1. Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers
Chapter 06
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers

2. The Current Procedural Terminology (CPT®)
Copyrighted and maintained by American Medical Association (AMA)
Used with other codes sets to report healthcare services performed in the United States
Established as an indexing/coding system to standardize terminology among physicians and other providers
The Current Procedural Terminology, or CPT®, Coding Manual is a compilation of guidelines, codes, and descriptions to report healthcare services performed by healthcare providers in the United States. The CPT® code set is copyrighted and maintained by American Medical Association, the AMA, and is used with other code sets established by the Department of Health and Human Services and other federally-named entities for healthcare reporting and reimbursement.
The first CPT® code set was developed and published by the AMA in 1966, and was established as an indexing or coding system to standardize terminology among physicians and other providers.
In 1983, the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services, or CMS) adopted CPT® and its own Healthcare Common Procedure Coding System (HCPCS) Level II, mandating these code sets be for use in all Medicare billings. These code sets largely standardized reporting of medical services, equipment, and supplies.
Medicaid agencies and commercial health plans soon adopted the code sets and began to require CPT® and HCPCS Level II codes for reporting healthcare services for reimbursement.

3. Introduction to CPT® Instructions for use of the CPT ® code book
Unlisted procedure
CPT ® use by any qualified health care professional
Parenthetical notes
Accuracy and quality of coding
Related guidelines
Parenthetical instructions
Other coding resources
Now that you have some history, let’s move on to the format of your CPT® book. Much of this information comes from the Introduction Section of CPT®. While I won’t go over all the information in this section, I do want to touch on a few of the subjects. I’d suggest you take the time to thoroughly read the Introduction on your own.
Now, turn with me to page X in your CPT coding manual. Here you will find the introduction to the CPT manual which is often overlooked, but there is important information for you to refer to.
First, under Instructions for Use of the CPT Codebook, your second sentence explains, do not select a CPT code that merely approximates the service provided, instead an unlisted procedure code should be used.
The second paragraph in this section clarifies for us that the listing of a service or procedure in a specific section of the CPT book does not restrict its use to a specific specialty group. Any qualified physician or other qualified health care professional may use any procedure or service in any section of the book.
The third paragraph indicates the importance of reading the parenthetical instructions surrounding the CPT codes. The parenthetical instructions are intended to prevent significant errors, but are not all inclusive.
The same paragraph in this section reminds us of the importance of accuracy and quality of coding by also referring to the parenthetical instructions, related guidelines, AMA CPT Assistant, and other coding resources. This is an added reminder of how important it is to know and teach through the guidelines.
This is all important information for you to remember as you venture into the world of coding. 3

4. Introduction to CPT®
The CPT® code set includes three categories of medical nomenclature with descriptors.
Category I
Category II
Category III
The CPT® code set includes three categories of medical nomenclature and descriptors: Category I, Category II, and Category III. All three categories are contained within the CPT® manual.

5. Category I CPT® Codes Five-digit numerical code, eg 12345
Over 7,000 service codes, plus titles and modifiers
Reviewed and updated annually
Mandatory to report for services and reimbursement
Category I CPT® codes utilize a five-digit numerical code, for example, Category I codes are the most commonly used codes for medical services, procedures, and professional services by physicians and other qualified health care professionals.
There are over 7,000 service codes, plus titles and modifiers, in the Category I CPT® code set. The codes are reviewed and updated annually by a panel established by the AMA. It is mandatory to use Category I CPT® Codes for reporting and reimbursement purposes.

6. Category I CPT® Codes
The CPT® coding manual divides Category I CPT® codes into six main section titles:
Evaluation and Management (99201–99499)
Anesthesiology ( )
Surgery ( )
Radiology ( )
Pathology and Laboratory ( )
Medicine ( )
The CPT® coding manual divides Category I CPT codes into six main section titles; Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology and Laboratory, and Medicine. Sections are presented in numeric order with the exception of the Evaluation and Management section. The evaluation and management section is found at the beginning of the listed sections because it contains codes most commonly used.

7. Category I CPT® Codes
Section titles have subsections divided by anatomic location, procedure, condition, or descriptor subheadings.
The subheadings, structured by CPT® conventions, may list alternate coding suggestions in parenthetical instructions.
Example:
Section: Surgery ( )
Subsection: Integumentary System
Subheading: Skin, Subcutaneous and Accessory Structures
Category: Debridement
(For dermabrasions, see – 15783)
(For nail debridement, see )
(For burn(s), see )
(For pressure ulcers, see )
Each Main Section title has subsections divided by anatomic location, procedure, condition, or descriptor subheadings. The subheadings, structured by CPT® conventions, may list alternate coding suggestions in parenthetical instructions.
In this example, the section is Surgery, the subsection is the Integumentary System, the subheading is Skin, Subcutaneous and Accessory Structures. The category is Debridement. Under debridement, you will see a paragraph of guidelines, followed by alternate coding suggestions for dermabrasions, nail debridement, burns, and pressure ulcers. The alternate coding suggestions are there to aid in helping you locate the correct code.
Alternate coding suggestions

8. Category I CPT® Codes
Specific guidelines presented at the beginning of each section identify correct coding protocols.
Example:
Section, Surgery
Subsection: Cardiovascular System ( )
Guideline:
Selective vascular catheterizations should be coded to include introduction and all lesser order selective catheterizations used in the approach (e.g., the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries).
Specific guidelines presented at the beginning of each section identify correct coding protocols. The guidelines define which codes are used together and may direct coders to information that is necessary for accurate coding.
You can find an example of this in the Cardiovascular subsection. Under the Cardiovascular System subheading, you will see guidelines giving you direction on how to code catheterizations.

