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Overview of
CPT Codes

Listing of terms & codes for
medical service & procedures.

CPT Codes

A uniform language describes medical, surgical & diagnostic services.

CPT Codes

reported for out-patient hospotal surgical procedures.

MMA

Medicare prescription drug improvement, & Modernization Act (MMA)

MMA requires

New, revised, & deleted ICD-9-CM codes be implemented ea. Oct. 1 & Updated ea. April

Changes to CPT &
HCPCS level II

national codes be implemented ea. January 1.

Submitted Claims

must link to ICD-9-CM code that justify the need for service or procedure.

Category I Codes:

Procedures / Services ID by 5-digit CPT code &

Descriptor nomenclature;

are codes traditionally associated with CPT & organized in 6 sections.

Category III Codes:

"emerging technology" temp. codes for data collection.

Alphanumeric ID + letter at end

(0001T) codes located after Medicine section they archived after 5 yrs. or placement in category I

CPT Sections

1: Evaluation & Management (E/M)

2: Anesthesia

3: Surgery

4: Radiology

5: Pathology & Laboratory

6: Medicine

:)

CPT Code
Number Format

5-digit number & narrative description ID procedure & service.

Appendix E

Codes exempt from modifier -51 reporting rules.

Exempt Codes ID

Circle with a / throught it

Appendix G

Summary of CPT code that moderate (conscious) sedation.

CPT Symbols

Bullet: located to the left of code # ID's: New procedures & services

Triangle @ left of #

ID's: description has been revised.

Horizontal triangles surround revised guidelines & notes:

This symbol is not used for revised code description.

( ; ) semicolon id used to save space in CPT

Some code descriptions are not printed entirely next to code #.

+ Plus symbol ID's add-on codes.

(Appendix D of CPT) procedures commonly, not always, performed at the same time & by the same surgeon.

Circle with slash / throught it:

Forbidden symbol ID's codes that are "not" to be used eith modifier
-51

Bull's-eye symbol ID'S:

Procedures that include moderate (conscious) sedations.

Moderate (Conscious) Sedations:

Administration of moderate sedation or analgesia.

results in a:

Drug-induced depression of consciousness.

Flash symbol (lighting bolt)

ID's codes: Classify products, pending FDA approval: has CPT code

# symbol precedes CPT code

Appears out of numerical order.

Guidelines:

CPT section.

Review before coding

Defines terms & explains assignment of codes for procedures & services

Located in a particular section

Guidelines in one section do not apply to another section.

Unlisted procedure or
Unlisted service

assigned when provider performs a procedure or service which no CPT code.

Special report

must accompany claims to describe the nature, extent & need for

Procedure / service along

with time, effort, & equipment necessary to provide service.

Descriptive qualifiers

Occur in middle of main clause after semicolon & may or may not be enclosed in parentheses.

CPT Index

organized alphabetical main terns printed in boldface,

represent procedures / services, organs

anatonis sites, conditions, eponyms, or abbreviations.

Single Codes &
Code Ranges

Index code #'s for specific procedures may represent as single code #.

Range of codes separted by dash -

a series of codes separated by commas, or combibation of single codes & ranges of codes.

CPT Modifiers

CPT modifiers clarify services & procedures performed by providers.

a 2-digit code added to the 5-digit CPT code

reported on claims submitted for provieder office services & procedures.

Modifier -25

Significant, Separately ID Evaluation & Management Service

by same physician

on same day of procedure or other services

-57

Decision for surgery

-22

Increased Procedural Services: also means above & beyond.

Assign when a procedure

requires greater than usual service.

Evaluation & Management (E/M) Section

Organized according to (POS) place of service

NF:

Office, Hospital, Home, Nursing Facility

ED

Emergency Department

TOS

Type of Service

E/M Level of Service

reflects amount of work involved, providing health care to patient.

Examination performed

as well, the complexity of medical decision making.

POS = Place of Service

location where service is provided.

TOS= Type of Service

Kind of service; Critical care, consultation, initial hospital care, subsequent hospital care (Follow up)

Concurrent Care

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

Each provider

shoul report different ICD-9-CM codes

E/M guidelines clarify

when an unlisted service code is reported, special report must be submitted with claim for medical appropriateness.

