Procedural Coding: Introduction to
5 CPT
Chapter 5
Lecture 2
5.3 Format and Symbols
• CPT uses a semicolon and indentions when a
common part of a main entry applies to
entries that follow (p153)
• Some codes and descriptors are followed by
indented see or use entries in parentheses,
which refer the coder to other codes (p153)
• Descriptors often contain clarifying examples
in parentheses, sometimes with the
abbreviation e.g. (p154)
5-10
5.3 Format and Symbols (Continued)
5-11
• Seven symbols are used in CPT (p154):
1. ● (a bullet or black circle) indicates a new procedure
code
2. ▲(a triangle) indicates that the code’s descriptor has
changed
3. ►◄ (facing triangles) enclose new or revised text
other than the code’s descriptor
4. + (a plus sign) before a code indicates an add-on
code that is used only along with other codes for
primary procedures
• Primary procedure—most resource-intensive CPT procedure
during an encounter
• Secondary procedure—additional procedure performed
• Add-on code—procedure performed and reported in
addition to a primary procedure
5.3 Format and Symbols (Continued)
5-12
• Seven symbols are used in CPT (continued):
5.  (a bullet in a circle) next to a code means that
conscious sedation is a part of the procedure
that the surgeon performs
•
Conscious sedation—moderate, drug-induced
depression of consciousness
6.  (a lightning bolt) is used for codes for vaccines
that are pending FDA approval
7. # (a number sign) indicates a resequenced code
• Resequenced—CPT procedure codes that have been
reassigned to another sequence
5.4 CPT Modifiers
(p154)
5-14
• A CPT modifier is a two-digit number that may be
attached to most five-digit procedure codes
– Modifiers communicate special circumstances
involved with procedures
• A procedure has two parts:
1.Technical component (TC)—reflects the technician’s
work and the equipment and supplies used in
performing it
2.Professional component (PC)—represents a
physician’s skill, time, and expertise used in
performing it
5.5 Coding Steps
(p158)
5-15
• The six general steps for selecting correct CPT
procedure codes:
Step 1. Review complete medical documentation
Step 2. Abstract the medical procedures from the
visit documentation
Step 3. Identify the main term for each procedure
Step 4. Locate the main terms in the CPT index
Step 5. Verify the code in the CPT main text
Step 6. Determine the need for modifiers (p154-7)
5-16
5.6 Evaluation and Management Codes
• E/M codes (evaluation and management
codes)—cover physicians’ services performed to
determine the optimum course for patient care
(159)
• Key component (p166)—factor documented for
various levels of evaluation and management
services
• Key components for selecting E/M codes:
– The extent of the history documented
– The extent of the examination documented
– The complexity of the medical decision making
5.6 Evaluation and Management Codes5-17
(Continued)
• Consultation—service in which a physician
advises a requesting physician about a
patient’s condition and care
• Outpatient—patient who receives health care
in a hospital setting without admission
5.7 Anesthesia Codes
(p171)
• The codes in the Anesthesia section are used
to report anesthesia services performed or
supervised by a physician
• Two types of modifiers are used with
anesthesia codes (p172):
1. Modifier that describes the patient’s health
status
1. Physical status modifier—code used with procedure
codes to indicate a patient’s health status
2. Standard modifiers
5-18
5.7 Anesthesia Codes (Continued)
• Patient’s physical status is selected from this list:
–
–
–
–
P1: Normal, healthy patient
P2: Patient with mild systemic disease
P3: Patient with severe systemic disease
P4: Patient with severe systemic disease that is a
constant threat to life
– P5: Moribund patient who is not expected to survive
without the operation
– P6: Declared brain-dead patient whose organs are
being removed for donation purposes
5-19
5.8 Surgery Codes
(p173)
5-20
• Codes in the Surgery section are used for surgical
procedures performed by physicians
• Surgical package (or global surgery rule)–
combination of services included in a single
procedure code
– Global period—days surrounding a surgical procedure
when all services relating to the procedure are
considered part of the surgical package
– Separate procedure—descriptor used for a procedure
that is usually part of a surgical package but may also
be performed separately
5.8 Surgery Codes (Continued)
5-21
• Reporting surgical codes:
– Bundling—using a single payment for two or more
related procedure codes
– Unbundling—incorrect billing practice of breaking
a panel or package of services/procedures into
component parts
– Fragmented billing—incorrect billing practice in
which procedures are unbundled and separately
reported
5.9 Radiology Codes
(p178)
5-22
• The Radiology section of CPT contains codes
reported for radiology procedures either
performed by or supervised by a physician
• Radiology codes follow the same types of
guidelines as noted in the Surgery section
– Contain a technical component and a professional
component
5.10 Pathology and Laboratory Codes 5-23
(p179)
• Cover services provided by physicians or by
technicians under the supervision of
physicians
• Panel—single code grouping laboratory tests
frequently done together
– To report a panel code, all the indicated tests must
have been done, and any additional test is coded
separately
5.11 Medicine Codes
(p181)
• Codes for the many types of evaluative,
therapeutic, and diagnostic procedures that
physicians perform
– Immunizations require two codes from the
Medicine section, one for administering the
immunization and the other for the particular
vaccine or toxoid that is given
• Ancillary services—services used to support a
diagnosis
5-24
5.12 Category II and Category III Codes5-25
(p182)
• Category II and Category III codes both have
five characters—four numbers and a letter
– Category II codes are for tracking performance
measures to improve patients’ health
– Category III codes are temporary codes for new
procedures that may enter the Category I code set
if they become widely used in the future