9. Category II CPT® Codes
Alphanumeric format, with the letter “F” in the last position, eg, 0001F
Optional “performance measurement” tracking codes
Physician Quality Reporting Initiative (PQRI)
Example:
A physician counsels a patient regarding prescribed Statin therapy for coronary artery disease.
Report:
4002F Statin therapy, prescribed (CAD)
Appropriate level office visit code (99211–99215).
Category II CPT® codes are recognized by their alphanumeric format, with the letter “F” in the last position, for example, 0001F. They are located near the back of the CPT® codebook after the Medicine Section, and are reported in addition to evaluation and management (E/M) services or clinical service CPT® Category I codes.
Category II CPT® codes are optional “performance measurement” tracking codes designed to facilitate data collection by the AMA and CMS regarding quality of care. They are also used for the Physician Quality Reporting Initiative (PQRI) to provide outcome measurements for certain medical conditions.
You can see the example here regarding a category II code for a physician who counsels a patient regarding prescribed Statin therapy for coronary artery disease. Statin Therapy is used to help a patient lower their LDL cholesterol measurement. The code is 4002F. We would also report the appropriate level of evaluation and management with this code.

10. Category II CPT® Codes
Due to the constant expansion of identifiable measures for quality patient care, the AMA lists criteria on their website:
Physician Quality Reporting Initiative (PQRI)
Due to the constant expansion of identifiable measures for quality patient care, the AMA lists criteria on their website.
PQRI is an incentive-based program developed by CMS to record evidence-based measures. The PQRI Measures Groups Specifications Manual is posted annually on the CMS website.

11. Category III CPT® codes
Temporary codes
Alphanumeric structure, with a “T” in the last position, eg, 0019T
Can be reported alone, without an additional Category I code
Example
A patient has gastric stimulation electrodes implanted in the lesser curvature of the stomach via laparotomy for the treatment of morbid obesity.
Report code 0157T Laparotomy, implantation or replacement of gastric stimulation electrodes, lesser curvature (eg, morbid obesity).
Category III CPT® codes are classified as temporary codes. They are used for data collection in the Food and Drug Administration (FDA) approval process regarding new and emerging technology, services, and procedures.
The Category III CPT® codes have an alphanumeric structure, with a “T” in the last position. Category III codes can be reported alone, without an additional Category I code and are located after the Category II code section. An example of a Category III code is 0157T which represents a patient who has gastric stimulation electrodes implanted in the lesser curvature of the stomach via laparotomy for the treatment of morbid obesity.

12. Category III CPT® codes
Updated twice a year
January 1
July 1
Implemented six months after
Updates are published on AMA’s website:
Category III CPT codes are updated twice a year, January 1 and July 1, and are implemented six months later. The updates are published on AMA’s website.
In the middle of the first paragraph of the guidelines for Category III codes, there is a sentence that states, “If a Category III code is available, this code must be reported instead of a Category I unlisted code." It is an important instruction for the reporting of Category III Codes so you may want to highlight it.

13. The CPT® Coding Manual CPT® Sections Section Guidelines
Section Table of Contents
Notes
Category II codes (0001F – 7025F)
Category III codes (0019T – 0259T)
Appendices A-N
Alphabetic Index
The CPT® Coding Manual is organized by CPT® Sections which contain Category I codes. The six sections include services and surgical procedures separated into subsections. Within each section there are section guidelines, and a table of contents for that section. At the end of each section, there is a place for the professional coder to add notes to help them with accurate and efficient coding. After the CPT Sections, Category II and Category III codes are listed, followed by Appendices A-N and the Alphabetic Index.

14. CPT® Guidelines
Referenced in the introduction of each section and subsection of the CPT® manual
Applicable to the section being referenced
Define the information necessary for choosing the correct code
CPT® guidelines are referenced in the introduction of each section and subsection of the CPT® manual. Guidelines are applicable to the section being referenced and do not apply to other sections within the CPT® manual. The guidelines in the CPT® coding manual define the information necessary for choosing the correct code to describe a medical service provided.

15. CPT® Conventions and Iconography
Used throughout the CPT® manual and include:
Indentations
Code symbols - iconology
Parenthetical instructions
An established set of conventions and symbols are used throughout the CPT® manual. CPT® Conventions and Iconography include indentations, code symbols, also referred to as iconology, and parenthetical instructions. These conventions and symbols communicate information in a clear and an easily recognizable format.

16. CPT® Conventions and Iconography
Example:
Debridement of extensive eczematous or infected skin; up to 10% of body surface.
each additional 10% of the body surface (List separately in addition to code for primary procedure)
(Use in conjunction with 11000)
Indentation
Iconography (Symbol)
An Example is easily viewed within CPT. Look for CPT codes and You see is indented. This means that part of its description comes from a parent code, which we will discuss in a minute. The plus sign is a symbol indicating it is an add-on code. Then below 11001, there is a parenthetical instruction for guidance.
Parenthetical Instruction

17. CPT® Conventions and Iconography
; The semicolon and the conventional use of indentions
The use of the semicolon divides the description of a code into two parts:
The “stand-alone” code or the “common procedure” code descriptor.
The indented descriptor is dependent on the preceding “stand-alone” code
In the description of 11000, we also see the application of a semicolon. The use of the semicolon divides the description of a code into two parts; the words before the semi-colon are considered the “stand-alone” code or the “common procedure” code descriptor and the indented descriptor is dependent on the preceding “stand-alone” code. Let’s look at an example.

