Chapter 19, Current Procedural Terminology
G. Ouattara, Instructor
June 2, 2015
CPT-4 CONTAINS STANDARDIZED CODES AND MEDICAL TERMS FOR PHYSICIAN SERVICES
 Facilitates communication, quick reading, and speedy claims processing
 Codes updated each December
 The fourth edition contains more than 7000 new codes
 Each five-digit numeric code has specific meaning
 Both inpatient and outpatient
 Code is entered on CMS-1500 universal claim form for submission to insurer
 General layout and features of CPT-4 book are user friendly
LAYOUT OF CPT-4
Divided into six major sections:
o Evaluation and management
o Anesthesia
o Surgery
o Radiology
o Pathology and laboratory
o Medicine
Sections followed by explanations and listing of Category I and Category II codes
NEXT ARE APPENDICES
 Most widely used in outpatient arena Appendix A-C
o Appendix A-list of modifiers
o Appendix B- summary of additions, deletions and revisions
o Appendix C-clinical examples
o Appendix D-I is rarely used in medical office
ALPHABETIC INDEX
 Located in back of book
 Organized by main terms like ICD-9 CM book
UNLIKE THE ICD-9 index, you locate codes by finding the procedure, the location or condition
o Example—code for removal of a colon polyp can be found under
o Removal
o Colon
o Polyp
 Once service or procedure is found—you will see either one code or a range of codes
o Cross reference by finding this section in tabular section to ensure correct code
TEXTBOOK LAYOUT
 Reading descriptors
 Read up to semicolon, then through indented items that go with that phrase to locate the appropriate one
 Locate the code for incision and drainage of infected bursa
 Proper code is 27604
o Indented under code 27603
o Read up to semicolon in code above
o Descriptor for 27603 refers to incision and drainage, leg or ankle; deep abscess or hematoma
o If incision and drainage was done in infected bursa of the leg or ankle, then code is 27604
o This descriptor is: Incision and drainage, leg or ankle; infected bursa
o You would use 27603 for an incision and drainage of a leg or ankle for a deep abscess or hematoma.
o Use of indentation and semicolon organizes codes and saves space
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Chapter 19, Current Procedural Terminology
G. Ouattara, Instructor
June 2, 2015
PLACE OF SERVICE
CPT-4 Book begins with “Place of service codes for professional Claims”
 Most payers require place of service code on each line of section 24, column B of CMS-1500 claim form
o Should confirm payer recognized codes listed in CPT-4
o Most commonly used place of service codes found in
SECTION GUIDELINES
 Each section begins with own specific guidelines and listing of specific procedures and services applicable in that field
contains:
o Definitions
o Explanatory notes
o Listing of previously unlisted procedures
o Direction on how to file special reports
o Modifiers for use in that section
o Definitions to assist coder
UNLISTED PROCEDURES AND SPECIAL REPORTS
 CPT provides unlisted codes at beginning of each section for unusual, variable, or new procedure
 Must submit copy of procedure report with claim
o Each section lists information to be included in special report
 Definition or description of nature, extent and need for procedure
 Time, effort, and equipment necessary to provide service
 Complexity of symptoms
 Final diagnosis
 Pertinent physical finding
 Diagnostic and therapeutic procedures
 Concurrent problems
 Follow-up care
EVALUATION AND MANAGEMENT CODES
 Five-digit numbers that begin with 9
o Most common codes — describe various patient histories, examination and decisions physician make in evaluating
and treating patients in various settings
o What physician does when interacting with patients
o Used in office, outpatient, hospital
Physicians documentation must meet standards so the physician and coder (medical assistant) can decide with level or type of
code to use for encounter
 Key components
o Two of three required for established patients
o Three of three required for new patients
ALL E/M CODES CONTAIN FOLLOWING COMPONENTS
o History
o Physical examination
o Medical decision making
o Counseling
o Coordination of care
o Nature of presenting problem
o Time
o Amount of history documented in patient’s record determines which of four classifications/levels assigned
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Chapter 19, Current Procedural Terminology
G. Ouattara, Instructor
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June 2, 2015
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
EXAMINATION
 Levels are same as for history taken
 Review of system is systematic way to assess the body
o Level of examination depends on number of systems examined
