Chapter 7 CPT Coding.

Chapter 7 CPT Coding

Overview of CPT CPT Provides a list of identifying and descriptive codes for reporting procedures and medical services. Uses uniform language that describes medical and surgical procedures and services.

Overview of CPT (cont.) CPT codes are used to report services and procedures. Codes are submitted on claims with linked ICD-9-CM or ICD-10-CM codes that justify the need for the service or procedure. New, revised, and deleted codes are implemented on January 1 and must be used.

Overview of CPT (cont.) Changes to CPT support
Electronic data interchange (EDI) Computer-based patient record (CPR) Electronic medical record (EMR) Reference/research database

Overview of CPT (cont.) Category I
Procedures/services identified by a five-digit CPT code and descriptor nomenclature Codes traditionally associated with CPT organized in six sections

Overview of CPT (cont.) Category II
Contains “performance measurements,” tracking codes that are assigned an alphanumeric identifier with a letter in the last field. Codes located after the Medicine section Use is optional.

Overview of CPT (cont.) Category III
Contains “emerging technology,” temporary codes assigned for data purposes and assigned alphanumerically with the letter in the last position. Codes are located after the Medicine section. They are archived after five years unless accepted for placement.

CPT Sections Category I procedures and services
Evaluation and Management (E/M) Anesthesia Surgery Radiology Pathology and Laboratory Medicine

CPT Sections CPT code number format
Five-digit number and description identifying each procedure and service listed in CPT

CPT Sections CPT appendices
CPT contains appendices located between the Medicine section and Index. Insurance specialists should become familiar with changes that affect the practice.

CPT Appendix Description
Appendix A Modifiers Detailed descriptions of each CPT modifier Appendix B Summary of additions, deletions, and revisions

CPT Appendix Description (cont.)
Appendix C Clinical examples Evaluation and Management (E/M) section codes AMA no longer revises this section but has retained previously created examples. Appendix D Add-on codes

Appendix E CPT codes exempt from modifier -51 Appendix F CPT codes exempt from modifier -63 Appendix G Summary of CPT codes that include moderate (conscious) sedation

Appendix H Alphabetic index of performance measures by clinical condition or topic Serves as a crosswalk to category II codes Appendix I Genetic testing code modifiers

Appendix J Electrodiagnostic medicine listing of sensory, motor, and mixed nerves Includes a table that indicates “type of study and maximum number of studies” Needle electromyogram (EMG) Nerve conduction studies Other EMG studies

Appendix K Products pending FDA approval Appendix L Vascular families Assist in the selection of first-, second-, third-, and beyond third-order branch arteries Appendix M Summary of cross-walked deleted CPT codes Appendix N Summary of resequenced CPT codes

CPT Symbols Symbols are located throughout the CPT coding book.
Bullet located to the left of a code number Identifies new procedures and services added to CPT.

CPT Symbols (cont.) Triangle located to the left of a code number
Identifies a code description that has been revised.

CPT Symbols (cont.) Horizontal triangles Semicolon
Surround revised guidelines and notes Not used for revised code descriptions Semicolon To save space in CPT Code descriptions are not printed in their entirety next to a code number.

CPT Symbols (cont.) Plus sign Identifies add-on codes
For procedures that are commonly, but not always, performed at the same time and by the same surgeon

CPT Symbols (cont.) Circle with a line through it Bull’s-eye symbol
Identifies codes that are not to be used with modifier 51. Bull’s-eye symbol Indicates a procedure that includes moderate sedation. Administration of moderate sedation or analgesia, which results in a drug-induced depression of consciousness

CPT Symbols (cont.) Flash symbol
Indicates codes that classify products that are pending FDA approval but have been assigned a CPT code.

Guidelines Located at the beginning of the CPT section
Should be reviewed each year before attempting to code from this section Define and explain the assignment of codes, procedures, and services in a particular section

Unlisted Procedures/Services
Unlisted procedure or service Assigned when a procedure or service is performed by a provider for which there is no CPT code

Special report Must be submitted when an unlisted procedure or service code is reported Narrative document must accompany the claim to describe the nature and extent of the need of service or procedure Some practices indicate in Box 19 of CMS-1500: “unlisted code = the closest related code of XXXXX.”

Notes Instructional notes are found throughout. Blocked unindented note Located below a subsection title and contains instructions that apply to all codes Indented parenthetical note Located below a subsection title, code description, or code description that contains an example Highlight and understand each of these notes

CPT Index This is organized by alphabetical main terms printed in boldface. Main terms represent procedures or services, organs, anatomic sites, conditions, eponyms, or abbreviations.

