CHAPTER 7
CPT Coding
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Introduction
• Chapter 7:
– Introduces assignment of Current Procedural
Terminology
– CPT:
• Services and procedure codes reported on
insurance claims
2
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Overview of CPT
• CPT
– Provides a list of identifying and descriptive
codes for reporting procedures and medical
services
– Uniform language that describes medical,
surgical procedures and services
3
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Overview of CPT
• CPT codes are used to report services
and procedures
• Submitted as claims with linked ICD-9-CM
codes
– Codes justify need for service or procedure
4
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Overview of CPT
• Changes to CPT
– CPT supports electronic data
– Exchange (EDI), Computer-based patient
– Record (CPR), or electronic medical
– Record (EMC) and reference/research
database
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Overview of CPT
• Improvements to CPT are underway
• In 2002
– AMA completed the CPT 5 Project, resulting
in the establishment of three categories of
CPT codes
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Overview of CPT
• Category 1
– Procedures/services identified by a five digit
CPT code and descriptor nomenclature
– Codes traditionally associated with CPT
organized in six sections
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Overview of CPT
• Category 2
– Contain “performance measurements”
tracking codes that are assigned an
alphanumeric identifier with a letter in the last
field (e.g., 1234A)
– Codes located after Medicine section
• Use is optional
8
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Overview of CPT
• July 2007
– New program from Medicare utilizing these
codes to justify documentation
– “PQRI’s” will begin a project for physicians’
practices
• Will receive additional percentage of revenue for
documentation compliance
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Overview of CPT
• Category 3 codes
– Contain “emerging technology” temporary
codes assigned for data purposes and
assigned in alphanumeric with the letter in
the last position
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Overview of CPT
• Field 0001T
– Codes are located after Medicine section
– Archived after five years unless accepted for
placement
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CPT Sections
• Category I procedures and services
– Evaluation and Management (E/M) 9920199499
– Anesthesia (00100-01999, 99100-99140)
– Surgery (10021-69990)
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CPT Sections
• Radiology (70010-79999)
• Pathology and laboratory (80048-89356)
• Medicine (90281-99199, 99500-99602)
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CPT Sections
• CPT code number format
– Five-digit number and description identifying
each procedure and service listed in CPT
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CPT Sections
• CPT Appendices
– CPT contains appendices located after the
Medicine section and Index
– Insurance specialist should become familiar
with changes that affect the practice
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CPT Appendix Description
• Appendix A
– Detailed description of each CPT modifier
• Appendix B
– Annual CPT coding changes
• Added, deleted, revised CPT codes
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CPT Appendix Description
• Appendix C
– Clinical examples for evaluation and
Management (E/M) section codes
• Appendix D
– Add-on codes
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CPT Appendix Description
• Appendix E
– Codes exempt from modifier -51 reporting
rules
• Appendix F
– CPT codes exempt from modifier -63
reporting rules
• Appendix G
– Summary of CPT codes that include moderate
(conscious) sedation
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CPT Appendix Description
• Appendix H
– Alphabetic index of performance measures by
clinical condition or topic
• Serves as a crosswalk to the category II
• Appendix I
– Genetic testing code modifiers
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CPT Appendix Description
• Appendix J
– Electro diagnostic medicine listing of sensory,
motor, and mixed nerves
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CPT Appendix Description
• There is also a table that indicates “type of
study and maximum of studies”
– Generally performed for needle
electromyogram (EMG)
– Nerve conduction studies
– Other EMG studies
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CPT Appendix Description
• Appendix L
– List of vascular families that is intended to
assist in selection of first, second, third, and
beyond third-order branch arteries
• Appendix M
– Crosswalk of deleted to new CPT codes
22
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CPT Symbols
• Symbols are located throughout CPT
coding book
• Bullet located to left of a code number
– Identifies new procedures and services
added to CPT
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CPT Symbols
• Triangle located to left of a code number
– Identifies a code description that has been
revised
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CPT Symbols
• Horizontal triangles
– Surround revised guidelines and notes
– Not used for revised code descriptions
– To save space in CPT
• Code descriptions are not printed in their entirety
next to a code number
25
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CPT Symbols
• Plus sign
– Identifies add-on codes
– For procedures that are commonly, but not
always, performed at the same time and by
the same surgeon
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CPT Symbols
• Circle with a line through it
– Identifies codes that are not to be used
with modifier
• Bull’s-eye symbol
– Indicates a procedure that includes
moderate sedation
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Guidelines
• Located at beginning of the CPT section
– Should be reviewed each year before
attempting to code from this section
• Guidelines define and explain the
assignment of codes, procedures, and
services in a particular section
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Unlisted Procedures/Services
• Unlisted procedure or service
– Codes are assigned when a procedure or
service is performed by a provider for which
there is no CPT code
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Unlisted Procedures/Services
• Special Report
– When an unlisted procedure or service
code is reported
30
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Unlisted Procedures/Services
• Special Report
– Narrative document must accompany claim
to describe nature and extent of the need
of service or procedure
• Some practices place in Box 19 of CMS 1500
claim form the “unlisted code = the closest
related code of XXXXX.”