18. CPT® Conventions and Iconography
Example:
Anesthesia for procedures on nose and accessory sinuses; not otherwise specified
radical surgery
biopsy, soft tissue
Interpreted:
Anesthesia for procedures on nose and accessory sinuses; not otherwise specified.
00162 Anesthesia for procedures on nose and accessory sinuses; radical surgery
00164 Anesthesia for procedures on nose and accessory sinuses; biopsy, soft tissue
Turn in your CPT code books to code Anesthesia for procedures on nose and accessory sinuses – semicolon - not otherwise specified. The subsequent codes, and 00164, demonstrate the conventional indentions and the dependent descriptors that are to be read or interpreted with the ‘common-procedure’ descriptor from The full description for is Anesthesia for procedures on nose and accessory sinuses; radical surgery. This convention is used throughout the entire CPT code book.

19. CPT® Conventions and Iconography
The “add-on” code symbol - Add-on codes are never reported alone
Example:
Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)
(Use in conjunction with 43280, 43281, 43282)
Another commonly used icon throughout the code book is the plus sign which denotes an add-on code. Some of the procedures listed in CPT® are only carried out with a primary procedure. Add-on codes are never reported alone. They will always be listed with another primary code.
Look in your code book at CPT code The plus sign before tells us this is an add-on code. After the add-on code, there is typically a reminder in parenthesis to list the code separately in addition to the code for the primary procedure which is seen here. In addition, there is usually a parenthetical instruction beneath the add-on code listing the primary procedure codes that the add-on code may be added to. For 43283, it can be used in conjunction with 43280, 43281, or

20. CPT® Conventions and Iconography
l The red circle - new procedure code
Example:
l Application of right and left pulmonary artery bands (eg, hybrid approach stage 1)
p The (blue) triangle - code revision
p Cholecystotomy or cholecystostomy,open, with exploration, drainage, or removal of calculus (separate procedure)
The red circle or bullet indicates a new procedure number has been added to the CPT® manual. You can see an example of this by looking at CPT code You can find a Summary of Additions, Deletions, and Revisions in Appendix B of your CPT book.
The blue triangle communicates a code revision that has altered the procedure descriptor. Look in your CPT book at code Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure). Here, you see the blue triangle, but are not shown what changed from last year. Now, turn to Appendix B in your CPT book and find code Here, the word “open” is underlined showing it has been added to the code descriptor.

21. CPT® Conventions and Iconography
ut The facing triangles - indicate new and revised text other than the procedure descriptors
Example:
Endoscopy
uWhen performing an endoscopy on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope beyond the splenic flexure, due to unforeseen circumstances, report the colonoscopy code with modifier 53 and appropriate documentation. t
46020 Placement of Seton
u (Do not report in addition to 46060, 46280, 46600,
0249T) t
The facing triangles are symbols used to indicate new and revised text other than the procedure descriptors. They are usually found within the guidelines or as a parenthetical instruction beneath a code. An example of this convention in the
Guidelines can be found under the heading Endoscopy talking about colonscopies and the use of modifier 53. An example of the parenthetical instructions can be found under CPT code

22. CPT® Conventions and Iconography
W The circle with a line through it - exempt from the use of modifier 51
Example:
W Intraventricular pacing
Occasionally, you will see a code with the universal symbol for “no” next to it. In the CPT book, this circle with a line through it identifies codes that are exempt from the use of modifier 51. Most of these codes are found in the medicine section of CPT. Look at code in your code book. This code has the circle with a line through it. When it is performed with other procedures, modifier 51 would not be appended. A list of codes that are modifier 51 exempt can be found in Appendix E of CPT.

23. CPT® Conventions and Iconography
8 The bulls eye - includes moderate sedation
Example:
Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
Moderate sedation is sometimes included in the procedure performed. The bulls eye symbol identifies codes that include moderate, or conscious, sedation. When this symbol is noted next to a CPT® code, the moderate sedation is not reported separately. A summary of codes that include moderate sedation can also be found in Appendix G of your CPT book. For an example, look at code in your CPT book. Notice is also a parent code to multiple indented codes. All of the indented codes, codes through 43232, also have the bulls eye symbol indicating moderate sedation is included in the procedure.

24. CPT® Conventions and Iconography
The lightening bolt symbol - codes for vaccines that are pending FDA approval.
Example:
Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
AMA CPT® “Category I Vaccine Codes” website:
Some of the vaccine codes have a lightning bolt symbol next to them. This symbol identifies codes for vaccines pending FDA approval. Some vaccine products have been assigned a CPT® Category I code in anticipation of future approval from the FDA. When the vaccine has been approved by the FDA, a revision notation will be provided on the AMA CPT® Category I Vaccine Codes website. A list of codes pending FDA approval can also be found in Appendix K of your CPT code book. An example can been seen with code

25. CPT® Conventions and Iconography
# The number symbol - Resequenced and are out of numerical order
Example:
Code is out of numerical sequence. See
# Hemorrhoidopexy (for prolapsing internal hemorrhoids) by stapling
With the exception of the evaluation and management codes in the beginning of the CPT code book, codes are listed in numerical order. Occasionally, a code description is modified or a new section is created causing the codes to be placed out of sequence. When this occurs, the AMA places a pound sign next to the code. Look in your CPT book for code You will see the code listed with a reference to see code range , which is the repair section of the Digestive System. At the end of this section, you will see code with a pound sign next to it, indicating it is out of numerical sequence. A list of codes that have been re-sequenced can be found in Appendix N of the CPT book.