CPT Index Single codes and code ranges
Index code numbers for specific procedures may be represented as a single code number, a range of codes separated by a dash, a series of codes separated by commas, or a combination of single codes and ranges of codes.

CPT Index Boldface type Cross-reference term
Main terms in the CPT index are printed in boldface type, along with CPT categories, subcategories, headings, and code numbers. Cross-reference term Directs coders to an index entry under which codes are listed. No codes are listed under the original entry.

CPT Index Italicized type Inferred words
Used for the cross-reference term Inferred words Used to save space in the CPT index when referencing subterms

CPT Index Clarify services and procedures performed by providers
Two-digit numeric codes added to five-digit CPT code Have always been reported on claims submitted for provider office services and procedures

CPT Index Coding tip List of all CPT modifiers with brief descriptions is located inside the front cover of the coding manual.

Coding Procedures and Services
Step 1 Read the introduction in the CPT coding manual. Step 2 Review the guidelines at the beginning of each section. Step 3 Review the procedure in the source document.

Coding Procedures and Services (cont.)
Step 4 Refer to the CPT index. Locate the main term for the procedure or service documented. Main terms can be located by referring to the following

a. Procedure or service documented b. Organ or anatomic site c. Condition documented in the record d. Substance being tested

Synonym (term with similar meaning) Eponym (procedures and diagnoses named for an individual) Abbreviation

Step 5 Locate subterms and follow cross-references. Step 6 Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements.

Step 7 Assign applicable code number and any add-on (+) or additional codes needed to accurately classify the statement being coded.

Evaluation and Management
Located at the beginning of CPT because these codes describe services most frequently provided by physicians. Before assigning E/M codes Make sure you review guidelines and apply any notes.

Evaluation and Management (cont.)
The E/M section is organized according to Place of service (POS) (e.g., office, hospital, home, nursing facility [NF], emergency department [ED], or critical care) Type of service (TOS) (e.g., new or initial encounter, follow-up or subsequent encounter, or consultation) Miscellaneous services (e.g., prolonged physician service or care plan oversight service)

E/M level of service reflects the amount of work involved in providing health care to a patient. Correct coding requires determining the extent of history and examination performed as well as the complexity of medical decision making.

Between three and five levels of service are included in E/M categories. Documentation in the patient’s chart must support the level of service reported.

Accurate assignment of E/M codes depends on Identifying the place of service (POS) and type of service (TOS) provided to the patient Determining whether the patient is new or established to the practice

Reviewing the patient’s record for documentation of level of service components Applying CMS’s Documentation Guidelines for Evaluation and Management Services Determining whether E/M guidelines (e.g., unlisted service) apply

Place of Service Refers to the physical location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, NFs, home health care, or EDs).

Type of Service Refers to the kind of healthcare services provided to patients. It includes critical care, consultation, initial hospital care, and subsequent hospital care.

New vs. Established Patient
New patient One who has not received any professional services from the physician, or from another physician of the same specialty who belongs to the same group practice, within the past three years

New vs. Established Patient
One who has received professional services from the physician, or from another physician of the same specialty who belongs to the same group practice, within the past three years

Concurrent Care Provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day. Providers must report different diagnoses.

Evaluation and Management Guidelines
Use of an unlisted code because there is no appropriate CPT code to report the service delivered that requires special report Complexity of patient’s symptoms Description of, nature of, extent of, and need for service Diagnostic and therapeutic procedures performed

Evaluation and Management Guidelines (cont.)
Follow-up care Patient’s final diagnosis and concurrent problems Pertinent physical findings Time, effort, and equipment required to provide the service

Levels of E/M Services Levels within categories and subcategories are not interchangeable. Levels of E/M services include conferences with or about patients, evaluations, examinations, preventive adult and pediatric health supervision, treatments, and other medical services.

Levels of E/M Services Typically, just one E/M code is reported each day by a provider for a patient. If an E/M service and another procedure or service are provided on the same day, append modifier 25.

Levels of E/M Services Based on seven components History Examination
Medical decision making Counseling Coordination of care Nature of presenting problem Time

Key Components E/M code selection is based on three key components
Extent of history Extent of examination Complexity of medical decision making All key components must be considered when assigning codes for new patients.

Key Components For established patients
Two of the three key components must be considered. It must be supported by documentation in the patient’s record.

Extent of History Interview of the patient that includes the following elements History of present illness (HPI) (including the patient’s chief complaint, CC) A review of systems (ROS) A past/family/social history (PFSH)

Extent of History Four levels Problem-focused Expanded problem-focused
Detailed Comprehensive

Extent of Examination Physicians and providers can use either the 1995 or 1997 documentation guidelines for Evaluation and Management services, which were jointly developed by CMS and the American Medical Association.

