Ch. 7 CPT Coding
CPT modifiers
clarify services and procedures performed by providers. Indicate that the description of the service or procedure performed has been altered. Reported as 2 digits added to the 5-digit CPT code (e.g., 99213 25).
Appendix C
clinical examples for Evaluation and Management (E/M) section codes.
unlisted procedure or unlisted service
code is assigned when the provider performs a procedure or service for which there is no CPT code.
Appendix T
codes that may be used to report synchronous real-time interactive audio-only telemedicine services
Appendix P
codes that may be used to report synchronous telemedicine services when appended with modifier -95. Such services require the use of electronic communication that facilitates interactive telecommunications via audio and video. Codes are preceded by the star.
Appendix M
crosswalk of deleted and renumbered CPT codes and citations from 2007-2009.
modifier 57
decision for surgery; is reported when the E/M service resulted in the initial decision to perform surgery on the day before or the day of surgery, exempting it from the global surgery package.
Appendix A
detailed descriptions of each CPT modifier
modifier 74
discontinued outpatient procedure after anesthesia administration; reported to describe discontinued procedures after the administration of anesthesia due to extenuating circumstances. (An ICD-10-CM code to document the reason the procedure was halted is also reported.) This modifier applies only to hospital and ASC outpatient settings.
modifier 73
discontinued outpatient procedure prior to anesthesia administration; reported to describe discontinued procedures prior to the administration of any anesthesia because of extenuating circumstances threatening the well-being of the patient. his modifier applies only to hospital outpatient and ambulatory surgery center (ASC) settings and is not reported for elective cancellation (e.g., patient changed their mind about undergoing the procedure) prior to anesthesia induction or surgical preparation in the operating suite.
modifier 53
discontinued procedure; reported when a provider has elected to terminate a procedure because of extenuating circumstances that threaten the well-being of the patient. This modifier applies only to provider office settings and is not reported for elective cancellation (e.g., by the patient) prior to anesthesia induction and/or surgical preparation in the operating suite.
modifier 59
distinct procedural service; is reported when same provider performs one or more distinctly independent procedures on the same day as other procedures or services, according to the following criteria: Procedures are performed at different sessions or during different patient encounters. Procedures are performed on different sites or organs and require a different surgical prep. Procedures are performed for multiple or extensive injuries, using separate incisions/excisions; for separate lesions; or for procedures not ordinarily encountered/performed on the same day. NEVER ADDED TO E/M CODES
Category III codes
emerging technology temporary codes assigned for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0075T); located after the Medicine section, and they are archived after 5 years unless accepted for placement within Category I sections of CPT.
Category II codes
evidence-based performance measurement tracking codes that are assigned an alphanumeric identified with a letter in the last field (e.g., 0012F); located after the Medicine section, and their use is optional.
CPT index
organized by alphabetical main terms printed in boldface.
practice expense
overhead costs involved in providing a service
physician work
physician's time and intensity in providing the service
modifier 52
reduced services; reported when a service has been partially reduced or eliminated at the provider's discretion and does not completely match the reported CPT code description.
Example of Modifier 52
A surgeon removed a coccygeal pressure ulcer and performed a coccygectomy. However, the surgeon did not use a primary suture or perform a skin flap closure because the wound had to be cleansed for a continued period of time postoperatively. Report code 15920 __. (When the surgeon eventually performs the wound closure procedure, an appropriate code would be reported.)
example of modifier 58
A surgical wound is not healing properly because of the patient's underlying diabetes. Patient was told prior to the original surgery that if this happened, additional surgery would be required for subcutaneous tissue debridement of the wound. Report code 11042-58 for debridement surgery.
add-on codes
identified in CPT with the + symbol. reported with its primary procedure code and cannot be reported alone.
double arrow sumbol
identifies CPT Category I PLA codes
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 of Modifier 25
During a routine annual examination, it was discovered that the 65-year-old established patient had an enlarged liver expanding the scope of level 4 evaluation and management services. Report codes 99397 and 99214 __.
Example of Modifier 22
During surgery, the patient experienced blood loss of 600 cubic centimeters and required intraoperative transfusions. Report the CPT surgery code with _________ __.
Coding Procedures and Services
(1) Read the introduction in the CPT coding manual (2) review guidelines in the beginning of each section (3) review the procedure or service listed in the source document. Code only what is documented; do not make assumptions about conditions, procedures, or services not stated. Obtain clarification from provider, if necessary. (4) refer to CPT index & locate main term (5) locate subterms & follow cross-reference terms (6) review descriptions and compare all qualifiers to descriptive statements (7) assign applicable code & any add-on or additional codes needed (8) review Appendix B to assign appropriate modifiers
Category I codes
5-character CPT codes and procedure/service descriptor nomenclature; traditionally associated with CPT and organized within 6 sections; each section contains subsections and anatomic, procedural, condition, or descriptor subheadings; presented in numerical order except for the Evaluation & Management section, which appears as the 1st section.