26. CPT® Code Basics
Review medical documentation thoroughly and gather additional reports
Reference the alphabetical index for a CPT® numerical code and/or code range.
Condition
Procedure or service
Anatomic site
Synonyms, eponyms and abbreviations
Review the numerical code and/or code range for specific descriptions
Follow CPT® Guidelines, Conventions and Iconology
In order to select the correct procedure code, there are some basic rules to follow. First, review medical documentation thoroughly and gather additional reports to select the procedures or services that accurately describe the care provided by the healthcare professional. Next, reference the alphabetical index for a CPT® numerical code or code range. To find a code in the index, you can look under either the condition, the name of the procedure or service performed, the anatomic site, or synonyms, eponyms, or abbreviations.
Then review the numerical code or code range for specific descriptions, matching the description to the procedure or service provided by the health professional. Pay attention to the CPT® Guidelines, Conventions and Iconology to select the correct CPT® code to report to payers.

27. CPT® Code Basics Index: Auditory System Ear Wax see Cerumen
Cerumen Removal………………
Removal Cerumen……………….69210
Auditory System
Removal impacted cerumen (separate procedure), one or both ears
Let’s look at an example. Let’s look up the code for Ear Wax Removal. Look in the CPT Index for Ear Wax and you are directed to see cerumen. Under Cerumen, removal, you are directed to code You can also look under the procedure which is “removal.” Removal, cerumen directs you to
Next, look at the code in the numeric section. In the Auditory section, is for removal of impacted cerumen.

28. Separate Procedure
Example:
Removal impacted cerumen (separate procedure), one or both ears
Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning).
In looking at 69210, you will notice “Separate Procedure” in parenthesis. This is another convention used throughout CPT. When the “separate procedure” classification is seen at the end of a code descriptor, it serves as a reminder to coders the separate procedure is ordinarily a component of a larger procedure and should only be reported separately when it is performed alone or when it is unrelated to the primary service.
Look for code for removal of impacted cerumen. In the descriptor, you will notice “separate procedure” in parenthesis. When removal of impacted cerumen is performed in conjunction with another procedure on the same ear, it is considered inclusive to that procedure. The example of reporting with would be considered unbundling would be denied because removal of any cerumen would be done when performing
Separate procedures are often bundled into other procedures in the NCCI edits.

29. National Correct Coding Initiative (CCI)
Implemented by CMS
Promotes correct coding methodologies
Controls the improper assignment of codes that results in inappropriate reimbursement
Medicare publishes CCI:
NCCI stands for National Correct Coding Initiative. CMS implemented the National Correct Coding Initiative (CCI) to promote correct coding methodologies and to control the improper assignment of codes that results in inappropriate reimbursement.
Medicare publishes many resources on their CMS website including The National Correct Coding Initiative (NCCI), which covers bundling, unbundling, separate procedures, and CPT® guidelines. Commercial payers may follow the NCCI edits, or may create their own bundling edits. Often, the commercial payer will follow NCCI edits, then add to it with their own edits.
CCI coding policies are based on the 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, and a review of current coding practices.

30. The Correct Coding file formats continue to include a Correct Coding Modifier, or CCM, indicator for both the Comprehensive/Component Table, seen here with the Column1/Columnn 2 edits, and the Mutually Exclusive Table. This indicator determines whether a CCM causes the code pair to bypass the edit. The indicator will be either a “0,” a “1,” or a “9.”
A 0 indicates a CCM is not allowed and will not bypass the edits. A 1 indicates a CCM is allowed and will bypass the edits. A 9 indicates the use of modifiers is not specified. This
indicator is used for all code pairs that have a deletion date that is the same as the effective
date. This indicator was created so that no blank spaces would be in the indicator field.

31. Sequencing Based on RBRVS Highest RBRVS listed first.
Physician Work
Practice Expense
Professional Liability/Malpractice Insurance
Highest RBRVS listed first.
Once you determine if code pairs can be billed together, you will need to accurately sequence the codes reported. Sequencing is based on the Resource-Based Relative Value Scale, or RBRVS. We discussed in Chapter 1 that the RBRVS is calculated based on physician work value, practice expense, and a component based on the Professional liability insurance. The RVUs can be found on the CMS website.

32. CPT® Assistant Articles answering everyday coding questions
CCI bundling information
E/M billing guidance
Current code use and interpretation
Case studies demonstrating practical application of codes
Anatomical illustration charts and graphs for quick reference
Information for appealing insurance denials
Information to validate code usage when audited
Throughout the CPT you will see references to the CPT Assistant. The references are listed below CPT code descriptors and indicate issues surrounding that particular code are referenced in the CPT Assistant. The CPT Assistant is published reference material. It offers articles answering everyday coding questions, NCCI bundling information, E and M billing guidance, current code use and interpretation, case studies demonstrating practical application of codes, anatomic illustration charts and graphs for quick reference, Information for appealing insurance denials, and information to validate code usage when audited. The CPT Assistant is a subscription that is considered an official resource.

33. CPT® Appendices Appendix A - Modifiers categorized as:
Modifiers applicable to CPT® codes
Anesthesia Physical Status Modifiers
CPT® Level I Modifiers approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use
Level II (HCPCS/National) Modifiers
Appendices A through N are located in the CPT® manual after the Category III CPT® codes. The Appendix section references topics that are important for coding specificity and provide examples for the reader.
Appendix A lists modifiers in separate categories. CPT Level I Modifiers lists all of the modifiers applicable to CPT codes followed by the Anesthesia Physical Status Modifiers. There is a separate list in the appendix for modifiers that are approved for Ambulatory Surgery Center and Hospital Outpatient Use. The last category of modifiers in this section contains commonly used Level II HCPCS Modifiers.
Modifiers are appended to CPT® and HCPCS Level II codes to report specific circumstances or alterations to a procedure, service, or medical equipment without changing the definition of the code. We will discuss modifiers later in this lecture.