Extent of Examination Physical examination is an assessment of the patient’s organ and body system/s. Categorized according to four types Problem-focused examination Expanded problem-focused examination Detailed examination Comprehensive examination

Complexity of Medical Decision Making
Complexity of establishing a diagnosis and selecting a management option as measured by the Number of diagnoses or management options Amount and complexity of data to be reviewed Risk of complications and morbidity or mortality

Patient’s Records Should Include
Laboratory, imaging, and other test results that are significant to the management of the patient’s care List of known diagnoses as well as those that are suspected Opinions of other physicians who have been consulted

Patient’s Records Should Include (cont.)
Planned course of action for the patient’s treatment Review of patient records obtained from other facilities

Complexity of Medical Decision Making
Determined by Straightforward Low complexity Moderate complexity High complexity

Assigning an E/M Code Once the extent of history, examination, and complexity of medical decision making are determined Select the appropriate E/M code.

Contributory Components
Counseling Coordination of care Nature of presenting problem Time

Counseling Discussion with a patient or family concerning one or more of the following areas Diagnostic results Impressions, as well as recommended diagnostic studies Prognosis Risks and benefits of management (treatment) options

Counseling (cont.) Instructions for management (treatment) and follow-up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education

Coordination of Care Physician makes arrangement with other providers or agencies for services to be provided to patient.

Presenting Problem CPT defines the nature of the presenting problem as “a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.”

Presenting Problems Minimal Self-limited or minor Low severity
Moderate severity High severity

Face-to-Face Time Amount of time the doctor spends with the family or the patient

Unit/Floor Time Amount of time the doctor spends at the patient’s bedside and on the management of the patient’s care on the unit or floor

E/M Time When claiming E/M time, one must have
Total length of time for the encounter Plus the length of time spent coordinating care and counseling the patient Issues discussed Relevant history, physical examination, and medical decision making

Observation Services Services are furnished in a hospital outpatient setting. Patient is considered an outpatient. They are reimbursed only when the doctor orders it. Medicare requires less than 48 hours.

Observation Subcategories
Observation care discharge services Initial observation care

Hospital Inpatient Services
E/M services provided to hospital inpatients, including partial hospitalization services

Subcategories Include
Initial hospital care Subsequent hospital care Observation/inpatient care services Assigned only if the patient is admitted to and discharged from observation/inpatient status on the same day Hospital discharge services

Consultations Type of service provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source. In 2010 CMS eliminated the reporting of consultation codes.

Criteria Consultation is requested by another doctor or provider.
Consultant renders an opinion or advice.

Criteria (cont.) Consultant initiates diagnostic or therapeutic services. Requesting physician documents the request and the need for the consultation in the patient’s record.

Criteria (cont.) Consultant’s opinion, advice, and any services rendered are documented in the patient’s record. These are reported to the requesting physician or source.

Subcategories Include
Office or other outpatient consultations Inpatient consultations

Preoperative Clearance
Surgeon requests a specialist or other physician (e.g., general practitioner) to examine a patient and provide an opinion about whether the patient can withstand the expected risks of a specific surgery. Considered a consultation when the referring surgeon documents the request

Emergency Department Services
Are given in a hospital setting that is open 24 hours a day to provide services that are not scheduled

Critical Care Services
Occur when a doctor provides services to someone who is critically ill or injured. The doctor should document the total time spent delivering critical care services. Excluding time for allowable services

Nursing Facility Services
These are provided at nursing facilities. Skilled nursing, intermediate care, and long-term care

Subcategories Initial nursing facility care
Subsequent nursing facility care Nursing facility discharge services Other nursing facility services

Prolonged Services May be reported when a doctor’s services involving patient contact are considered beyond the usual service in either an inpatient or outpatient setting

Subcategories Prolonged physician services with direct face to face
Prolonged physician services without face to face Physician standby services

Preventive Medicine Services
Routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical examination Use of modifier -33 Preventive Services indicates that the service was preventive.

Subcategories New patient Established patient
Counseling and risk factor reduction intervention Preventive medicine, individual counseling Preventive medicine, group counseling Other preventive medicine services

Newborn Care Includes services provided to newborns in a variety of health care settings (e.g., hospital, birthing center, and home birth).

