CPT/HCPCS

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CPT

Used to report services and procedures by physicians

The CPT is published and updated annually and becomes effective

January 1st

The CPT is published and updated annually and comes out in

November

Category II Codes

Supplemental codes used for performance measurements

Category III Codes

Temporary codes for emerging technology, services and procedures

Category I Codes

Represent services and procedures widely used by many health care professionals in clinical practice in multiple locations and have been approved by the FDA

Guidelines

Are at the beginning of each section and provide specific coding rules for that section

The CPT manual is composed of

Eight sections

The CPT coding system used indented format

to save space

Stand-alone codes

Contain the full description of the procedure for the code

Indented codes

Are listed under associated stand-alone codes

Add-on codes

used for procedures that are always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separately

Modifiers

Provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code

Triangle

Represents a change in the code description since the last edition

Two triangular symbols

represent changes in the text or definition between the triangles

Bullet

Represents a new procedure or service code added since the previous edition of the manual

Plus Sign

Indicates add-on codes

Circle with a line through it

respresents exemption from the use of modifier -51

The three parts of the CPT manual are

the main text, the appendices, and the alphabetic index

Evaluation & Management

99201-99499

Anesthesia

00100-01999,99100-99140

Surgery

10021-69990

Radiology

77010-79999

Pathology & Laboratory

80048-89356

Medicine

90281-99199,99500-99602

Never used alone; rather they are always reported in addition to a primary procedure code

Add-on codes

The CPT Index is arranged in alphabetical order by

Main terms, which are further divided by subterms

Parentheses

Used to enclose supplementary words; non essential modifiers

Brackets

Used to enclose synonyms, alternative wording, or explanatory phrase

One of five location methods in the CPT

Synonym/Eponym

Level I Codes

Consist of codes found in the CPT manual

Level II Codes

National codes; codes for physician and non-physician services not found in the CPT (Level I)

Is for the Durable Medical Equipment category which covers reusable medical equipment ordered by the physician for use in the home, such as wheel chairs or portable oxygen tanks

Ex. E Section

Level III Codes

Were used locally or regionally and have been eliminated by the CMS since the implementation of HIPAA

Modifier -24

Attached to the code of the E/M service provided to a patient during the postoperative period to indicate that the service is not part of the postoperative care which is usually part of a package of services of the surgery performed

Modifier -26

Is attached to the procedure to indicate that the physician provided only the professional component

Modifier -32

Used to indicate that the service provided was required by a third party payer, governmental, legislative, or regulatory body

Modifer -50

Is used when the same procedure is performed on a mirror-image part of the body

Modifier -51

Used when more than one procedure is performed during the same surgical episode; one code doesn't describe all of the procedures performed; and the secondary procedure is not minor or incidental to the major procedure

Modifier -58

Used to explain that the procedure or service done during a postoperative period was planned at the time of the orginal procedure

Modifier -78

To report a circumstance in which the physician returns to the operating room to address a complication stemming from the initial procedure

Modifier -79

Used to indicate that the procedure or service provided during the postoperative period was not associated with the initial procedure

Modifier -90

Used to indicate that the procedure was done by an outside laboratory and not by the reporting facility or clinic

Modifier -99

Used to report a procedure or service that has more than one modifier but the third-party payer does not allow the additon of multiple modifiers to the code

Are listed first in the CPT manual because they are used by all the different specialties

Evaluation & Management (E/M) Codes

History

The set of information the physician gathers from the patient

Chief Complaint (CC)

The reason the patient came to see the physician

History of Present illness (HPI)

A chronological account of the development of the complaint from the first sign or symptom that the patient experienced to the present

Review of Systems (ROS)

The inventory of the constitutional symptoms regarding the various body systems

Past, Family and Social History (PFSH)

Consists of the patient's personal experiences with illnesses, surgeries and injuries; information of illnesses predominant in the family; patient's educational background, occupation, marital status, and other factors

List of modifiers are found where in the CPT

Appendix A

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