31
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Unlisted Procedures/Services
• Notes
– Instructional notes are found throughout
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Unlisted Procedures/Services
• Blocked unindented note:
– Located below a subsection title and contains
instructions that apply to all codes
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Unlisted Procedures/Services
• Indented parenthetical note:
– Located below a subsection title, code
description, or code description that contains
an example
• Highlight and understand each of these notes
34
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CPT Modifiers
• Clarify services and procedures
performed by providers
• Have always been reported on claims
submitted for provider office services and
procedures
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CPT Modifiers
• Coding tip:
– List of all CPT modifiers with brief
descriptions is located inside front cover of
coding manual
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CPT Modifiers
• Documented history, examination, and
medical decision making
– Must “stand on its own” to justify reporting
modifier -25 with the Evaluation and
Management (E/M) code
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CPT Modifiers
• E/M service:
– Must be “above and beyond” what is normally
performed during a procedure
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Coding
Procedures and Services
• Step 1:
– Read introduction in CPT coding manual
• Step 2:
– Review guidelines at beginning of each
section
• Step 3:
– Review procedure
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Coding
Procedures and Services
• Step 4:
– Refer to CPT index
– Locate main term for procedure or service
documented
• Main terms can be located by referring to the
following:
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Coding
Procedures and Services
a.
b.
c.
d.
Procedure or service documented
Organ or anatomic site
Condition documented in the record
Substance being tested
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Coding
Procedures and Services
e. Synonym (term with similar meaning)
f. Eponym (procedures and diagnoses
named for an individual)
g. Abbreviation
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Coding
Procedures and Services
• Step 5:
– Locate sub terms and follow cross references
• Step 6:
– Review descriptions of service/procedure
codes, and compare all qualifiers to
descriptive statements
43
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Coding
Procedures and Services
• Step 7:
– Assign applicable code number and any addon (+) or additional codes needed to
accurately classify statement being coded
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Surgery Section
• Surgery section is organized by body
system
– Some subsections are further subdivided by
procedure categories
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Surgery Section
•
•
•
•
•
Incision
Excision
Introduction or removal
Repair, revision, or reconstruction
Grafts
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Surgery Section
• Suture
• Other procedures
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Code Surgeries Properly
• Three questions must be asked:
– What body system was involved?
– What anatomic site was involved?
– What type of procedure was performed?
• Carefully read the procedure outlined in
the operative report
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Evaluation and Management
• Evaluation and management
– Located at the beginning of CPT because
these codes describe services most
frequently provided by physicians
• Before assigning E/M codes
– Make sure you review guidelines and apply
any notes
49
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Evaluation and Management
• For established patients
– Two of three key components must be
considered
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Evaluation and Management
• E/M code reported to a payer
– Must be supported by documentation in the
patient’s record
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Key Components
• E/M code selection is based on three key
components:
– Extent of history
– Extent of examination
– Complexity of medical decision making
• All key components must be considered
when assigning codes for new patients
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Extent of Examination
• Physical examination is an assessment of
the patient’s organ and body system/s
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Extent of Examination
• Categorized according to four types:
– Problem focused examination
– Expanded problem focused examination
– Detailed examination
– Comprehensive examination
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Complexity of
Medical Decision Making
• Complexity of establishing a diagnosis
and/or selecting a management option as
measured by the:
– Number of diagnoses or management options
– Amount and/or complexity of data to be
reviewed
– Risk of complications and/or morbidity or
mortality
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Patient’s
Records Should Include
• Laboratory, imaging, and other test results
that are significant to the management of
the patient care
• List of known diagnoses as well as those
that are suspected
• Opinions of other physicians who have
been consulted
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Patient’s
Records Should Include
• Planned course of action for the patient’s
treatment
• Review of patient records obtained from
other facilities
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History and Examination
• Determined by:
– Straightforward
– Low complexity
– Moderate complexity
– High complexity
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History and Examination
• Once the extent of history, extent of
examination, and complexity of medical
decision making are determined
– Select the appropriate E/M code
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Presenting Problem
• CPT defines nature of the presenting
problem as “a disease, condition, illness,
injury, symptom, sign, finding, complaint,
or other reason for the encounter, with or
without a diagnosis being established at
the time of the encounter.”
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Presenting Problems
•
•
•
•
•
Minimal
Self-limited or minor
Low severity
Moderate severity
High severity
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Face-to-Face Time
• Amount of time the doctor spends with the
family or the patient
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Unit/Floor Time
• Amount of time the doctor spends at the
patient’s bedside and at the management
of the patient’s care.
