CPT Coding
Modifying Terms
Main term may be followed by subterms that modify main term and/or terms they follow. Subterms may also be followed by additional subterms that are indented
Category II CPT codes
Reported to track performance measurements Use is optional.
Complexity of Medical Decision Making
Complexity of establishing diagnosis and/or selecting management option Measured by: Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Types of medical decision making: Straightforward Low complexity Moderate complexity High complexity
Notes
Instructional notes—appear throughout CPT to clarify assignment of codes Blocked unindented note—located below subsection title and contains instructions that apply to all codes in that subsection Indented parenthetical note—located below subsection title, code description, or a code description that contains an example
CPT Modifiers
Reported as two-digit numeric codes added to the five-digit CPT code
E/M Level of Service
Reflects amount of work involved in providing care to patient: Extent of history performed Extent of examination performed Complexity of medical decision making Three to five levels of service are included in E/M categories. Documentation in chart must support level of service
Guidelines
define and explain assignment of codes, procedures, and services in a particular CPT section
Nature of the presenting problem Contributory Components
disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without diagnosis established at time of encounter
Key components
history, examination, and medical decision making
Stand-alone code
includes complete description of procedure or service
Type of service
kind of health care services provided to patients (e.g., critical care)
CPT Modifiers
Modifiers indicate that description of service or procedure performed has been altered. Clarify services and procedures performed by providers. CPT code and description remain unchanged.
Contributory components
components—counseling, coordination of care, nature of presenting problem, and time Must be focus of visit to be used in selection of E/M code
New patient
patient—one who has not received any professional services from physician, or from another physician of same specialty who belongs to same group practice, within past three years
Place of service
physical location where care is provided (e.g., physician office)
Transfer of care
physician who is managing some or all of patient's problems releases patient to another provider's care
CPT Category III Codes
Allow for utilization tracking of emerging: Technology Procedures Services Facilitate data collection/assessment about new services/procedures during FDA approval process Alphanumeric and consist of four digits followed by the alpha character T
Anesthesia Section
Anesthesia codes describe general anatomic area or service associated with surgical procedures. There is no one-to-one correspondence for Anesthesia to Surgery section codes. The same Anesthesia section code is often reported for different surgical procedures that share similar anesthesia requirements.
Qualifying Circumstances for Anesthesia
Anesthesia services provided during situations or circumstances that make anesthesia administration more difficult, as follows: 99100 (Anesthesia for patient of extreme age, younger than one year and older than 70) 99116 (Anesthesia complicated by utilization of total body hypothermia) 99135 (Anesthesia complicated by utilization of controlled hypotension) 99140 (Anesthesia complicated by emergency conditions)
CPT Appendices
Appendix A—CPT modifiers/descriptions Appendix B—Added/deleted/revised codes Appendix C—E/M clinical examples Appendix D—Summary list of add-on codes
Unlisted Procedures/Services
Assigned for procedure or service for which there is no CPT code Special report (e.g., copy of procedure report) is attached to claim to describe: Nature Extent Need for procedure or service Time, effort, and equipment necessary
Category III CPT codes
Contains "emerging technology" temporary codes Assigned for data purposes Archived after five years unless accepted for placement
Counseling Contributory Components
Counseling—discussion with patient and/or family concerning one or more of the following areas: Diagnostic results Impressions Recommended diagnostic studies Prognosis Risks and benefits of management options Instructions for management/follow-up Importance of compliance with chosen management options Risk factor reduction Patient and family education
CPT coding system
Descriptive terms and identifying codes for reporting medical services and procedures Provides uniform language that describes medical, surgical, and diagnostic services Published by the American Medical Association (AMA)
Cross-reference term See
Directs coders to index entry under which code is listed Italicized type is used for cross-reference term See.
CPT Category I Sections
Evaluation and Management (E/M) Anesthesia Surgery Radiology Pathology and Laboratory Medicine
CPT codes
Five digits in length Descriptions reflect health care services and procedures performed in modern medical practice. Reviewed by AMA to update codes and descriptions annually
Category I CPT codes
Five-digit CPT code and descriptor nomenclature Organized in six sections
global surgery
Global period—number of days associated with surgical package; designated as 0, 10, or 90 days
Accurate Assignment of E/M Codes
Identify place of service (POS). Identify type of service (TOS). Determine whether patient is new or established. Review documentation for level of service components. Apply CMS's Documentation Guidelines for Evaluation and Management Services
Single Codes and Code Ranges
Index code numbers are represented by: Single code number Range of codes, separated by: Dash Series of codes separated by commas Combination of single codes and ranges of codes Note: Review all listed codes before assigning a code for the procedure or service.
Evaluation and Management Section
Located at beginning of CPT because these codes describe services most frequently provided by physicians Accurate assignment is essential to success of physician practice because most revenue is generated by these services.
