ch 7

guidelines

define terms and explain the assignment of codes for procedures and services located in a particular section. This means that guidelines in one section do not apply to another section in CPT. Should be carefully reviewed before attempting to code.

cross-reference terms

direct coders to a different CPT index entry because no codes are found under the original entry

See

directs the coder to refer to another term in the index to locate the code

counseling

discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) options; instructions for management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.

CPT organizes Category I procedures and services within six sections

evaluation and management anesthesia surgery radiology pathology and laboratory medicine

Relative Value Unit (RVU)

factor assigned to a medical service based on the relative skill and required time

CPT Code Number Format

five-character code number and a narrative description identify each procedure and service listed in cpt. they are organized into six sections

separate procedure

follows a CPT code description to identify procedures that are an integral part of another procedure or service.

The forbidden symbol 🚫

identifies CPT codes that are not to be used with modifier 51. These codes are reported in addition to other codes, but they are not classified as add-on codes. Example: (forbidden symbol) 20974. Electrical stimulation to aid bone healing; noninvasive (nonoperative)

category II codes

optional CPT codes that track performance measures. evidence-based performance measurements

Category II Codes

optional evidence-based performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A); these codes will be located after the Medicine section; their use is optional.

CPT Index

organized by alphabetical main terms printed in boldface Figure 7-4 Selection from the CPT index

medical decision making

refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity or mortality.

type of service (TOS)

refers to the kind of health care services provided to patients; a code required by Medicare to denote anesthesia services.

Placement of nasogastric tube

43752

Modifying Terms

A main term may be followed by sub terms that modify the main term and/or terms they follow. The sub terms may also be followed by additional sub terms that are indented

coding conventions (CPT) boldface type

highlights main terms in the CPT index and categories, subcategories, headings, and code numbers in the CPT manual

The double arrow symbol (⬆️ and arrow down, side by side)

identifies CPT Category I PLA codes Although PLA codes are included in the Pathology and Laboratory section of CPT, they do not fulfill Category I criteria unless the double arrow symbol precedes the code

Closed treatment of wrist dislocation

25660, 25675, 25680

Example of Indented code description

27780 Closed treatment of proximal fibula or shaft fracture; without manipulation 27781 with manipulation

Example of stand-alone code description

27870. Arthrodesis, ankle, open

Dilation of vagina

57400

radiological exam of the pharynx including fluoroscopy

70370

magnetic resonance imaging (MRI), wrist

73221

face-to-face time

Amount of time the office or outpatient care provider spends with the patient and/or family.

Appendix B

Annual CPT coding changes (added, deleted, and revised CPT codes) Coding Tip Carefully review Appendix B because it will serve as the Basis for updating encounter forms and chargemasters.

Main Terms

CPT Index is organized according to main terms, which can stand alone or be followed by modifying terms. Main terms can represent: Procedure or service (e.g., endoscopy) Organ or anatomic site (e.g., colon) Condition (e.g., abscess) Synonyms, eponyms, and abbreviations (e.g., Bricker Operation, Fibrinase, EEG)

qualifying circumstances

CPT Medicine Section codes reported in addition to Anesthesia Section codes when situations or circumstances make anesthesia administration more difficult (e.g., patient of extreme age, such as under one year or over 70).

stand-alone codes

CPT code that includes a complete description of the procedure or service. Most CPT procedures and services are classified as stand-alone codes which include a complete description of the procedure or service

indented code

CPT code that is indented below a stand-alone code, requiring the coder to refer back to the common portion of the code description that is located before the semicolon.

Appendix C

Clinical examples for Evaluation and Management (E/M) section codes Note The AMA halted the project to revise E/M code descriptions using clinical examples (or vignettes) in 2004. However, previously developed clinical examples are still included Appendix C

Appendix A

Coding tip Place a marker at the beginning of Appendix A because you will refer to this appendix often

PLA test codes

published quarterly at www.ama-assn.org. you can locate these by entering "CPT PLA codes" in the search box

Code Ranges

Index code numbers for specific procedures may be represented as a single code, 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. All codes listed next to an index entry should be investigated before assigning a code for the procedure or service

Conventions

Main terms in the CPT index are printed in Boldface type, along with CPT categories, subcategories, headings, and codes. See and see also are cross-reference terms that direct coders to an index entry under which codes are listed. No codes are listed under the See entry, while codes may be listed under See also entry Example: AV Shunt See Arteriovenous Shunt In this example, you are directed to the index entry for Arteriovenous Shunt because no codes are listed for AV Shunt

example of telemedicine

New York State department of health (www.health.ny.gov) data about potentially preventable emergency department encounters identifies common conditions (e.g., ear and sinus infections, sore throats) that represent millions of annual visits to hospital emergency departments. Such encounters could have been avoided or treated elsewhere if patients had been able to schedule an appointment with their primary care providers. Face-to-face encounters with a physician remains the ideal method for having minor conditions addressed; however, if the patient is unable to obtain an appointment for an immediate office visit, the patient can ask whether the issue could be addressed using telemedicine. This results in: 1. cost savings due to avoiding a potentially preventable emergency department encounter, and 2. treatment by the patient's primary care provider. (The patient would schedule an appointment with the provider for follow-up of the condition treated using telemedicine).

