Brain: See BrainstemIndex: Stem, Brain: See Brainstem

48 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Appendices of CPT Appendix A: ModifiersAppendix A: Modifiers Appendix B: Additions, Deletions, RevisionsAppendix B: Additions, Deletions, Revisions Appendix C: Clinical Examples, E/M CodesAppendix C: Clinical Examples, E/M Codes Appendix D: Add-On CodesAppendix D: Add-On Codes Appendix E: -51 Exempt CodesAppendix E: -51 Exempt Codes Appendix F: -63 Exempt CodesAppendix F: -63 Exempt Codes Appendix G: Includes Moderate (Conscious) SedationAppendix G: Includes Moderate (Conscious) Sedation

49 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Appendices of CPT (…Cont’d) Appendix H: Performance Measures, Category II CodesAppendix H: Performance Measures, Category II Codes Appendix I: Genetic Testing ModifiersAppendix I: Genetic Testing Modifiers Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed NervesAppendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix K: Product Pending FDA ApprovalAppendix K: Product Pending FDA Approval Appendix L: Vascular FamiliesAppendix L: Vascular Families Appendix M: Crosswalk to Deleted CPT CodesAppendix M: Crosswalk to Deleted CPT Codes

50 Copyright © 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CPT codes are copyright of the American Medical Association. CPT only © Current Procedural Terminology, 2009, American Medical Association. All Rights Reserved. Conclusion CHAPTER 1 INTRODUCTION TO THE CPT