34. CPT® Appendices
Appendix B - changes and additions to the CPT® codes from the previous year
Appendix C - clinical E/M examples for different specialties
Appendix D – Add-on Codes
The next several appendices were mentioned earlier in this lecture. Appendix B contains the actual changes and additions to the CPT® codes from the previous year. This is where you would look to see what changes were made to codes modified from the previous year. Appendix C provides clinical examples for evaluation and management services for different specialties. Appendix D is a summary of codes not reported as single or stand-alone codes. The codes listed in this appendix are identified throughout CPT® with the plus symbol.

35. CPT® Appendices
Appendix E – Exempt from the use of modifier 51 (multiple procedures)
Appendix F – Exempt from the use of Modifier 63 (procedures performed on infants less than 4kg)
Appendix G – Include Moderate (Conscious) Sedation
We also mentioned Appendix E earlier. This appendix contains a summary of CPT® codes exempt from the use of modifier 51.
Appendix F contains a summary of CPT® codes exempt from the use of Modifier 63. Modifier 63 is appended to CPT codes to indicate the procedure was performed on infants weighing less than 4kg. The list of codes in this appendix generally include codes involving congenital anomalies and those that have increased complexity associated with working on a premature infant already valued in the code making modifier 63 unnecessary. Throughout the CPT book, these codes are also followed by a parenthetical statement reminding the coder not to append modifier 63 to that specific code.
Appendix G contains a summary of CPT® codes that include Moderate Sedation, which we discussed earlier in this lecture.

36. CPT® Appendices
Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic
Available only on the AMA website
Appendix I – Genetic Testing Code Modifiers
Molecular laboratory procedures related to genetic testing
Use in conjunction with CPT® and HCPCS codes to provide diagnostic granularity of service
Appendix H previously contained an alphabetic index of performance measures by clinical condition or topic. These codes are constantly updated so the AMA has removed them from the CPT book and provides them to you on their website.
Appendix I contains a unique set of modifiers. Genetic Testing Code modifiers are reported with molecular laboratory procedures related to genetic testing. The modifiers are two alphanumeric characters. The first character is a number which identifies the disease category such as 1 for a sarcoma or 2 for a lymphoid neoplasia. The second character is a letter which identifies the gene type.

37. CPT® Appendices
Appendix J - Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves
Assigns each sensory, motor, and mixed nerve with its appropriate nerve conduction study code
Table containing maximum number of studies
Appendix K - Product Pending FDA Approval
Identified throughout the CPT® book with a lightening bolt symbol
For updated vaccine approvals by the FDA, visit the AMA CPT® Category I Vaccine Code information on their website:
Appendix J provides a summary that assigns each sensory, motor, and mixed nerve with its appropriate nerve conduction study code in order to enhance accurate reporting of codes 95900, 95903, and This appendix also contains a table showing the reasonable maximum number of studies for a physician to arrive at a diagnosis.
Appendix K is a list of products pending FDA approval and was discussed earlier in this lecture.

38. CPT® Appendices Appendix L - Vascular Families
Based on the assumption that a vascular catheterization has a starting point of the aorta
Illustrates vascular “families” that emerge from the aorta using brackets to identify the order of vessels.
Appendix M - Crosswalk to Deleted CPT® Codes
Crosswalks noting the deleted CPT® codes and descriptors from the previous year to the current year.
Essential when updating charge masters, charge capture documents, etc.
Based on the assumption that a vascular catheterization has a starting point of the aorta, Appendix L illustrates vascular “families” that emerge from the aorta using brackets to identify the order of vessels: First, Second, Third, and Beyond Third Order of vascular branches. The largest “First Order Branch” emerges from the aorta. The “Second Order Branch” emerges from the “First Order Branch”, and so on to include the vessel’s “Third Order Branch” and “Beyond Third Order Branches”. If the starting point of the catheterization is other than the aorta, the orders might change.
Appendix M contains a crosswalks noting the deleted CPT® codes and descriptors from the previous year to the current year. This is an essential tool when updating charge masters, charge capture documents, and any system or process using CPT® codes.

39. CPT® Appendices
Appendix N - Summary of Resequenced CPT® Codes - This listing is a summary of CPT® codes not appearing in numeric sequence. This allows for existing codes to be relocated to an appropriate location.
The last appendix, appendix N, is a listing of CPT® codes that have been re-sequenced as we discussed earlier in this lecture.

40. CPT® Global Surgical Package
Includes a standard package of preoperative, intraoperative, and postoperative services
Payer policies may vary
May be furnished in any service location
For example, a hospital, an ambulatory surgical center (ASC), or physician office
Now that we are familiar with the CPT code book, let’s discuss a few coding guidelines. Knowing surgical guidelines and a Payer’s definition of a surgical global package helps a coder with correct CPT reporting.
Payment for surgical procedures includes a standard package of preoperative, intraoperative, and postoperative services. This is known as the Surgical Global Package.
Most health plans have adopted the CMS global package concept, although, some health plans write variances within their policies. Each health plan has leniency to determine if a global period is applicable to surgery procedures. The services included in the global surgical package may be furnished in any service location, that is a hospital, an ambulatory surgical center, or physician office.

41. CPT® Global Surgical Package
Included in the surgery package and not separately billable:
Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)
Immediate postoperative care, including dictating operative notes, talking with the family and other physicians
Evaluating the patient in the postanesthesia recovery area
Writing orders
Typical postoperative follow-up care
Inclusive
In your CPT code book, you will find a list of services included in the global surgical package. Because these services are inclusive to the surgery, they are not separately billable. The list can be found in the Surgery Guidelines before the Integumentary System. You may want to highlight or bracket this list to indicate these services are inclusive of the global surgical package. Services which fall outside of the global package may be billed separately.

