Listing of terms & codes for
medical service & procedures.
A uniform language describes medical, surgical & diagnostic services.
reported for out-patient hospotal surgical procedures.
Medicare prescription drug improvement, & Modernization Act (MMA)
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.
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 &
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
1: Evaluation & Management (E/M)
5: Pathology & Laboratory
5-digit number & narrative description ID procedure & service.
Codes exempt from modifier -51 reporting rules.
Exempt Codes ID
Circle with a / throught it
Summary of CPT code that moderate (conscious) sedation.
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
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.
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
assigned when provider performs a procedure or service which no CPT code.
must accompany claims to describe the nature, extent & need for
Procedure / service along
with time, effort, & equipment necessary to provide service.
Occur in middle of main clause after semicolon & may or may not be enclosed in parentheses.
organized alphabetical main terns printed in boldface,
represent procedures / services, organs
anatonis sites, conditions, eponyms, or abbreviations.
Single Codes &
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 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.
Significant, Separately ID Evaluation & Management Service
by same physician
on same day of procedure or other services
Decision for surgery
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
Office, Hospital, Home, Nursing Facility
Type of Service
E/M Level of Service
reflects amount of work involved, providing health care to patient.
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)
provision of similar services such as hospital inpatient visits, to same patient by more than one provider on same day.
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
Parient's final diagnosis & cincurrent problems.
Pertinent physical findings
Time, effort & equipment required to provide service.
E/M service code to assign
Medical decision making
Coordination of care
Nature of presenting problem
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
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
2. Self-limited or minor
3. Low severity
4. Moderate severity
5. High severity
amount of time provider spends at patient's bedside & management or patient's care.
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.
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.
discontinued outpatient hospital/ambulatory surgery center procedure after anesthesia admin.
Anesthesia Time Units
Anesthesia codes: time unit is one 15-minute increment.
subsections are organized by body system.
code description ID procedures, an integral part of another procedure / service.
" 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.
When the word "complete" is found in the code description, one code is reported to "completely" describe procedure performed.
Radiologic exam vobers the supervision of procedure & interpretation & writing a report describing exam & findings.
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.
Hematology & Coagulation
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.