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 2 codes
contain "performance measurements" tracking codes that are assigned an alphanumeric identifier with a letter in the last field. these codes will be located after the medicine section and THEIR use is optional.
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)
codes exempt from modifier -51 reporting rules.
located at the beginning of CPT because these codes are reported by all specialties.
cpt codes exempt from modifier -63 reporting rules.
Summary of CPT codes that include moderate (conscious) sedation.
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) signe
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.
CPT Symbols - forbidden symbol
identifies codes that are not to be used with modifier -51
CPT Symbols - bull's eye symbol
indicates a procedure that includes moderate (conscious) sedation.
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.
appear througout CPT sections to clarify the assignment of codes.
blocked unindented note
is located below a subsection title and contains instructions that apply to all codes in the subsection
indented parenthetical note
is located below a subsection title, code description, or code description that contains an example.
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.
decision for surgery.
distinct procedural service
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.
is one who has not received any professional services from the physician, or from another physician of the same speciality who belongs to the same group practice within the past 3 years
is one has received professional services from the physician or from another physician of the same specialty within the past 3 years.
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.
Elements that need to be provided when submitting a "special report"
1. complexity of patient's symptoms
2. description of, nature of, extent of, and need for service
3. diagnostic & therapeutic procedures perfromed.
4. follow up care
5. pt's final diagnosis and concurrent problems.
6. pertinent physical findings.
7. time, effort & equipment required to provide the service
E/M service level code descriptions:
medical decision making
coordination of care
nature of presenting problem
observation or inpatient care services
assigned only if the patient is admitted to and discharged from observation/inpatient status on the same day
Nursing Facility Services
are provided at a nursing facility, skilled nursing facility, intermediate care facility/mentally handicapped, long term care facility, or psychiatric residential treatment facility.
Subcategories that are part of a Nursing Facility:
Initial nursing facility care
Subsequent nursing facility care
Nursing facility discharge services
Other nursing facility services
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
are associated with the administration of analgesia and or anesthesia as provided by an anesthesiologists (physician) or certified registered nurse anesthetist (CRNA).
Anesthesia services include:
the administration of local, regional, epidural, general anesthesia, monitored anesthesia care (MAC), and/or the administration of anxiolytics
Anesthesia Time Units
when reporting Anesthesia codes, be sure to report the time units in BLOCK.
Anesthesia Time Unit
is one 15-minute increment.
contains subsections that are organized by body system. each subsection is subdivided into categories by specific organ or anatomic site.
Examples of procedures that are bundled (included) with the surgical package code include:
local infiltration of medication
closure of surgically created wounds
exploration of operative area
fulguration of bleeding points
application of dressings
application of splints with musculoskeletal procedures
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.
multiple surgical procedures
two or more surgeries performed during the same operative session.
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.
codes for noninvasive, invasive diagnostic and therapeutic procedures, in addition to CT, MRI and magnetic resonance angiography (MRA).
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.
codes for laboratory tests that determine whether a drug or a specific classification of drugs is present in blood or urine.
therapeutic drug assays
codes for laboratory tests performed to determine HOW MUCH of a specific prescribed drug is in the pt's blood.
require no surgical incision or excision and they are not open procedures.
minimally invasive procedures
include percutaneous access.
medicine section also includes:
chemotherapy administered in addition to other cancer treatments, such as surgery and or radiation therapy.
unbundling CPT Codes
providers are responsible for reporting the CPT and HCPCS level II codes that most comprehensively describes the services provided.
involves reporting multiple codes for a service when a single comprehensive code should be assigned.