42. CMS Global Surgical Package
Major Surgery: Has a preoperative period of 1 day with 90 days for the postoperative period.
Minor Surgery: The preoperative period is the day of the procedure with a postoperative period of either 0 or 10 days depending on the procedure.
The CMS global package is determined by the classification of major or minor surgery. The classification determines the preoperative and postoperative periods inclusive in the global package. A major surgery has a preoperative period of 1 day with 90 days for the postoperative period. For minor surgery, the preoperative period is the day of the procedure with a postoperative period of either 0 or 10 days depending on the procedure.

43. CMS Global Surgical Package
To find the global days, you would access the RVU file. The RVU file also shows the percentage of the payment that is considered pre-operative work, intra-operative work, and post-operative work.
For example, CPT code has a 10 day global period indicating it is a minor procedure. 10% of the work considered for payment is for pre-operative work. 80% is for the actual surgery and another 10 % considered for post-operative work.
Another example is CPT code has a 90 day global period so it is considered a major procedure. For this procedure code, 10% of the payment is for pre-operative work, 69% for the actual surgery, and another 21% for the post-operative work.

44. CMS Global Surgical Package
MMM and XXX
Global concept does not apply
YYY
Subject to individual pricing
ZZZ
Always included in the global period
Global period days for Medicare patients may be accessed on the CMS website:
In the Global Days column, you will see additional indicators. Triple Ms mean the codes are maternity codes and the usual global period does not apply. Examples are and Triple Xs represent codes such has Evaluation and Management services, Anesthesia, Radiology and Laboratory codes. The global concept does not apply to these codes either. Triple Ys represent unlisted codes. These codes are subject to individual pricing. Triple Z codes are add-on codes. Since add-on codes are always related to another primary service they are included in the global period for their primary service.
By researching the surgical CPT® codes on the healthcare payer’s contract or website, you can determine if a surgery is classified as a minor or major procedure. Global period days for Medicare patients are found in the physician fee schedule RVU file on the CMS website.

45. Global Package Modifiers
54 Surgical care only
55 Postoperative management only
56 Preoperative management only
When services are performed during a global surgery package, but a provider needs to indicate it is not part of the global package, or that the provider performed only a portion of the global package, a modifier is appended to the procedure code. The function of a modifier is to provide a method for reporting ~ or specify ~ that a service or procedure has been altered in some way by a specific circumstance but does not change the definition of the code. Modifiers may affect the way payment is made by an insurance company
Modifiers 54 through 56 indicate a provider has performed only a portion of the global service. 54 represents surgical care only, 55 the postoperative management only, and 56 represents the preoperative management only. Looking back at our example of 22521, if a provider only performed the postoperative care, and appended a modifier 55 to the service, payment would be for 10% of the fee. If he only performed the surgery and appended a modifier 54, payment would be for 80 % of the fee.

46. Global Package Modifiers
24 Unrelated E/M by the same physician during a postoperative period
25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
57 Decision for surgery
Then there are modifiers to append to the code to indicate there is a special evaluation and management circumstance during the global period. Modifier 24 indicates an unrelated evaluation and management services is performed by the same physician during a postoperative period. An example of this would be if a provider performs a hip replacement on a patient. Within the global period, the provider sees the patient for shoulder pain. Since the visit was unrelated to the hip replacement surgery, modifier 24 would be appended to the evaluation and management service for the shoulder problem.
Modifier 25 indicates a significant and separately identifiable evaluation and management service is performed on the same day of a procedure or other services. For example, a patient visits the family doctor for chest pain. The provider performs a complete work up of the chest pain and also removes a lesion on the patient’s arm. The procedure of removing the lesion is separately identifiable from the office visit. Modifier 25 would be appended to the office visit. Modifier 25 can only be appended to evaluation and management codes.
Modifier 57 is used when the decision for a major surgery is made during the preoperative period. For example, a patient visits the provider with acute right lower quadrant abdominal pain that increases with cough and motion. The provider determines the patient has appendicitis and decides to immediately perform an appendectomy. Because the decision for surgery was made during that office visit, and the visit falls within the preoperative global period, modifier 57 would be appended to the evaluation and management code.
These modifiers will be discussed further in the evaluation and management chapter of the curriculum.

47. Global Package Modifiers
58 Staged or related procedure or service by the same physician during the postoperative period
78 Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period
79 Unrelated procedure or service by the same physician during the postoperative period
Other modifiers affecting the global package include modifier 58 for a staged or related procedure, modifier 78 for an unplanned return to the operating room, and modifier 79 for an unrelated procedure during the postoperative period.
Modifier 58 is used to indicate there was a planned procedure performed during the postoperative period, or a related service is performed during the postoperative period that is more extensive than the original procedure. It can also be used to indicate therapy performed following a surgical procedure. For example, a patient has a breast biopsy March 2. The patient is diagnosed with breast cancer and the same physician performs a modified radical mastectomy on the right breast on March 6. The modified radical mastectomy would be submitted with modifier 58.
Modifier 78 is used when there is an unplanned return to the operating room. For example, a patient has gastric bypass surgery in January. In March the patient is diagnosed with an incisional hernia at the location of the bypass incision. The patient is taken back to the operating room in March for an incisional hernia repair. The hernia repair is related to the bypass surgery and modifier 78 would be used on the hernia repair code.
Modifier 79 is for an unrelated procedure or service by the same physician during the postoperative period. For example, In January a patient is seen for an injury to the right index finger and the finger is amputated at the DIP joint. In March of the same year the patient has a below the knee amputation of the right leg due to untreated peripheral artery disease. The BKA is not related to the finger amputation and would be coded with modifier 79 appended to the procedure code.

