1. Procedural Coding: Introduction to CPT Chapter 5
© 2010 The McGraw-Hill Companies, Inc. All rights reserved.

2. Learning Outcomes After studying this chapter, you should be able to:
5.1 Discuss the purpose of the CPT code set.
5.2 Explain how to locate the periodic updates to CPT codes.
5.3 Describe the structure and content of the index and the main text in CPT.
5.4 Interpret the formats, conventions, and symbols used in CPT.
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3. Learning Outcomes (Continued)
5.5 Describe the purpose and correct use of CPT modifiers.
5.6 List the three general steps for selecting correct CPT procedure codes.
5.7 Discuss the purpose, structure, and key guidelines for each of the six sections of CPT Category I codes.
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4. Learning Outcomes (Continued)
5.8 Discuss the key components that are the basis for selection of CPT Evaluation and Management codes, and describe the steps for selecting correct codes.
5.9 Analyze procedural statements, apply appropriate physician practice coding guidelines, and assign correct CPT codes.
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5. Key Terms Add-on code Ancillary services Bundling Category I codes
Category II and III codes
Conscious sedation
Consultation
Current Procedural Terminology (CPT)
Descriptor
E/M codes
Fragmented billing
Global period
Global surgery rule
Key component
Modifier
Outpatient
Panel
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6. Key Terms (Continued) Physical status modifier Primary procedure
Professional component (PC)
Secondary procedure
Section guidelines
Separate procedure
Special report
Surgical package
Technical component (TC)
Unbundling
Unlisted procedure
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7. CPT Insurance claims and encounter forms
HIPAA-mandated codes from the American Medical Association
Used to report physician services and procedures on
Insurance claims
and
encounter forms
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8. CPT
Accurate procedural coding ensures maximum reimbursement for services
Insurance Specialists
combine expertise in
working with the CPT
and knowledge of
specific payer guidelines
for claims submission $
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9. CPT Category I Codes Category II Codes Category III Codes
Five-digit (no decimals) codes
Two-digit modifiers may be added to indicate special circumstances
Category II Codes
Track performance measures
Four digits and one alphabetic character
Category III Codes
Temporary codes for emerging technologies
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10. CPT Organization and Format
The codes
themselves are
listed in the main
text (six sections)
and are generally
grouped by
body system or by
types of procedures
CPT contains :
six sections of Category I codes
thirteen appendices
an index
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11. Six Sections of Category I Codes
Evaluation and Management (E&M)
( )
Anesthesia ( )
Surgery ( )
Radiology ( )
Pathology and Laboratory ( )
Medicine ( )
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12. CPT Updates Category I Codes Categories II and III Codes
Major changes announced October 1st for use the following January 1st
Categories II and III Codes
Released by the AMA every six months
Can be used when released
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13. The index is used first in the process
of selecting a code
Terms are listed alphabetically by
Name of the procedure or service
Name of the organ or site
Name of the condition
Synonym or eponym for the term
Abbreviation for the term
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14. CPT Codes are NEVER selected from the index entry alone
The index may use two types of cross-references
See is a mandatory instruction to look under a different listing
See also refers the coder elsewhere if the procedure is not listed here
The main text contains additional entries and important guidelines.
CPT Codes are NEVER selected
from the index entry alone
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15. Look it Up! 28296 Mitchell Procedure Exercise Stress Test
Adhesions, pelvic, lysis
PKU
ECG Monitoring
58740
84030
93271
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16. Look it Up! Radical resection of the distal humerus with autograft
(Hint - look under resection)
24151
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17. The Main Text E&M Anesthesia Surgery Radiology Pathology/Lab Medicine
Each section begins with coding guidelines unique to that section
Topics include definitions and rules such as
unlisted codes
special reports
specific subsections
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18. The Main Text When a main entry has more than one code
a semicolon ; follows the common part of the descriptor in the main heading
unique descriptions of the main entry are indented below it
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19. Look it Up! Chemical peel, facial ;epidermal 15788 ;dermal 15789
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20. The Main Text Special symbols: • New procedure
 Change in code’s description
 New or revised information
+ Add-on codes (procedures carried out in addition to other procedures)
Code cannot be used with -51 modifier
 Code includes conscious sedation
 Pending FDA approval
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21. CPT Modifiers -80 58210 Modifiers are two-digit codes
added to a five-digit CPT Code to indicate
special circumstances
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22. CPT Modifiers
CPT modifiers are two-digit numbers that communicate special circumstances involved with a service/procedure.
