© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Chapter 8 Introduction to CPT Coding

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. History of CPT 1966 –Published by AMA 1970 –Five-digit codes 1983 –Adopted as part of HCPCS (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. History of CPT 1986 –Omnibus Budget Reconciliation Act (OBRA) 1996 –HIPAA 2004 –MMA (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Mandated Reporting Home health care and hospice agencies Outpatient hospital departments Physicians who are employees of a health care facility Physicians who see patients in their offices or clinics and in patients’ homes

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Non-Reportable Services Considered integral to procedure No separate code reported

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Examples of Non-Reportable Services Administering sedatives Cleansing, shaving, and prepping of skin Draping and positioning of patient Irrigating wound Inserting and removing drains

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Categories Category I codes –Procedures and services Category II codes –Performance measures Category III codes –Emerging technology

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Organization of CPT Six sections –Evaluation and Management (E/M) (99201–99499) –Anesthesia (00100–01999, 99100–99140) –Surgery (10021–69990) –Radiology (70010–79999) –Pathology and Laboratory (80048–89398) –Medicine (90281–99199, 99500–99607)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Index Alphabetic main terms –Boldfaced –Represent procedures or services, organs, anatomic sites, conditions, eponyms, or abbreviations –Subterms are indented below

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Selection from CPT Index © Cengage Learning 2014

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Index Organization –Procedures or services (e.g., endoscopy) –Organs or other anatomic sites (e.g., elbow) –Conditions (e.g., wound) –Synonyms (e.g., finger joint or intercarpal joint) –Eponyms (e.g., Whitman procedure) –Abbreviations (e.g., MRI) (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Index Boldfaced type –Main terms, categories, subcategories, and code numbers Italicized type –Cross-reference terms (e.g., see) –Directs coders to index entry under which codes are listed (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Appendices Appendix A –List of modifiers and descriptions Appendix B –Annual CPT coding additions, deletions, and revisions Appendix C –Clinical examples for codes found in E/M section (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Appendices Appendix D –List of add-on codes –Identified with plus symbol (+) Appendix E –List of codes exempt from modifier -51 Appendix F –List of codes exempt from modifier -63 (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Appendices Appendix G –Summary of CPT codes identified with bull’s eye symbol –Codes that include Moderate (Conscious) Sedation (MCS) (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Appendices Appendix H –Alphabetic index of performance measures by clinical condition or topic Appendix I –Genetic testing modifiers (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Appendices Appendix J –Electrodiagnostic medicine listing of sensory, motor, and mixed nerves Appendix K –List of codes pending Food and Drug Administration (FDA) approval (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Appendices Appendix L –List of vascular families Appendix M –List of deleted CPT codes and descriptions with crosswalk to new CPT codes Appendix N –Summary of Resequenced CPT codes (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Symbols Bullet located to the left of code identifies new procedures and services Triangle located to the left of code identifies revision of code description Horizontal triangle symbols surround revised guidelines and notes (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Symbols Semicolon saves space in CPT (;) Plus identifies add-on codes for procedures commonly, but not always, performed at the same time and by the same surgeon as the primary procedure (+) (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Symbols Circle with slash identifies forbidden or prohibited codes exempt from modifier -51 Bull’s eye identifies procedure that includes MCS Flash identifies codes that classify products pending FDA approval (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Symbols SymbolCPT Entry Use of semicolon 11000Debridement of extensive eczematous or infected skin; up to 10% of body surface Use of plus symbol Each additional 10% of body surface (List separately in addition to code for primary procedure) Use of -51 modifier exemption symbol 17004Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions Use of bull’s eye symbol 33206Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial © Cengage Learning (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. CPT Guidelines Define terms and explain assignment of codes for procedure and services Located at beginning of each CPT section –Guidelines from one CPT section do not apply to another CPT section Should be reviewed before assigning code

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Sections, Subsections, Categories, and Subcategories Six sections subdivided into the following: –Subsections –Categories –Subcategories (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Sections, Subsections, Categories, and Subcategories Guidelines at beginning of each subsection Notes, parenthetical notes, and descriptive qualifiers in each section, subsection, category, and subcategory (continues) (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Sections, Subsections, Categories, and Subcategories Selection from CPT that illustrates sections, subsections, categories, subcategories, notes, and descriptive qualifiers © Cengage Learning 2014 (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Unlisted Procedures and Services Unlisted procedure or unlisted service –Assigned when provider performs procedure or service for which there is no CPT code Special report must accompany claim to provide more information –e.g., copy of procedure report

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Instructional Notes Blocked unindented note Indented parenthetical note Parenthetical note

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Descriptive Qualifiers Terms that clarify assignment of CPT code

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Modifiers Clarify services and procedures performed by providers Reported as two-digit numeric codes added to five-digit CPT code HCPCS level II national two-digit alpha- numeric modifiers also added to five-digit CPT code (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Modifiers Modifiers that apply to components of the CPT surgical package © Cengage Learning 2014 (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Special E/M Cases -24 Unrelated E/M service by same physician during postoperative period -25 Significant, separately identifiable E/M service by same physician on same day of procedure or other service -57 Decision for surgery

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Greater, Reduced, or Discontinued Services -22 Increased procedural services -52 Reduced services -53 Discontinued procedure -73 Discontinued outpatient hospital/ ambulatory surgery center procedure prior to anesthesia (continues)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Greater, Reduced, or Discontinued Services -74 Discontinued outpatient hospital/ ambulatory surgery center procedure after anesthesia administration (cont’d)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Global Surgery -54 Surgical care only -55 Postoperative management only -56 Preoperative management only

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Special Surgical and Procedural Events -58 Staged or related procedure or service by same physician -59 Distinct procedural service -63 Procedure performed on infants less than 4 kilograms (kg) -78 Return to operating room for related procedure during postoperative period -79 Unrelated procedure or service by same physician during postoperative period

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Bilateral and Multiple Procedures -50 Bilateral procedure -27 Multiple outpatient hospital E/M encounters on same date -51 Multiple procedures

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Repeat Services -76 Repeat procedure by same physician -77 Repeat procedure by another physician

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Multiple Surgeons -62 Two surgeons -66 Surgical team -80 Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when qualified resident not available)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Professional and Technical Components -26 Professional component TC Technical component –Found in HCPCS level II manual

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Mandated Services -32 Mandated services -23 Unusual anesthesia -47 Anesthesia by surgeon

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Laboratory Services -90 Reference (outside) laboratory -91 Repeat clinical diagnostic laboratory test -92 Alternative laboratory platform testing

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Multiple Modifiers -99 Multiple modifiers

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. NCCI Promotes national correct coding methodologies Controls improper code assignment Implemented by CMS Edits used to process Medicare Part B claims for outpatient and physician services

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. NCCI Edits Two types –Comprehensive/component edits –Mutually exclusive edits

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Advanced Beneficiary Notice (ABN) Form completed and signed by Medicare beneficiary each time provider believes: –Normally covered service will not be covered –Provider wants to bill beneficiary directly for service

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Notice of Exclusions from Medicare Benefits (NEMB) Form completed and signed by Medicare beneficiary before items, procedures, and services excluded from Medicare benefits are provided

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Unbundling Reporting multiple codes for service when single, comprehensive code should be assigned