Parenthetical Notes

Note: Parenthetical Notes within a code series provide information about deleted codes . Such content does not have to be included in provider documentation

established patient

One who has received professional service from the physician or another physician in the exact same specialty and subspecialty in the same group within the last 3 years

add-on code

Reported when another procedure is performed in addition to the primary procedure during the same operative session; modifier -51 (multiple procedures) is not used with add-on codes.

Foreign Body/Implant Definition

The Foreign Body/Implant Definition guideline applies to the Surgery, Radiology, and Medicine sections to clarify that 1) an object intentionally placed into the patient is considered an implant, and 2) an object unintentionally placed (due to ingestion or trauma) is considered a foreign body. However, when an implant shifts from its original position or becomes broken, it is considered a foreign body for coding purposes (especially when it becomes a hazard to a patient). The exception is when CPT coding instructions provide guidance to specific codes that describes the removal of a shifted or broken implant.

Coding Procedures and Services

Step 1 Read the introduction in the CPT coding manual Step 2 Review guidelines at the beginning of each section Step 3 Review the procedure or service listed in the source document (e.g., encounter form, progress note, operative report, laboratory report, pathology report). Code only what is documented in the source document; do not make assumptions about conditions, procedures, or services not stated. If necessary, obtain clarification from the provider. ​

coding Procedures and Services

Step 4 Refer to the CPT index and locate the main term for the procedure or service documented. Main terms can be located by referring to the: a. procedure or service documented. Example: Arthroscopy b. Organ or anatomic site. Example: Arm c. Condition documented in the record. Example: Hernia Repair d. Substance being tested. Example: Blood e. Synonym (terms with similar meanings) Example: Pyothorax f. Eponym (procedures and diagnoses named for an individual). g. Abbreviation Example: CBC ​

Coding Procedures and Services

Step 5: Locate sub terms an follow cross-reference terms. Example: The patient underwent an Abbe-Estlander procedure that required full-thickness excision of lip with reconstruction and cross lip flap. In the CPT index, go to main term Abbe-Estlander Procedure and sub terms lip Reconstruction to look up codes 40527, 40761

coding Procedures and Services

Step 6: Review descriptions of service/procedure codes, and compare all qualifiers to descriptive statements Example: The operative report documents an Abbe-Estlander procedure requiring full-thickness excision of lip with reconstruction and cross lip flap. Review of CPT index entries 40527, 40761 (for main term Abbe-Estlander Procedure, and subterm Lip Reconstruction) results in the assignment of code 40527 for Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander). (Code 40761 is reported for a full-thickness lip repair and Abbe-Estlander procedure that is performed during the same operative episode.) Hint: If the main term is located at the bottom of a CPT index page, turn the page and check to see if the main term and subterm(s) continue.

Coding Procedures and Services

Step 7: Assign the applicable code and any add-on or additional codes needed to accurately classify the statement being coded. Step 8: Review Appendix B in the CPT coding manual to assign appropriate modifiers. Note: When entering CPT codes on the CMS-1500 claim, enter codes based on highest to lowest reimbursement (e.g., provider-based charge). Third-party payers will determine reimbursement based on the patient's health plan contract, and the assignment of multiple procedure/service modifiers results in discounted reimbursement. Coding Tip: You may have to refer to synonyms, translate terms to ordinary English, or substitute medical words for English terms documented in the provider's statement to find the main term in the index. Some examples are: Procedure State= Word Sub Placement of a Shunt = Insertion of Shunt Peacemaker implantation = Pacemaker insertion Resection of tumor = Excision or removal of tumor Radiograph of the chest = X-ray of chest Suture laceration = repair open wound Placement of nerve block = Injection of nerve anesthesia ​

inferred words

Used to save space in the CPT index when referencing subterms.

moderate (conscious) sedation

administration of moderate sedation or analgesia, which results in a drug-induced depression of consciousness.

global surgery

also called package concept or surgical package; includes the procedure, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal, uncomplicated follow-up care.