A modifier affects the normal level of reimbursement for the code to which it is attached. $
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23. CPT Modifiers All modifiers are listed in Appendix A
Some modifiers apply only to certain sections
Modifiers are shown by appending them with a hyphen:
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24. The Appendixes
The thirteen appendixes contain information helpful to the coding process:
Appendix A – Modifiers
Appendix B – Summary of Additions, Deletions, and Revisions
Appendix C – Clinical Examples
Appendix D – Summary of CPT Add-on Codes
Appendix E – Summary of CPT Codes Exempt from Modifier – 51
Appendix F – Summary of CPT Codes Exempt from Modifier – 63
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25. The Appendixes
Appendix G – Summary of CPT Codes Which Include Conscious Sedation
Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic
Appendix I – Genetic Testing Code Modifiers
Appendix J – Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves
Appendix K – Product Pending FDA Approval
Appendix L – Vascular Families
Appendix M – Crosswalk to Deleted CPT Codes
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26. Coding Steps 1 2 3 Determine the procedures and services to report
Identify the correct codes 3
Determine the need for modifiers
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27. Three Steps to CPT Coding1
Determine the procedures and services to report
Review the encounter slip and/or patient record .
Use knowledge of CPT and payer's policies to determine what services may be charged and reported.
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28. Three Steps to CPT Coding2
Identify the correct codes
Decide what coding system to use (CPT or HCPCS)
Look up the main term in the index
Verify the code in the main text
Report codes ranked in the order of highest to lowest level of reimbursement
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29. Three Steps to CPT Coding3
Determine the need for modifiers
Review the procedure or service. Were there any special circumstances?
Note the patient’s diagnosis. Does this indicate the need for a modifier?
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30. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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31. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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32. Evaluation and Management Codes
Physician services
performed to determine
the best course for patient care.
Definition
Organized by place
and/or type of service
Structure
New/established patients;
Other definitions;
Unlisted services;
Special reports;
Selecting an E/M service
Key Guidelines
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33. Selecting E&M Codes Key Components History Examination
Medical decision making
These key
components
are considered
when selecting
the level
of service.
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34. Additional Components
Selecting E&M Codes
Additional Components
Counseling
Coordination of care
Nature of presenting problem
Time
Additional
components
are used
mostly for
counseling or
coordination
of care
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35. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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36. 1) Determine the category and subcategory of service based on the place of service and the patient’s status
Categories are based on place or type of service
Subcategories provide further definition
Hospital Inpatient services
Office or Other
Outpatient Services
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37. 1) Determine the category and subcategory of service based on the place of service and the patient’s status
Categories are based on place or type of service
Subcategories provide further definition
New Patient
Established Patient
Initial Hospital Care
Subsequent Hospital Care
Hospital Discharge Services
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38. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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39. 2) Determine the extent of the history that is documented
Chief complaint,
Brief history of present
illness or problem
Problem -focused
Expanded problem-focused
Detailed
Comprehensive
Above, plus...
Problem pertinent
system review
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40. 2) Determine the extent of the history that is documented
Problem -focused
Expanded problem-focused
Detailed
Comprehensive
Chief complaint,
Extended history
of the present illness,
Review of problem-pertinent
and additional systems,
Pertinent past, family and/or
social history
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41. 2) Determine the extent of the history that is documented
Problem -focused
Expanded problem-focused
Detailed
Comprehensive
Chief complaint,
Extended history of present illness
Complete review of systems
Complete past, family
and social history.
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42. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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43. 3) Determine the extent of the examination that is documented
Limited exam of the
affected body area
or system
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
Limited exam of the
affected body area
or system
and
other related areas.
