1. Chapter 18
CPT Medicine

2. CPT Medicine Section
Classifies diagnostic and therapeutic procedures and services
Noninvasive
No surgical incision or excision
Minimally invasive
e.g., percutaneous access
(continued)

3. CPT Medicine Section Last section of CPT Procedure-oriented
e.g., immunizations
Applies to various medical specialties
e.g., gastroenterology, ophthalmology
(continued)

4. CPT Medicine Section
Applies to different types of health care providers
e.g., physical therapists (PTs), occupational therapists (OTs)

5. Medicine Section Guidelines
Provide instruction about the following
Multiple procedures
Add-on codes
Separate procedures
Subsection information
Unlisted service or procedure
Special report
Materials supplied by physician

6. Instructional Notes Unique to subsection
Provide coding clarification and direction

7. Angles of Injection
Administration of therapeutic, prophylactic, and diagnostic medication
Delmar/Cengage Learning

8. Multiple Procedures
When performed on same date, report separate code for each procedure and/or service

9. Add-On Codes
Reported for procedures and services performed in addition to primary procedure
Do not add modifier -51 (multiple procedures) to add-on codes

10. Separate Procedures
Considered integral component of complete procedure
Identified by description “separate procedure”
Only report “separate procedure” code in addition to code for comprehensive procedure if “separate procedure” performed independently
(continued)

11. Separate Procedures Modifier -59 (distinct procedural service)
When “separate procedure” performed independently from other services, add modifier -59 to “separate procedure” code

12. Bundled Medicine Codes
Use OCE or NCCI software to identify bundled codes
Unbundling
Reporting component codes in addition to major procedure code
Fraud

13. Unlisted Service
Assigned when no specific code describes procedure performed
Submit written report that describes procedure

14. Special Report Submitted when unlisted procedure reported
Includes the following:
Adequate description of nature, extent, and need for procedure or service
Time, effort, and equipment necessary to provide service
(continued)

15. Special Report Additional items that may be documented
Complexity of symptoms
Concurrent problems
Diagnostic and therapeutic procedures
Final diagnosis
Follow-up care
Pertinent physical findings

16. Material Supplied by Physician
Supplies other than those typically included with procedure or service reported separately

17. Medicine Subsections Immunization administration
Report these codes in addition to vaccine/toxoid codes

18. Reporting E/M Codes with Immunizations
E/M service must exceed services included with immunization administration codes
Add modifier -25 to E/M code to identify “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”

19. Hydration, Therapeutic, Prophylactic, and Diagnostic Injections
The following services are not separately coded and reported:
Administration of local anesthesia
Intravenous (IV) insertion
Access to catheter, IV, or port
Routine syringe, tubing, and other supplies
Flushing performed upon completion of infusion

20. Coding Tips
When multiple injections or infusions or combination services provided, report initial code just once
Except when two, separate IV sites required
When length of infusion time included in code description, report code based on actual infusion time

21. Hydration
Review for documentation that physician supervised the following:
Patient assessment
Patient consent
Patient safety
Staff who provided infusion services

22. Coding Tips
Placement of peripheral vascular access devices integral to vascular infusions
Codes for placement of these devices not separately reported
Administration of IV fluids to maintain line patency not separately coded and reported

23. Psychiatric Procedures
Complete mental status examination includes the following
Orientation to time, place, and person
Recent and remote memory
Attention span and concentration
Language
Fund of knowledge
Mood and affect

24. Biofeedback Reviewing patient history Preparing biofeedback equipment
Placing electrodes
Reading and interpreting responses
Monitoring the patient
Controlling muscle responses

25. Coding Tip
When individual psychotherapy and group psychotherapy services provided on same date to same patient, report code for each service provided

26. Dialysis Subsection includes the following headings:
End-stage renal disease (ESRD) services
Hemodialysis
Miscellaneous dialysis procedures

27. Hemodialysis
Filters waste from patient's blood; blood leaves body via an artery, is filtered, and then returned into a vein
Delmar/Cengage Learning

28. Coding Tips
All E/M services related to ESRD and rendered during dialysis included in dialysis procedure code
E/M service related to ESRD performed on day of dialysis not separately coded and reported

29. Ophthalmology Subsection includes the following headings
General ophthalmological services
Special ophthalmological services
Contact lens services
Spectacle services

30. Special Ophthalmological Services
Vestibular function tests without electrical recording but with observation and evaluation by physician
Vestibular function tests with recording, electronystagmography (ENG), photoelectronystagmography (PENG), and medical diagnostic evaluation
(continued)

31. Special Ophthalmological Services
Audiologic function tests with medical diagnostic evaluation
Evaluation and therapeutic services
Other procedures

32. Coding Tips
Routine ophthalmoscopy included in general ophthalmological services
Other special ophthalmological services not included
Coded and reported separately when performed

33. Cardiovascular Subsection includes the following headings
Therapeutic services and procedures
Cardiography
Echocardiography
Cardiac catheterization
Intracardiac electrophysiological studies
(continued)

34. Cardiovascular Subsection includes the following headings
Peripheral arterial disease rehabilitation
Noninvasive physiologic studies and procedures
Other procedures

35. Electrocardiogram Shows disruptions of heart rhythms
(A) Paroxysmal atrial tachycardia (PAT)
(B) Atrial fibrillation
(C) Ventricular fibrillation
Delmar/Cengage Learning