NOT
Although PLA codes are included in the Pathology and Laboratory section of CPT, they do ___ fulfill Category I criteria unless the double arrow symbol precedes the code.
informational modifiers
clarify aspects of the procedure or service provided for the payer (e.g., procedure performed on right or left side only).
professional billing
CPT codes are assigned to inpatient hospital professional services and procedures provided by physicians and other qualified health care professionals.
example of modifier 56
Dr. Berger preoperatively cleared an established patient during an E/M level 4 service for scheduled surgery by Dr. Jian, and reports code 99214 56.
Example of modifier 73
Hospital outpatient developed a heart arrhythmia prior to anesthesia administration, and the laparoscopic cholecystectomy procedure was canceled. Report code 47562 __.
example of modifier 74
Hospital outpatient was prepped and draped, and general anesthesia was administered. The anesthesiologist noted a sudden increase in blood pressure, and the laparoscopic cholecystectomy procedure was terminated. Report code 47562 __.
5 characters
How long are CPT codes?
institutional billing
ICD-10-PCS codes are assigned to inpatient hospital services and procedures provided by the hospital.
Evaluation and Management
In what section of CPT would you find the code for office visits?
Example of Modifier 24
One week after surgical treatment to release a frozen shoulder, an established patient received level 3 evaluation and management services for treatment of the flu. Report code 99213 __.
example of modifier 59
Patient has two basal cell carcinomas removed, one from the forehead with a simple closure (11640) and the other from the nose requiring adjacent tissue transfer (14060). Report codes 14060, 11640 51 (forehead), and 11640 59 51 (nose).
Example of Modifier 57
The patient received E/M level 4 services for chest pain in the emergency department, and a decision was made to insert a coronary artery stent. Report code 99284 __ in addition to the stent procedure code.
Example of modifier 53
The surgeon inserted the colonoscope and removed it right away because the patient had not been properly prepared for the procedure. Report code 45378 __. The patient received instructions about properly preparing for a colonoscopy procedure, and the procedure was rescheduled.
Category I, II, and III
What are the 3 categories of CPT codes?
Evaluation & Management, Anesthesia, Surgery, Radiology, Pathology & Laboratory, & Medicine
What are the 6 sections of Category I procedures of CPT?
Modifier
What do you call two-digit codes added to the CPT code that indicate the procedure has been altered in some manner?
Main Body
What is the largest component of the CPT codebook?
Sinusotomy
What is the main term in this procedure: Endoscopic right maxillary sinusotomy with partial polypectomy?
CPT
What is the medical coding classification system that is used to report the healthcare procedures and services provided to patients by physicians?
Bullet
What symbol is placed before a code number to alert you to a completely new code and description?
example of modifier 55
While on vacation, the patient sustained a tibial shaft fracture and underwent closed treatment by Dr. Charles. Upon return home, the patient received follow-up care from Dr. Smith, a local orthopedist. Dr. Smith reports code 27750 55.
example of modifier 54
While on vacation, the patient sustained a tibial shaft fracture and underwent closed treatment by Dr. Ruiz. Upon returning home, the patient received follow-up care in the office from Dr. Cho, a local orthopedist. Dr. Ruiz reports code 27750 54. Dr. Cho reports an appropriate office or other outpatient service E/M code.
Because these codes are reported by all specialities
Why is the evaluation and management located at the beginning of CPT?
Appendix B
annual CPT coding changes (added, deleted, and revised CPT codes). Basis for updating encounter forms and chargemasters
instructional notes
appear throughout CPT sections to clarify the assignment of codes. They are typeset into 2 patterns: a blocked unindented note and indented parenthetical note.
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.
Foreign Body/Implant Definition
applies to the Surgery, Radiology, and Medicine sections to clarify that an object intentionally placed into the patient is considered an implant and an object unintentionally placed (due to ingestion or trauma) is considered a foreign body.
global surgery modifiers
apply to four areas related to the CPT surgical package, which includes local infiltration; metacarpal/digital block or topical anesthesia when used; the procedure; and normal, uncomplicated follow-up care. Do not apply to obstetrical coding, where the CPT description of specific codes clearly describes separate antepartum, postpartum, and delivery services for both vaginal and cesarean deliveries.
Appendix S
artificial intelligence (AI) taxonomy for medical services and procedures, which provides guidance about the description and classification of AI applications.
relative value units (RVUs)
assigned by the CMS to each CPT and HCPCS Level II Codes. Represent the cost of providing a service and include the following payment components: physician work, practice expense, and malpractice expense.
proprietary laboratory analyses (PLA) codes
available to any clinical laboratory or manufacturer that wants to specifically identify their commercially available tests that are used on human specimans. Published quarterly.
main terms
can stand alone or be followed by modifying terms. Can represent procedure or service (e.g., endoscopy), organ or anatomic site, condition (eg., abscess), or synonyms, eponyms, and abbreviations.
inverted parens 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 O of the CPT manual.
stand-alone codes
include a complete description of the procedure or service
modifier 22
increased procedural services; reported when a procedure requires greater than usual services. Documentation that would support using this modifier includes difficult, complicated, extensive, unusual, or rare procedures.
flash symbol
indicates codes that classify products that are pending FDA approval but have already been assigned a CPT code.