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44. 3) Determine the extent of the examination that is documented
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
An extended exam of
the affected body area
or system and
other related areas
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45. 3) Determine the extent of the examination that is documented
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
General multisystem exam
Or complete exam of a
single organ system
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46. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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47. 4) Determine the complexity of medical decision making that is documented
Straightforward
Low-complexity
Moderate complexity
High complexity
Minimal amount of:
Diagnosis or management options
Data to be reviewed
Risk of complications and/or
morbidity or mortality
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48. 4) Determine the complexity of medical decision making that is documented
Straightforward
Low-complexity
Moderate complexity
High complexity
Limited amount of:
Diagnosis or management options
Data to be reviewed
Risk of complications and/or
morbidity or mortality
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49. 4) Determine the complexity of medical decision making that is documented
Straightforward
Low-complexity
Moderate complexity
High complexity
Moderate amount of:
Diagnosis or management options
Data to be reviewed
Risk of complications and/or
morbidity or mortality
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50. 4) Determine the complexity of medical decision making that is documented
Straightforward
Low-complexity
Moderate complexity
High complexity
Extensive amount of:
Diagnosis or management options
Data to be reviewed
Risk of complications and/or
morbidity or mortality
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51. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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52. 5) Analyze the requirements to report the service level
Each E/M code has a descriptor explaining the standards for its use.
The requirements are based on the three key components:
History
Examination
Decision making
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53. 5) Analyze the requirements to report the service level
Examples of when all three key components must be met:
New patient, office
Initial visits, inpatient
Examples of when two of the three key components are required:
Established patients, office
Subsequent visits, inpatient
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54. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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55. Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination 7) Verify that the documentation is complete
The history, examination, and medical decision making must be documented in the patient record.
Documentation is necessary to support the medical necessity and appropriateness of the services provided.
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56. Steps for Selecting E&M Codes
Determine the category and subcategory of service based on the place of service and the patient’s status
Determine the extent of the history that is documented
Determine the extent of the examination that is documented
Determine the complexity of medical decision making that is documented
Analyze the requirements to report the service level
Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination
Verify that the documentation is complete
Assign the code
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57. 8) Assign the code The appropriate code is assigned.
The need for any further modifiers is also reviewed.
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58. Look it Up!
Office Visit for an established six-year-old patient with a sore throat
99212
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59. Look it Up! History and physical exam of a normal newborn 99431
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60. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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61. The Six Sections Anesthesia Codes
Anesthesia performed or
supervised by a physician.
Includes general, regional
and local anesthesia.
Definition
Structure
Organized by body site.
Time based; Services “bundled”;
Unlisted services/ special reports;
Qualifying circumstances;
Physical Status Modifiers
Key Guidelines
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62. Look it Up!
Anesthesia for procedure of the upper anterior abdominal wall
00700
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63. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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64. The Six Sections Surgery Codes
Surgical procedures performed by physicians
Definition
Organized by body system, then body
site, followed by procedural groups
Structure
Surgical package definition;
Follow-up care definition;
Add-on codes;
Separate procedures;
Subsection notes;
Unlisted services/
special reports
Key Guidelines
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65. Look it Up! Anesthesia for total hip replacement 01214
Surgical procedure for total hip replacement
27130
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66. Look it Up!
Tympanostomy bilateral with insertion of ventilating tubes with general anesthesia
69436
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67. Look it Up! Co-surgeon for total abdominal hysterectomy 58150 - 62
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68. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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69. The Six Sections Radiology Codes
Radiology services provided by
or supervised by a physician.
Definition
Organized by type of procedure
followed by body site
Structure
Unlisted services/special reports;
Professional vs. technical component;
with/without contrast materials
Key Guidelines
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70. Look it Up!
Professional reading of chest x-ray, two views, PA and lateral
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71. Look it Up! 73110 Professional reading of bilateral mammogram
Radiological exam of the wrist; complete, three views
73110
Professional reading of bilateral mammogram
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72. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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73. The Six Sections Pathology and Laboratory Codes
Pathology/laboratory procedures
performed by a physician or
physician-supervised technicians.
Definition
Structure
Organized by type of procedure
Complete procedure;
Panels;
Unlisted services/
special reports
Key Guidelines
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74. Look it Up! Hepatic function laboratory panel 80076
Professional reading of TSH
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75. The Six Sections Evaluation and Management Anesthesia Surgery
Radiology
Pathology and Laboratory
Medicine
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76. The Six Sections Medicine Codes
Evaluation, therapeutic, and
diagnostic procedures performed
or supervised by a physician
Definition
Organized by type of service or procedure
Structure
Subsection notes;
Multiple procedures
reported separately;
Add-on codes;
Separate procedures;
Unlisted services/
special reports
Key Guidelines
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77. Look it Up! Determination of refractive state 92015
Right heart catheterization
93501
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78. Category II Codes Category III Codes
Track performance measures
0004F Tobacco use cessation intervention, counseling
Category III Codes
Temporary codes for emerging technology, services, and procedures
0003T Cervicography
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