CPT codes are used to report services & procedures performed on patients:
1. by providers in offices, clinics and private homes
2. by providers in hospitals, nursing facilities and hospices
3. when d provider is employed by the healthcare facility
4. by a hospital outpatient department.
Category 1 codes
procedures/services identified by a 5 digit CPT code and descriptor nomenclature; these are codes traditionally associated with CPT and organized within 6 sections.
Category 3 codes:
contain "emerging technology" temporary codes assigned for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field.. these codes are located after the medicine section, and they will be archived 5 years unless accepted for placement.
CPT sections (6 total)
1. evaluation and management (E/M)
electrodiagnostic medicine listing of sensory, motor and mixed nerves that are reported for motor and nerve studies codes.
CPT Symbols - a bullet -
located to the left of a code number identifies new procedure and services added to CPT
CPT Symbols - a triangle
located to the left of a code number identifies a code description that has been revised.
CPT Symbols - Horizontal triangles
surround revised guidelines and notes. this symbol IS NOT USED for revised code description.
CPT Symbols - a semicolon
is used to save space in CPT and some code descriptions are not printed in their entirety next to a code number.
CPT Symbols - a + (plus) sign
identifies add-on codes for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure.
are located at the beginning of each CPT section and should be carefully reviewed before attempting to code.
define terms and explain the assignment of codes for procedures and services located in a particular section.
are terms that clarify the assigment of a CPT code. they can occur in the middle of a main clause or after the semicolon and may or may not be enclosed in parentheses.
clarify services and procedures performed by providers. they are reported as 2 digit numeric codes added to the 5 digit CPT code.
have always been reported on claims submitted for provider office services and procedures.
increased procedural services. also means above and beyond. assign when a procedure requires greater than usual services.
unusual anesthesia. when a pt's circumstances warrant the administration of general or regional anesthesia instead.
significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other services.
How is the E/M section organized?
it is organized according to the place of service (POS), type of service (TOS) and miscellaneous services.
the E/M level of service
reflects the amount of work involved in providing health care to a patient, and correct coding requires determining the extent of history and examination performed as well as the complexity of medical decision making.
Unlisted Service code (E/M)
is assigned when the provider furnishes an E/M service for which there is no CPT code.
always submitted with the insurance claim to demonstrate medical appropriateness when an unlisted service code is reported.
E/M service level code descriptions:
medical decision making
coordination of care
nature of presenting problem
Preventive medicine services:
include routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical.
Subcategories that are part of Preventive Medicine services
counseling and or risk factor reduction intervention
preventive medicine, individual counseling
preventive medicine, group counseling
other preventive medicine services
Anesthesia services include:
the administration of local, regional, epidural, general anesthesia, monitored anesthesia care (MAC), and/or the administration of anxiolytics
contains subsections that are organized by body system. each subsection is subdivided into categories by specific organ or anatomic site.
follows a code description identifying procedures that are an integral part of another procedure or service. it is also reported if the proecedure or service is performed independently of the comprehensive procedure or service.
major surgical procedure
is the procedure reimbursed at the highest level. is always reported first on the claim and the lesser surgeries listed on the claim in descending order of expense.
For each lesser surgical procedure,
a modifier -51 is added to the CPT code number that does not have the symbol X or + in front of the code.
to code diagnostic radiology procedures accurately, the following need to be identified:
type of procedure
number of views
laterality of the procedure
use of contrast media.
uses high energy ionizing radiation to treat malignant neoplasms and certain nonmalignant conditions.
Therapeutic modalities (methods) directed at malignant and benign lesions include:
brachytherapy, hyperthermia, stereoactic radiation, and teletherapy.
professional component of a radiologic examination
covers the supervision of the procedure and the interpretation and writing of a report describing the examination & its findings.
technical component of an examination:
covers the use of the equipment, supplies provided, and employment of the radiologic technicians.
pathology and laboratory section
this section is organized according to the type of pathology or laboratory procedure performed. within each subsection, procedures are listed alphabetically.
organ or disease oriented panels
there are single code numbers which consist of a series of blood chemistry studies routinely ordered by providers at the same time for the purpose of investigating a specific organ or disorder. the composition of the panel is very specific and no substitutions are allowed.
chemotherapy administered in addition to other cancer treatments, such as surgery and or radiation therapy.