Appendix H
list of CPT category II codes - alphabetical clinical topics was removed from CPT
Appendix O
list of administrative codes for multianalyte assays with algorithmic analyses (MAAA) procedures, which are procedures that use multiple results generated from assays of various types, including molecular pathology assays, and so on.
Appendix I
list of generic testing coding modifiers was removed from CPT
Appendix L
list of vascular families to assist in selecting first-, second-, third-, and beyond third-order branch arteries
Current Procedural Terminology (CPT)
listing of descriptive terms and identifying codes for reporting medical services and procedures provided in an outpatient setting.
blue reference symbol
located before a code description in some CPT coding manuals indicates that the coder should refer to the CPT changes: An Insider's View annual publication that contains all coding changes for the current year.
green reference symbol
located below a code description in some CPT coding manuals indicates that the coder should refer to the CPT Assistant monthly newsletter.
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.
blocked unindented note
located below a subsection title and contains instructions that apply to all codes in the subsection.
indented parenthetical note
located below a subsection title, code description, or code description that contains an example.
appendices
located between the Medicine section and the Index.
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
triangle symbol
located to the left of a code and identifies a code description that has been revised in CPT.
bullet symbol
located to the left of a code number and identifies new codes for procedures and services added to CPT
modifier 55
postoperative management only; reported when a provider other than the surgeon is responsible for the postoperative management of a surgery that was performed by another provider. Documentation in the medical record should detail the date of transfer of care to calculate the percentage of the fee to be billed for postoperative care. (The modifier is added to the surgical procedure code. Does not apply when a second provider occasionally covers for the surgeon and where no transfer of care occurs.)
number symbol
precedes CPT resequenced code, which appear out of numerical order
modifier 56
preoperative management only; reported when a provider other than the operating surgeon performs preoperative care and evaluation of the patient for surgery (e.g., preoperative clearance).
functional modifier
pricing modifier; assists in reimbursement decision making.
Appendix K
products pending Food and Drug Administration (FDA) approval but have been assigned a CPT code. In the CPT manual, these codes are preceded by the flash symbol.
modifier 25
significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service; is reported when a documented E/M service was performed on the same day as another procedure because the patient's condition required the assignment of a significant, separately identifiable, additional E/M service that was provided "above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed." The documented medical decision making must "stand on its own" to justify reporting modifier 25 with the E/M code. The separate E/M service provided must be "above and beyond" what is normally performed during a procedure.
modifier 58
staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period; is reported to indicate that additional related surgery is required during the postoperative period of a previously completed surgery and is performed by the same provider. Do not report when the CPT code description describes multiple sessions of an event.
Appendix J
summary electrodiagnostic medicine listing of sensory, motor, and mixed nerves (reported for motor and nerve studies codes)
Appendix D
summary list of CPT add-on codes.
Appendix E
summary list of CPT codes exempt from modifier -51 reporting rules.
Appendix F
summary list of CPT codes exempt from modifier -63 reporting rules. Codes that are exempt from modifier -63 is the parenthetical instruction "(Do not report modifier -63 in conjunction with ....)"
Appendix G
summary list of CPT codes that include moderate (conscious) sedation was removed from CPT.
Appendix N
summary list of resequenced CPT codes
modifier 54
surgical care only; reported when a provider performed only the surgical portion of surgical package and personally administered required local anesthesia. Different provider(s) will have performed preoperative evaluation and/or provided postoperative care.
horizontal triangles symbol
surround revised CPT guidelines and notes. NOT USED FOR REVISED CODE DESCRIPTIONS.
Appendix R
table of digital medicine-services taxonomy services for clinican-to-patient services and clinician-toclinician services.
Appendix Q
table of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccines and associated vaccine product codes and immunization administration codes.
descriptive qualifiers
terms that clarify the assignment of a CPT code. Can occur in the middle of a clause or after the semicolon and may not be enclosed in parentheses. Read all code descriptions carefully to properly assign CPT codes that require this.
modifier 24
unrelated evaluation and management service by the asme physician or other qualified health care professional during a postoperative period; this is reported with evaluation and management (E/M) service codes to indicate that an E/M service was performed during the standard postoperative period for a condition unrelated to the surgery. The E/M service code to which the modifier is attached must be linked to a diagnosis that is unrelated to the surgical diagnosis previously submitted.
loudspeaker symbol
used to identify codes that may be used to report audio-only telemedicine services when appended with modifier 93.
star symbol
used to identify codes that may be used to report telemedicine services when appended with modifier 95
semicolon symbol
used to save space in CPT, and some code descriptions are not printed in their entirety next to a code number. Entry is indented and the coder must refer back to the common portion of the code description that is located before the semicolon.
special report
when an unlisted procedure or service is reported, this must accompany the claim to describe the nature, extent, and need for the procedure or service along with the time, effort, and equipment necessary to provide the service.