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E/M Time
• Claiming E/M on time you must have:
– Total length of time for the encounter
– Plus the length of time spent coordinating
care and/or counseling patient
– Issues discussed
– Relevant history, exam, and medical decision
making
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Observation Services
• Are furnished in a hospital outpatient
setting
– Patient is considered an outpatient
• They are reimbursed only when the doctor
orders it
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Subcategories Include
• Observation care discharge services
• Initial observation care
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Hospital Inpatient Services
• E/M services provided to hospital
inpatients, including partial hospitalization
services.
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Subcategories Include
•
•
•
•
Initial hospital care
Subsequent hospital care
Observation care services
Hospital discharge services
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Consultations
• Type of service provided by a physician
whose opinion or advice regarding
evaluation and/or management of a
specific problem requested by another
physician or other appropriate source.
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Criteria
• Consultation is requested by another
doctor or provider
• Consultant renders an opinion or advice
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Criteria
• Consultant initiates diagnostic or
therapeutic services.
• Requesting physician documents in the
patient’s record, the request, and the need
for the consultation.
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Criteria
• Consultant’s opinion, advice, and any
services rendered are documented in the
patient’s record
– These are reported to the requesting
physician or source
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Subcategories Include
• Office or other outpatient consultations
• Inpatient consultations
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Emergency
Department Services
• Are given in a hospital setting that is open
24 hours to provide services that are not
scheduled.
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Critical Care Services
• When a doctor provides services to
someone who is critically ill or injured.
• The doctor should document the total time
spent delivering critical care services
– Excluding time for allowable services
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Neonatal
• A neonate is a newborn up until 28 days,
and an infant is 29 days to a year old.
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Subcategories
• Inpatient pediatric critical care
• Inpatient neonatal critical care
• Continuing intensive care services
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Nursing Facility Services
• Are provided at nursing facilities:
– Skilled nursing, intermediate care, and longterm care
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Subcategories
•
•
•
•
Initial nursing facility care
Subsequent nursing facility care
Nursing facility discharge services
Other nursing facility services
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Prolonged Services
• May be reported when a doctor’s services
involving patient contact are considered
beyond the usual service in either an
inpatient or outpatient setting.
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Subcategories
• Prolonged physician service with direct
face-to-face
• Prolonged physician services without
face-to-face
• Physician standby services
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Newborn Care
• Includes services provided to newborns in
a variety of health care settings.
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Qualifying
Circumstances for Anesthesia
• When situations or circumstances make
anesthesia administration more difficult
and increases the patient’s risk factor.
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Physician Status Modifiers
• Each “status modifier”
– Reported with an anesthesia code to indicate
the patient’s condition at the time anesthesia
was administered.
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Modifiers
• P1
– Normal health
• P2
– Mild systemic disease
• P3
– Severe systemic disease
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Modifiers
• P4
– Severe systemic disease that is a constant
threat to life
• P5
– Not expected to survive without the operation
• P6
– Declared brain-dead and whose organs are
being removed for donor purposes
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Anesthesia Time Units
• Be sure to record the time with the
anesthesiologist
• Anesthesia time unit is one 15-minute
increment
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Calculating Anesthesia
• Examination and evaluation of the patient
by the anesthesiologist or CRNA prior to
administration of anesthesia
• Nonmonitored interval time
• Recovery room time
• Routine postoperative evaluation by the
anesthesiologist or CRNA
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Separate Procedure
• Follows a code explanation identifying
procedures that are an important part of
an additional procedure or service.
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Complete Procedure
• When the word “complete” is established
in the code definition
– One code is reported to “completely” explain
the procedure performed
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Pathology and Laboratory
• Organized according to the kind of
pathology or laboratory procedure
performed
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Pathology and
Laboratory Subsections
•
•
•
•
•
Organ or disease oriented panels
Drug testing
Therapeutic Drug Assays
Consultations (Clinical Pathology)
Urinalysis, chemistry, hematology and
coagulation immunology
• Microbiology
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Pathology and
Laboratory Subsections
•
•
•
•
•
•
Anatomic pathology
Cytopathology and cytogenetic studies
Surgical pathology
Transcutaneous procedures
Other procedures
Reproductive medicine procedures
93
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National
Correct Coding Initiative
• To encourage national correct coding,
methodologies, and manage the improper
assignment of codes.
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National
Correct Coding Initiative
• Incorrect coding
– Results in inappropriate repayment of
Medicare Part B claims
– Centers for Medicare and Medicaid Services
implemented the National Correct Coding
Initiative
95
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NCCI Coding Policies
• Analysis of standard medical and surgical
practice
• Coding conventions included in CPT
• Coding guidelines developed by national
medical specialty societies
• Local and national coverage
determinations
• Review of current coding practices
96
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