Provider shourl document the following elements on report;

complexity of patient's aymptons

Description of, nature of, extent of & need for service

Diagnostic & Therapeutic procedures performed

Follow-up care

Parient's final diagnosis & cincurrent problems.

Pertinent physical findings

Time, effort & equipment required to provide service.

E/M service code to assign

History
Examination
Medical decision making

Counseling
Coordination of care

Nature of presenting problem
Time

E/M
3 Key components

Extent of history
Extent of examination
Complexity of medical decision making

Extent of History

Patient History of Present illness (HPI), Chief Complant (CC) Reviwiew of systems (ROS) & Past/family/ social history (PFSH)

Problem focused history

Expanded problem focsed history

Detailed history

Comprehensive history

Counseling

discussion with patient / family concerning one or mreareas:

Diagnostic results, impressions, or

diagnostic studies; [rognosis; risks & benefits of options (treatment)

Coordination of Care

Physician makes arrangements with other providers or agencies to procid services to patient.

5 types of presenting problems

1. Minimal
2. Self-limited or minor
3. Low severity

4. Moderate severity
5. High severity

....

Unit/floor time

amount of time provider spends at patient's bedside & management or patient's care.

Consultations:

1. Requested by another physician or source 3-party payer, (ifconsultation is mandated by payer, attach modifier -32 to services code.)

2. renders an opinion or advice.

3. initiates diagnostic or therapeutic services

4. requesting physician has documented patient's record the request & need for consultation.

5. opinion, adcice & andy services rendered are documented in patient's record & communicated to requesting physician or source, generally in written report.

Subcategories include:

1. Office or other outpatient consultations
2. Inpatient consultations.

Emergtency department services (ED)

Provided in hospital, open 24 hours to provide unscheduled episodic services to patients require immediate medical attention.

Preventive medicine services

Routine examinations , risk management counseling for kids / adults no overt signs or symptoms.

Physical status modifier

added to ea. reported anesthesia code to indicate patient's condition at time anesthesia was asministered.

-74 modifier

discontinued outpatient hospital/ambulatory surgery center procedure after anesthesia admin.

-99 modifier

multiple modifiers.

Anesthesia Time Units

Anesthesia codes: time unit is one 15-minute increment.

Surgery section:

subsections are organized by body system.

Separate Procedure

code description ID procedures, an integral part of another procedure / service.

In addition,
" separate procedure code

reported if procedure / service is performed independently of comprehensive procedure / service, is unrelated, distinct from procedure / service performed at same time.

Multiple Surgical Procedures

First code highest level procedure, then the lesser surgeries listed in decending order of expense.

Modifier -51 is added to CPT # for ea. lesser procedure

that does not have the (X or +) symbol in front of code.

Radiological exam of soft tissue & internal structures of breast.

Screening mammography is performed when patient presents without signs & symptoms of breast disease.

Diagnostic mammography includes

assessment of suspected disease & is reported when abnormality is found or suspected.

"Complete"

When the word "complete" is found in the code description, one code is reported to "completely" describe procedure performed.

Professional component

Radiologic exam vobers the supervision of procedure & interpretation & writing a report describing exam & findings.

Techinical Component

exam vobers the use of equipment, supplies provided & employment of radiologic technicians.

Pathology & Laboratory

organized according to pathology or lab procedure performed.

Organ or Disease Oriented Panels

Single code #'s assigned to Organ or Disease Oriented Panels, a series of blood chemistry studies

routinely ordered by providers the same time for purpose of investigating a

specific organ or disorder. Compostion of panel is very specific, & no substitutions are allowed.

Urinalysis
Chemistry

Hematology & Coagulation
Immunology

Anatomic Pathology

Codes reported for postmortem exam. (also called Autopsy or Necropsy)

CPT Medicine Section

Classifies noninvasive or minimally invasive diagnostic & therapeutic procedures & services, Specialty services

1. Nonivasive procedures require no surgical incision or excision, & are not open procedures.

2. Minimally invasive procedures include percutaneous access.

Chemotherapy & Other Highly complex Biologic Admin.

Chemotherapy admin. in addition, cancer treatments, such as surgery & or radiation therapy, is called adjuvant chemotherapy.

Unbundling occurs when one service is divided into component parts.

A code for each component is reported as if separate services.

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