48. Surgical Modifiers 22 – Increased Procedural Service
50 - Bilateral Procedure
51 - Multiple Procedures
52 - Reduced Services
53 - Discontinued Procedure
In addition to the surgical global package modifiers, there are additional modifiers to helps us tell our story to the insurance carriers. Modifiers may seem overwhelming at first. We will review the modifiers in this chapter, but they will also be addressed in each of the chapters as they apply to the topic.

49. Modifier 22 - Increased Procedural Service
Services required to perform the procedure are significantly greater than usually reported with the procedure
Bill with the operative report
Modifier 22 is used for Increased Procedural Service. When the usual work to perform a procedure is significantly greater than typically required, you would add modifier 22 to the procedure code. When using this modifier you would submit the operative report with the claim form. The documentation in the operative report must support the additional work and the reason for the additional work which may be increased time, technical difficulty, severity of patient’s condition, etc. This modifier is not used on an evaluation and management service codes.

50. Modifier 22 - Increased Procedural Service
Example:
A patient has a colonoscopy and a polyp is removed. The removal of the polyp causes excessive bleeding and an extra 30 minutes is spent controlling the bleeding. Modifier 22 would be added to the surgical code and the operative report and/or letter would be sent with the claim to the payer.
An example of correct modifier 22 use would be a patient has a colonoscopy and a polyp is removed. The removal of the polyp causes excessive bleeding and an extra 30 minutes is spent controlling the bleeding. Modifier 22 would be added to the surgical code for the extra time spent controlling the bleed.

51. Modifier 50 - Bilateral Procedure
Check with payers on how to submit:
One line item with modifier 50
Two line items with modifier 50 on the second code
Two lines using RT/LT
Modifier 50 indicates Bilateral Procedure. The CPT definition for modifier 50 is “unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five digit code.” Payers differ on how to submit bilateral procedures. Some payers ask that you submit the code as one line item on the claim form with modifier 50 appended to it; others may request two line items with modifier 50 on the second line; or they may want two lines items using HCPCS Level II modifier RT and/or LT.

52. Modifier 50 - Bilateral Procedure
Pay close attention to code descriptions.
Some codes specify ‘unilateral’ and include a parenthetical statement. Look at code
Some codes say 1 or both. Look at code
You want to pay close attention to the code descriptions as some codes include in their description ‘unilateral or bilateral’. When you see codes with “bilateral” in the descriptor, you would not append modifier 50. There will be other codes that specify ‘unilateral” and may have a parenthetical statement that says “to report a bilateral procedure use the code with modifier 50.” An example of each would be code Look up in your CPT book. This code is for Ablation, 1 or more renal tumors, percutaneous, unilateral, radiofrequency. Below the code, there is a parenthetical statement telling us to use modifier 50 for a bilateral procedure. Now find code This is the removal of impacted cerumen, 1 or both ears. You wouldn’t use modifier 50 on this code if the impacted cerumen was removed from both ears.

53. Modifier 51 - Multiple Procedures
More than one procedure performed at the same session by the same provider
Not used on E/M services, Physical Medicine or Rehabilitation Services, the provision of supplies such as vaccines or codes designated as ‘add-on’ codes.
Example:
An orthopedic surgeon performs a closed treatment of a femoral shaft fracture on the left leg and a closed treatment of a right knee dislocation during the same operative session. It would be coded as LT and RT.
Modifier 51 is used when multiple procedures are performed during the same session by the same provider. The primary procedure would be reported as listed and the additional procedure(s) identified with modifier 51. An example would be an orthopedic surgeon who performed a closed treatment of a femoral shaft fracture on the left leg and a closed treatment of a right knee dislocation during the same operative session. This would be coded as LT and RT. Modifier 51 isn’t used on E/M services, Physical Medicine or Rehabilitation Services, the provision of supplies such as vaccines or codes designated as ‘add-on’ codes.

54. Modifier 52 - Reduced Services
Procedure partially reduced at physician discretion
Service not completed in its entirety
Example: Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (For individual component placement, report with modifier 52)
Modifier 52 is used to indicate reduced services. If a procedure is partially reduced or eliminated at the physician’s discretion you would append 52 to the code. If a bilaterally service is performed unilaterally, modifier 52 would be appended to the procedure code. Sometimes, you will see a parenthetical instruction explaining the circumstance in which to use modifier 52. Turn in your CPT book to code Under 43770, there is a parenthetical instruction telling the coder to report modifier 52 with for individual component placement.

55. Modifier 53 - Discontinued Services
Procedure terminated due to:
Extenuating circumstances
Circumstances threatening the well-being of the patient
Do not use:
Elective cancellation prior to induction of anesthesia
Example:
A patient who is having a surgical procedure and after the administration of general anesthetic exhibits unstable vital signs. At the recommendation of the anesthesiologist the surgeon decides to terminate the procedure.
Modifier 53 represents a discontinued Procedure. If a procedure is terminated due to extenuating circumstances and/or circumstances that threaten the well-being of the patient, you would use this modifier with the procedure code. You will see a Note in the definition of this modifier telling us NOT to use 53 to report the elective cancellation of a procedure prior to the induction of anesthesia and/or surgical prep in the OR suite. An example might be a patient who is having a surgical procedure and after the administration of general anesthetic exhibits unstable vital signs. At the recommendation of the anesthesiologist the surgeon decides to terminate the procedure.