unlisted procedure

also called unlisted service; assigned when the provider performs a procedure or service for which there is no CPT code. use a special report in this case. Note: Do not add a modifier to CPT unlisted procedure/service codes because they do not include specific descriptions that would justify modifying their meaning. Medicare and other third-party payers often requires providers to report HCPCS Level II (national) codes instead of unlisted procedure or service CPT codes

instructional notes

appear throughout CPT sections to clarify the assignment of codes. They are typeset in two patterns: 1. A Blocked indented note is located below a subsection title and contains instructions that apply to all codes in the subsection 2. An indented parenthetical note is located below a subsection title, code description, or code description that contains an example.

indented code

appears below a stand-alone code, requiring the coder to refer back to the common portion of the code description that is located before the semicolon

proprietary laboratory analyses (PLA)

available to any clinical laboratory or manufacturer that wants to specifically identify their commercially available tests that are used on human species

The inverted parents symbol )( with a line through this symbol

identifies duplicate proprietary laboratory analyses (PLA) tests. Descriptor language of some PLA codes are identical, and codes are differentiated only by reviewing proprietary names listed in Appendix 0 of the CPT manual

global period

includes all services related to a procedure during a period of time (e.g., 10 days, 30 days, 90 days, depending on payer guidelines).

The flash symbol ⚡

indicates codes that classify products that are pending FDA approval but have already been assigned a CPT code Example: ⚡ 90671. Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use

physical status modifier

indicates the patient's condition at the time anesthesia was administered.

current procedural terminology

lists descriptive terms and identifying codes for reporting medical services and procedures performed by physicians and non-physician practitioners. Provides a language that designates medical, surgical, and diagnostic services and accurately and effectively provides a mean of reliable, nationwide communication among health care practitioners, clients, and third parties.

See also

located after a main term or subterm in the index and directs the coder to another main term (or subterm) that may provide additional useful index entries.

evaluation and management (E/M) section

located at the beginning of CPT because these codes describe services (e.g., office visits) that are most frequently provided by physicians and other health care practitioners (e.g., nurse practitioner, physician assistant).

The blue reference symbol (blue 🔵 with an arrow through it)

located before a code description in some CPT coding manuals indicates the the coder should refer to the CPT Changes: An Insider's View annual publication that contains all coding changes for the current year. Example: (with blue reference symbol) CPT Changes: An Insider's View 2016

The green reference symbol (same as blue)

located below a code description in some CPT coding manuals indicates that the coder should refer to the CPT Assistant monthly newsletter

The red reference symbol

located below a code description in some CPT coding manuals indicates that the coder should refer to the Clinical Examples in Radiology quarterly newsletter Example: 73501. Radiological examination, hip, unilateral, with pelvis when performed; 1 view (with red reference symbol) Clinical Examples in Radiology Fall 15:9, Summer 16:8

The plus symbol +

located to the left of a CPT code identifies add-on codes (listed in Appendix D of CPT) for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure. Example: 22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical +22216. each additional vertebral segment (list separately in addition to primary procedure) Coding Tip: Codes identified with + are never reported as stand-alone codes; they are reported with primary procedure codes. Also, so not append add-on codes with modifier 51

The triangle symbol ∆

located to the left of a code and identifies a code description that has been revised in CPT. Example: Code 92065 was revised in CPT 2023 to add "performed by a physician or other qualified health care professional" to the code description. ∆ 92065. Orthoptic training; performed by a physician or other qualified health care professional

The bullet symbol •

located to the left of a code number and identifies new codes for procedures and services added to CPT. Example: Code 15853 was added to CPT 2023 • 15853 removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code)

Procedures and services submitted on a claim must be linked to the ICD-10-CM code that justifies the need for the service or procedure, which demonstrates the necessity for the service or procedure to receive reimbursement consideration by insurance payers

medical

special report

must accompany the claim when a CPT unlisted procedure or service code is reported to describe the nature, extent, and need for the procedure or service.

transfer of care

occurs when a physician who is managing some or all of a patient's problems releases the patient to the care of another physician who is not providing consultative services.

new patient

one who has not received any professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

The number symbol #

precedes CPT resequenced codes, which appear out of numerical order. Example: #33227. Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system

stand alone codes

procedure and services which include a complete description of the procedure or service

Category I codes

procedures/services identified by a five-digit CPT code and descriptor nomenclature; these codes are traditionally associated with CPT and organized within six sections.

category I codes

procedures/services identified by a five-digit CPT code and descriptor nomenclature; these codes are traditionally associated with CPT and organized within six sections.