36. Echocardiography
Large area of red shows flow of blood through abnormal opening between aorta and right atrium
Delmar/Cengage Learning

37. Therapeutic Services
The following therapeutic procedures should be reported in addition to cardiac catheterization codes
Cardiopulmonary resuscitation (CPR)
Transcutaneous pacing
Cardioversion
Circulatory assist procedures
(continued)

38. Therapeutic Services
The following therapeutic procedures should be reported in addition to cardiac catheterization codes
Thrombolysis
Transcatheter placement of stents
PTCA
Atherectomy

39. Cardiac Catheterization
Fluoroscopic guidance procedures integral to invasive intravascular procedures
Not separately coded and reported
(continued)

40. Cardiac Catheterization
Percutaneous coronary artery interventions include the following
Stent placement
Atherectomy
Balloon angioplasty
(continued)

41. Cardiac Catheterization
For a given coronary artery and its branches, report only most complex intervention
Regardless of number of stent placements, atherectomies, or balloon angioplasties performed in that coronary artery and its branches
(continued)

42. Cardiac Catheterization
Do not add modifier -59 to codes reported for percutaneous coronary artery stent placement, atherectomy, or balloon angioplasty
(continued)

43. Cardiac Catheterization
Review documentation to determine
Catheter placement
Injection procedure
Supervision and interpretation
(continued)

44. Cardiac Catheterization
Once catheter is inserted into heart, contrast medium is injected, and an angiogram is performed to detect coronary vessel patency (openness)
Delmar/Cengage Learning

45. Pulmonary Services
Ventilator management
Spirometry

46. Allergy Testing
When percutaneous or intracutaneous single tests performed on same date as other “sequential and incremental” tests, report codes for both tests if tests were performed for different allergens
Allergy testing not usually performed on same day as allergy immunotherapy
(continued)

47. Allergy Testing
When single test for antigen positive and sequential tests with three additional, different dilutions of same antigen performed, report one code for single test and separate codes for sequential tests
(continued)

48. Allergy Testing
When allergy testing is integral part of rapid desensitization kits, do not separately code and report

49. Scratch Test
Allergens placed on skin; skin scratched; allergen labeled. Reactions usually occur within 20 minutes; for example, reaction to ragweed
Delmar/Cengage Learning

50. Neurology and Neuromuscular Procedures
Sleep studies
Routine electroencephalography (EEG)
Muscle and range of motion testing
Electromyography and nerve conduction test
Intraoperative neurophysiology
Autonomic function tests
(continued)

51. Neurology and Neuromuscular Procedures
Evoked potentials and reflex tests
Special EEG test
Neurostimulator
Analysis-programming
Motion analysis
Functional brain mapping

52. Chemotherapy Administration
Oral
Implantation of catheter port into central vein or body cavity
Infusion or injection of IV chemotherapy into vein
(continued)

53. Chemotherapy Administration
Injection of intramuscular (IM) chemotherapy into muscle
Injection of subcutaneous (SQ) chemotherapy under skin

54. Special Dermatological Procedure
Performed in addition to E/M service
Photodynamic therapy
Ultraviolet (UV) light
Goeckerman treatment (UV-B light)
Psoralen ultraviolet A (PUVA)
Goeckerman and/or PUVA treatment for at least four to eight hours
Laser treatment

55. Physical Medicine and Rehabilitation (PT, OT )
Physical therapy (PT) and occupational therapy (OT) evaluations
Modalities under supervision
Therapeutic procedures
Active wound care management
Tests and measurements
Orthotic and prosthetic management

56. Medical Nutrition Therapy
Type of assessment
Individual or group therapy
Length of time

57. Osteopathic Manipulative Treatment (OMT)
Provider who performs cannot separately report anesthesia services for OMT
Codes include pre-manipulation patient assessment

58. Chiropractic Manipulative Treatment
Additional E/M services may be reported separately by adding modifier -25
If patient’s condition requires separate E/M service beyond usual preservice and postservice work

59. Education and Training for Patient Self-Management
Qualified, non-physician health care professional who uses standardized curriculum
97802
Initial assessment and intervention, individual patient, face-to-face for 15 minutes
(continued)

60. Education and Training for Patient Self-Management
Qualified, non-physician health care professional who uses standardized curriculum
97803
Reassessment and intervention, individual patient, face-to-face for 15 minutes
97804
Group of two or more patients each for 30 minutes

61. Non-Face-to-Face, Non-Physician Service
Provided by qualified health care professional
Telephone services
Report for physician telephone services
98969
Online medical evaluation

62. Moderate (Conscious) Sedation
Drug-induced depression of consciousness that requires no interventions to maintain airway patency or ventilation
Does not include minimal/deep sedation or monitored anesthesia care
(continued)

63. Moderate (Conscious) Sedation
Includes the following:
IV access
Agent administration
Oxygen saturation monitoring
Some procedures include moderate (conscious) sedation
Code indicated by bull’s eye symbol

64. Medication Therapy Management Services (MTMS)
Face-to-face encounter with pharmacist for assessment and interventions to:
Optimize patient’s response to medication
Manage treatment-related medication interactions or complications
Do not report for dispensing or any other routine dispensing-related activities