Subcategories Inpatient Neonatal Intensive Care Services
Pediatric and Neonatal Critical Care Services

Anesthesia Administration of analgesia or anesthesia as provided by an anesthesiologist (physician) or certified registered nurse anesthetist (CRNA)

Anesthesia Includes the administration of Local Regional Epidural
General anesthesia Monitored anesthesia care (MAC) Administration of anxiolytics (drugs that relieve anxiety) or amnesia-inducing medications

Assigning Anesthesia Codes
Codes 00100–01860 are reported for anesthesia services administered during surgical interventions. Codes 01916–01936 are reported when anesthesia is administered during interventional radiology. Codes 01951–01953 are reported for anesthesia for burn excisions or debridement. Codes 01958–01969 are reported when anesthesia is administered for obstetric procedures Codes 01990–01999 are reported for miscellaneous anesthesia services.

Qualifying Circumstances for Anesthesia
When situations or circumstances make anesthesia administration more difficult and increase the patient’s risk factor

Physician Status Modifiers
Each “status modifier” Reported with an anesthesia code to indicate the patient’s condition at the time anesthesia was administered

Physician Status Modifiers (cont.)
Normal health P2 Mild systemic disease P3 Severe systemic disease

Physician Status Modifiers (cont.)
Severe systemic disease that is a constant threat to life P5 Not expected to survive without the operation P6 Declared brain dead and whose organs are being removed for donor purposes

HCPCS Level II Modifiers
-AA (anesthesia services performed personally by anesthesiologist) -AD (medically supervised by a physician for more than four concurrent procedures) -G8 (monitored anesthesia care for deep complex, complicated, or markedly invasive surgical procedure)

HCPCS Level II Modifiers (cont.)
-G9 (monitored anesthesia care for patient who has history of severe cardiopulmonary condition) -QK (medical direction of two, three, or four concurrent procedures involving qualified individuals) -QS (monitored anesthesia care provided by an anesthesiologist)

HCPCS Level II Modifiers (cont.)
-QX (CRNA service, with medical direction by physician) -QY (medical direction of one CRNA by an anesthesiologist) -QZ (CRNA service, without medical direction by physician)

CPT Modifiers -23 (unusual anesthesia) (used when a patient’s circumstances warrant the administration of general or regional anesthesia instead of the usual local anesthesia) -59 (distinct procedural service)

CPT Modifiers (cont.) -74 (discontinued outpatient hospital/ambulatory surgery center procedure after anesthesia administration) -99 (multiple modifiers)

Anesthesia Time Units Be sure to record the time with the anesthesiologist. Anesthesia time unit is one 15-minute increment.

Calculating Anesthesia
Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesia Nonmonitored interval time Recovery room time Routine postoperative evaluation by the anesthesiologist or CRNA

Surgery Section Surgery section is organized by body system.
Some subsections are further subdivided by procedure categories.

Surgery Section (cont.)
Incision Excision Introduction or removal Repair, endoscopy Revision or reconstruction Destruction

Surgery Section (cont.)
Grafts Suture Other procedures

Code Surgeries Properly
Three questions must be asked Which body system was involved? Which anatomic site was involved? What type of procedure was performed? Carefully read the procedure outlined in the operative report.

Surgical Package Includes a variety of services provided by a surgeon
Surgical procedure performed Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia One related E/M encounter on the date immediately prior to or on the date of the procedure

Surgical Package Immediate postoperative care, including dictating operative notes, talking with family and other physicians, writing postoperative orders, and evaluating the patient in the postanesthesia recovery area

Surgical Package Typical postoperative follow-up care, including pain management, suture removal, dressing changes, local incisional care, and removal of operative packs/cutaneous sutures/staples/lines/ wires/tubes/drains/casts/splints (however, casting supplies can usually be billed separately)

Surgical Package Global period
Number of days associated with the surgical package (or global surgery), designated by the payer as 0, 10, or 90 days. All postoperative services are included in the procedure code. Postoperative services cannot be separately reported and billed.

Surgical Package Procedures that are bundled
Local infiltration of medication Closure of surgically created wounds Minor debridement Exploration of operative area Fulguration of bleeding points Application of dressings Application of splints with musculoskeletal procedures

Separate Procedure Procedures that are an important part of an additional procedure or service Reported if the procedure or service is performed independently or is unrelated to or distinct from another procedure or service performed at the same time

Multiple Surgical Procedures
Major surgical procedure (the procedure reimbursed at the highest level) should be reported first on the claim, and the lesser surgeries listed on the claim in descending order of expense.

Modifier -51 is added to the CPT number for each lesser surgical procedure that does not have the symbol X or + in front of the code.