o CPT recognized the following body systems
 Eyes
 Ears, nose, throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary
 Musculoskeletal
 Skin
 Neurologic
 Psychiatric
 Hematologic
 immunologic
MEDICAL DECISION MAKING
 Classifications of medical decisions
o Straightforward
o Low complexity
o Moderate complexity
o High complexity
 Time spent with patient
o If it exceeds 50% of typical, time becomes deciding factor in code
OTHER CATEGORIES OF EVALUATION AND MANAGEMENT CODES
 Medical assistant is responsible for billing of provider-employer
o Will assist physician in assigning codes for visits and procedures outside office
 Other categories include:
o Observation codes
o Hospital inpatient services
o Initial care
o Subsequent care
o Section for consultation ordered by other physicians
 Emergency department codes used only when service rendered in 24-hour hospital
o Specializes in treatment of unscheduled events
 Refer to CPT code book for complete list of subsections and categories
ANESTHESIA CODES
 Five-digit numbers that begin with 0
 Categorized by anatomic site and procedure type
 Modifiers used to add detail to code
o Standard modifiers
o Physical status modifier
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Chapter 19, Current Procedural Terminology
G. Ouattara, Instructor
June 2, 2015
 P1–P5 indicating health of patient — P1 healthy and P5 will not survive without procedure
SURGERY CODES
 Organized by body systems begin with 1–6
 Procedures billed together as surgical package

Surgical package = local infiltration; metacarpal, metatarsal, or digital block or topical; surgery; normal
uncomplicated follow-up
o Cannot bill separately for pre-/postoperative care
o Must use modifier
o related complications are coded separately
 For surgical service itself
o Pre-/postoperative components coded separately
 Third party payers have different rules about surgery package
o Must double check
o Some carriers have set number of follow-up days
o Fees for fracture care and delivery also include care given before and after service
CONTENT OF THE SURGERY SECTION
 Subheadings are as follows
o Integumentary
o Musculoskeletal
o Respiratory
o Cardiovascular
o Hemic and lymphatic
o Urinary
o Digestive
o Male genital
o Intersex surgery
o Female genital
o Maternity care and delivery
o Endocrine
o Nervous
o Eye and ocular adnexa
o Auditory system
 Each subheading contains subsections that are organized by location and type
 It is helpful to be familiar with suffixes and definitions related to surgical procedures
RADIOLOGY CODES
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Five-digit numbers that begin with 7
Arranged by anatomic site from top to bottom
Descriptors include with or without contrast medium
Subsections:
o Diagnostic radiology/diagnostic imaging
o Diagnostic ultrasound
o Radiation oncology
o Nuclear medicine
 The descriptors for the test specify “with contrast” and “without contrast”
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Chapter 19, Current Procedural Terminology
G. Ouattara, Instructor
June 2, 2015
 Performance of procedure and interpretation are coded separately
 A written report in patient record necessary for billing these codes
PATHOLOGY AND LABORATORY CODES
 Five-digit numbers that begin with 8
 Sections for panels of laboratory tests and pathology procedures
 Each tissue specimen is coded separately for diagnosis
 Codes represent level of work
 Automated multichannel tests — some tests have multiple components but are coded singly
 Qualitative and quantitative used in drug screening test
 Example digoxin for heart—tested for therapeutic level
 When testing for illegal drugs, amount does not matter
MEDICINE CODES
 Like E/M codes are five-digit numbers that begin with 9
 Immunization section especially important
o Immunizations are coded separately from other procedures even if occurring simultaneously
o Must specify content of injection
 Medicare combines cost of administering injections in cost of office visit
o Drug itself is separate
 Ensure charges verifiable
o Use most specific code possible and keep invoices
 Other examples include:
 Esophageal procedures
 Cochlear implants
 Vascular studies
 Allergy testing
o Cardiac diagnostics
 Electrocardiography
 Echocardiography
o CPR
o Dialysis
CPT-4 MODIFIERS
 Add detail to procedure codes
 Must always be used with procedural codes, never alone
 Different ways to write:
o Five-digit code followed by two-digit modifier separated by hyphen
o Code, modifier and no hyphen
o Multiple modifiers signified by code followed by –99 with modifiers
o In Appendix A of CPT-4
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