Boldface type
Main terms in the CPT index are printed in boldface type. Note: CPT categories, subcategories, headings, and code numbers are also printed in boldface type.
National Correct Coding Initiative (NCCI)
NCCI code pairs—codes that cannot be reported on same claim for same date of service Also called NCCI edit pairs
Unbundling
Not allowed Defined as assigning multiple codes to procedures/services when just one comprehensive code should be reported
National Correct Coding Initiative (NCCI)
Promotes national correct coding methodologies Controls improper assignment of codes that results in inappropriate reimbursement of Medicare Part B claims
CPT Index
Organized by alphabetical main terms Main terms represent: Procedures or services Organs or anatomic sites Conditions Synonyms, eponyms, and abbreviations
Surgery Section
Organized by body system Subsections are subdivided into categories by specific organ or anatomic site. To code surgeries properly, ask the following questions: What body system was involved? What anatomic site was involved? What type of procedure was performed?
Separate Procedure
Parenthetical note following code description Identifies procedures that are an integral part of another procedure or service Reported if procedure or service is: Performed independently of comprehensive procedure or service Unrelated to or distinct from another procedure or service performed at the same time
Professional vs. Technical Component
Professional component—covers supervision of procedure and interpretation/ documentation of report describing examination and findings Technical component—covers use of equipment, supplies provided, and employment of radiologic technicians
Unbundling CPT Codes
Providers are responsible for reporting CPT and HCPCS level II codes that most comprehensively describe services provided. NCCI edits are designed to detect unbundling, which is the reporting of multiple codes for a service when a single comprehensive code should be assigned. Unbundling occurs because: Provider's coding staff unintentionally report multiple codes because they misinterpreted coding guidelines. Reporting multiple codes is done to maximize reimbursement. One service is divided into its component parts and a code for each component part is reported as if performed as separate services. A code for the separate surgical approach (e.g., laparotomy) is reported in addition to a code for the surgical procedure; procedures performed to gain access to an area or organ system are not separately reported.
Radiology Section
Radiologic views—studies taken from different angles Number of views determines code selection for many radiology procedures. Review radiology report or charge slip and code descriptions to select appropriate code. Complete—reference to number of views required for full study of designated body part
Home Health Procedures/Services Subsection
Reported by nonphysician health care professionals who perform procedures and provide services to patient in patient's residence, including assisted living facility or group home
Moderate (Conscious) Sedation Subsection
Reported for drug-induced depression of consciousness that requires no interventions to maintain airway patency or ventilation Does not include minimal sedation (e.g., anxiolysis), deep sedation, or monitored anesthesia care (MAC)
Coding Procedures and Services
Step 1—Read introduction in CPT manual. Step 2—Review guidelines at beginning of each section. Step 3—Review procedure or service listed in the source document (e.g., patient record). Code what is documented in source document. Obtain clarification from provider if necessary. Step 4—Refer to CPT index, and locate main term for procedure or service documented. Main terms can be located by referring to: Procedure or service documented Organ or anatomic site Condition documented in the record Substance being tested Synonym Eponym Abbreviation Step 5—Locate subterms, and follow cross-references. Step 6—Review descriptions of codes, and compare qualifiers to descriptive statements. Step 7—Assign code number, applicable add-on or additional codes, and/or modifiers.
Descriptive Qualifiers
Terms that clarify assignment of CPT code Can occur in middle of main clause or after the semicolon May or may not be enclosed in parentheses
CPT Category II Codes
Tracking codes used for performance measurement in compliance with PQRS Assigned for certain services or test results that support performance measures Alphanumeric and consist of four digits followed by alpha character F Reporting is optional.
Complete Procedure
When complete is found in code description, one code is reported to "completely" describe procedure performed. When complete is found in parenthetical note below code, it may be necessary to report more than one code to "completely" describe the procedure performed.
Multiple Surgical Procedures
When two or more surgeries are performed during the same operative session: Major surgical procedure code is reported first on CMS-1500 claim. Lesser surgical procedure codes are reported on CMS-1500 claim, in descending order of expense. Modifier -51 is added to lesser surgical procedure codes, if symbols or are not located in front of the codes.
Indented code
appears below stand-alone code, requiring coder to refer back to common portion of code description located before semicolon
Coordination of care Contributory Components
care—when physician makes arrangements with other providers or agencies for patient services
Established patient
one who has received professional services from physician, or from another physician of same specialty who belongs to same group practice, within past three years
Concurrent care
provision of similar services to same patient by more than one provider on same day
HCPCS level II (national)
two-character alphanumeric modifiers are added to CPT codes when reporting outpatient services.
Inferred words
used to save space when referencing subterms