Ranking into major and minor procedures is done to accommodate the fact that most insurance companies will reduce the fee for the second surgery by 50 percent of the regular fee and the third, fourth, and so on, by 50 to 75 percent of the regular fee.

Diagnostic radiology (imaging) Diagnostic ultrasound Radiation oncology Nuclear medicine

The number of radiologic views (studies taken from different angles) described in the report or on the charge slip determines the code selection for many diagnostic radiologic procedures.

Diagnostic Radiology Codes for noninvasive (noninterventional) and invasive (interventional) diagnostic and therapeutic procedures, in addition to CT, MRI, and magnetic resonance angiography

Diagnostic Radiology Code diagnostic radiology procedures accurately, and identify the following Anatomic site Type of procedure Number of views Laterality of the procedure (e.g., unilateral or bilateral) Use of contrast media

Diagnostic Ultrasound
Use of high-frequency sound waves (e.g., mechanical oscillations) to produce an image Codes organized according to anatomic site Procedures often performed as follow-up studies for inconclusive diagnostic radiology procedures

Diagnostic Ultrasound
Intraoperatively (e.g., during endoscopic procedures) Guidance for biopsies, cyst localization, invasive procedures, paracentesis, pericardiocentesis, placement of radiation therapy fields, and thoracentesis

Radiologic Guidance Performed during a procedure to visualize access to an anatomic site Contains four headings Fluoroscopic guidance Computed tomography guidance Magnetic resonance guidance Other radiologic guidance

Breast Mammography Radiological examination of the soft tissue and internal structures of the breast. Screening mammography is performed when a patient presents without signs and symptoms of breast disease. Diagnostic mammography includes an assessment of suspected disease. Reported when an abnormality is found or suspected

Radiation Oncology Uses high-energy ionizing radiation to treat malignant neoplasms and certain nonmalignant conditions Brachytherapy Hyperthermia Stereotactic radiation Teletherapy

Nuclear Medicine Use of radioactive elements (e.g., radionuclides and radioisotopes) for diagnostic imaging (e.g., scan) and radiopharmaceutical therapy

Nuclear Medicine Diagnostic procedures Bone scans Cardiac scans
Renal scans Thyroid scans Hepatobiliary scans

Nuclear Medicine Therapeutic procedures treat Chronic leukemia
Hyperthyroidism Thyroid cancer

Complete Procedure When the word “complete” is included in the code definition One code is reported to “completely” explain the procedure performed When the word “complete” is found in a parenthetical note More than one code may be needed to “completely” report the procedure performed

Professional vs. Technical
Professional component of radiological procedures Supervision of the procedure and the interpretation and writing of a report describing the examination and its findings

Professional vs. Technical
Technical component covers Use of the equipment, supplies provided, and employment of the radiologic technicians

Pathology and Laboratory
Organized according to the kind of pathology or laboratory procedure performed

Pathology and Laboratory Subsections
Organ- or disease-oriented panels Drug testing Therapeutic drug assays Evocative suppression testing Consultations (clinical pathology) Urinalysis, chemistry, hematology, and coagulation immunology

Pathology and Laboratory Subsections (cont.)
Transfusion medicine Microbiology Anatomic pathology Cytopathology and cytogenetic studies Surgical pathology

Pathology and Laboratory Subsections (cont.)
Transcutaneous procedures Other procedures Reproductive medicine procedures

Medicine Section Classifies noninvasive or minimally invasive diagnostic and therapeutic procedures and services

Medicine Section Noninvasive procedures require no surgical incision or excision, and they are not open procedures. Minimally invasive procedures include percutaneous access.

Medicine Section Subsections
Classify procedures and services, which are procedure oriented (e.g., immunizations). Apply to various medical specialties (e.g., gastroenterology, ophthalmology, otorhinolaryngology, and psychiatry). Apply to different types of healthcare providers (e.g., physical therapists and occupational therapists).

National Correct Coding Initiative
To encourage national correct coding methodologies and manage the improper assignment of codes

National Correct Coding Initiative
Incorrect coding Results in inappropriate repayment of Medicare Part B claims. Centers for Medicare and Medicaid Services implemented the National Correct Coding Initiative.

NCCI Coding Policies Analysis of standard medical and surgical practice Coding conventions included in CPT Coding guidelines developed by national medical specialty societies Local and national coverage determinations Review of current coding practices

Unbundling Unbundling occurs when one service is divided into its component parts, and a code for each component part is reported as if they were separate services.

Unbundling Reasons Provider’s coding staff unintentionally reports multiple codes based on misinterpreted coding guidelines. Reporting multiple codes is intentional and is done to maximize reimbursement.

Chapter 7 CPT Coding.

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