CPT codes are assigned to inpatient hospital services and procedures provided by physicians and other qualified health care professionals for billing

professional

appendices

provide additional guidance for proper CPT code assignment, such as Appendix A (list of CPT modifiers and detailed descriptions)

modifier

provide additional information about a procedure or service (e.g., left-sided procedure).

monitored anesthesia care (MAC)

provision of local or regional anesthetic services with certain conscious-altering drugs when provided by a physician, anesthesiologist, or medically directed CRNA; monitored anesthesia care involves sufficiently monitoring the patient to anticipate the potential need for administration of general anesthesia, and it requires continuous evaluation of vital physiologic functions as well as recognition and treatment of adverse changes.

telemedicine

provision of remote medical care an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site; an alternative to in person face-to-face encounters provision of remote medical care using an interactive audio and video telecommunications system that permits real-time communication between the provider, located at the distant site (e.g., physician's office), and the patient, located at the originating site (e.g., patient's home several hours driving distance away from the provider). It is an alternative to in-person face-to-face encounters, which allows patients to receive health care services for minor medical conditions (instead of going to an emergency room), for chronic conditions that are well managed, from specialists located in other areas of the country, or when patients cannot leave work to see their provider. The availability of telemedicine is the result of advancements in clinical decision making and user-friendly technology. It is also seen as an affordable option for patients who have high-deductible health insurance plans

concurrent care

provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day.

Inferred Words

save space in the CPT index when referencing subterms, inferred words are used. Example: Abdomen Exploration (of)........49000, 49010 In this example, the word (of) is inferred and does not actually appear in the CPT index Coding Tip: The descriptions of all codes listed for a specific procedure must be carefully investigated before selecting a final code. As with ICD-10-CM (and ICD-10-PCS), CPT coding must never be performed solely from its index.

surgical package

see global surgery

unlisted service

see unlisted procedure

professional component

supervision of procedure, interpretation, and writing of the report.

The horizontal triangles symbol ><

surround revised CPT guidelines and notes. This symbol is not used for revised code descriptions. Example: The parenthetical instruction above code 80503 indicates that CPT codes 80500 and 80502 were deleted in a new edition of the coding manual. >(80500, 80502 have been deleted. To report a clinical pathology consultation, limited or comprehensive, see 80503, 80504, 80505, 80506)< Coding Tip: A complete list of code additions, deletions, and revisions is found in Appendix B of CPT. Revisions marked with horizontal triangles (><) are not included in Appendix B and require review all CPT guidelines and notes

Category III Codes

temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0001T) these codes are located after the Medicine section, and will be archived after five years unless accepted for placement within Category I sections of CPT.

Category III codes

temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0001T) these codes are located after the Medicine section, and will be archived after five years unless accepted for placement within Category I sections of CPT.

descriptive qualifier

terms that clarify assignment of a CPT code. They can occur in the middle of a main clause or after the semicolon and may or may not be enclosed in parentheses. Be sure to read all code descriptions very carefully to properly assign CPT codes that require descriptive qualifiers. Example: 17000 Destruction (eg, laser surgery, electro surgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion +17003 second through 14 lesions, each (List separately in addition to code for first lesion) The underlining identifies descriptive qualifiers in the code description for 17003 Coding Tip: Coders working in a provider's office should highlight descriptive qualifiers in CPT that pertain to the office's specialty. This will help ensure that qualifiers are not overlooked when assigning codes.

place of service (POS)

the physical location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, nursing facilities, home health care, or emergency departments); the two-digit location code is required by Medicare.

The E/M section is located at the beginning of CPT

these codes are reported by all specialties

Medicine section codes (99100-99140) that classify Qualifying circumstances for anesthesia services are explained in the Anesthesia section guidelines

they are to be reported with Anesthesia section codes

technical component

use of equipment and supplies for services performed.

The loud speaker symbol 🔊

used to identify codes that may be used to report audio-only telemedicine services when appended with modifier 93 (e.g., 90791 93)

The Star symbol ⭐

used to identify codes that may be used to report telemedicine services when appended with modifier 95 (e.g., 90791 95). Example: ⭐ 90845. Psychoanalysis

The semicolon symbol ;

used to save space in CPT, and some code descriptions are not printed in their entirety next to a code number. Instead, the entry is indented and the coder must refer back to the common portion of the code description that is located before the semicolon. The common portion begins with a capital letter, and the abbreviated (or subordinate) descriptions are indented and begin with lowercase letters. Example: The code description for 67255 is scleral reinforcement with graft. 67250. Scleral reinforcement (separate procedure); without graft 66255 with graft Coding Tip: CPT uses proportional spacing, and careful review of code descriptions to locate the semicolon is necessary. Coding Tip: CPT uses proportional spacing, and careful review of code descriptions to locate the semicolon is necessary

CPT organizes Category I procedures and services within six sections

• Evaluation and Management (E/M) (99202-99499) • Anesthesia (00100-01999, 99100-99140) • Surgery (10004-69990) • Radiology (70010-79999) • Pathology and Laboratory (80047-89398, 0001U-0354U) • Medicine (90281-99199, 99500-99607, 0001A-0112A ​

CPT symbols

• the bullet symbol is located to the left of a code number and identifies new codes for procedures and services added to CPT. Example: • 15853 ​