56. Modifier 59 - Distinct Procedural Service
Procedures not normally reported together
Different Session or Patient Encounter
Different Procedure or Surgery
Different Site or Organ System
Separate Incision/Excision
Separate Lesion
Modifier 59 indicates Distinct Procedural Service. You might use it in these instances: for procedures not normally reported together; a different site or organ system; a separate incision/excision; a separate lesion.

57. Modifier 59 - Distinct Procedural Service
Example:
A patient had a colonoscopy and a lesion is removed proximal to the splenic flexure. During the same colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure.
An example would be a patient who had a colonoscopy and a lesion is removed proximal to the splenic flexure. During the same colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure.
More information can be found on the use of Modifier 59 in the NCCI documentation on the CMS website.

58. Modifier 63 - Procedures Performed on Infants Less than 4kg
Increased work intensity
Temperature control
Obtaining IV access
Maintenance of homeostasis
Read the “Note” in the description to make sure you’re using the modifier correctly
Modifier 63 is used for procedures performed on infants weighing less than 4 kg. There is increased complexity of the physician work associated with these patients such as temperature control and obtaining IV access. You’ll want to read the Note that’s a part of the definition to make sure you use the modifier correctly.

59. Modifier 76 - Repeat Procedure or Service by Same Physician
Example:
A patient who goes to the Emergency Room with a trauma to the chest. A two-view chest x-ray is taken that shows a pneumothorax. After a chest tube is placed a repeat two-view chest x-ray is taken to verify the placement of the chest tube. You would report and
Modifier 76 is used to report a repeat procedure or service by the same physician. An example would be a patient who goes to the Emergency Room with trauma to the chest. A two-view chest x-ray is taken that shows a pneumothorax. After a chest tube is placed a repeat two-view chest x-ray is taken to verify the placement of the chest tube. You would report and

60. Modifier 77 - Repeat Procedure or Service by Another Physician
Example:
A patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG. The second EKG would be reported with modifier 77.
Modifier 77 indicates a repeat procedure by another physician. An example is a patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG. The second EKG would be reported with modifier 77.

61. Multiple Surgeon Modifiers
62 – Two Surgeons
Work together as primary surgeons
Perform distinct parts of a procedure
Dictate op report of their distinct part
Each will submit the same code and append modifier 62
66 – Surgical Team
Highly complex procedures
Require differently specialties
Modifier 66 appended to procedures coded by the surgical team
Modifier 62 and 66 are multiple surgeon modifiers. Modifier 62 is used when two surgeons work together as primary surgeons performing distinct parts of a single surgical procedure. Each surgeon would dictate an operative report of their distinct operative work and each would submit the same CPT code and append modifier 62.
Modifier 66 indicates a surgical team was used for the procedure. Some highly complex surgeries may require the expertise of several physicians, often of different specialties. Modifier 66 would be appended to the procedures coded by the surgical team. Often you will see modifier 66 used with organ transplant procedures.

62. Assistant Surgeon Modifiers
Assistant surgeon present for entire or substantial portion of the operation
Reports the same surgical procedure with modifier 80 appended
81 – Minimum Assistant Surgeon
Circumstances present that require the services of an asst surgeon for a short time. Minimal assistance.
Reports the same surgical procedure with modifier 81 appended
82 – Assistant Surgeon (when qualified resident surgeon not available)
Used in a teaching hospital that employs residents
No residents available and another surgeon is used
Assistant surgeon modifiers are 80, 81 and 82. Modifier 80 is used when one physician assists another physician in performing a procedure. If an assistant surgeon assists a primary surgeon and is present for the entire operation, or a substantial portion, then the assisting physician reports the same surgical procedure as the primary surgeon and appends modifier 80.
Modifier 81 would be used for Minimum Assistant Surgeon. There may be instances when a primary surgeon plans a surgery alone, however during the operation circumstances arise that require the services of an assistant surgeon for a relatively short time. In this case, the second surgeon provides only minimal assistance and would report the surgical procedure code with modifier 81 appended.
Modifier 82 is used when a qualified resident surgeon is unavailable. An example here is a teaching hospital with surgical residents on staff but no residents are available to assist. In this case, another surgeon is called on to be the assistant surgeon. The assistant surgeon would use modifier 82 with their procedure reporting.

63. Ancillary Modifiers
Global – a procedure containing both a technical and a professional component
Modifier 26 – Professional Component
Modifier TC – Technical Component
Certain procedures are a combination of a physician component and a technical component. Global ancillary modifiers 26 and TC are used for procedures containing both a technical and professional component. Modifier 26 indicates the professional component and modifier TC represents the technical component. These modifiers are discussed in more detail in the radiology section.

64. Ancillary Modifiers Example:
A patient comes to the office with wheezing and congestion. The physician takes a 2-view chest X-ray using his or her own equipment and sends it out to be read by a radiologist. The office would code TC for the use of the equipment (technical)
The radiologist would bill for his/her interpretation and report (professional service).
If the office took the X-ray and also did the interpretation and report, they would code – without any modifiers – to indicate they did the global service…..both the technical and professional components
An example would be a patient who comes to the office with wheezing and congestion. The physician takes a 2-view chest x-ray using his/her own equipment and sends it out to be read by a radiologist. The office would code TC for the use of the equipment (technical) and the radiologist would bill for his/her interpretation and report of the films, the professional service. If the office took the x-ray and also did the interpretation and report, they would code – without any modifiers – to indicate they did the global service…..both the technical and professional components.

65. Laboratory Modifiers 90 – Reference (Outside) Laboratory
Used to bill for lab services purchased from an outside lab
91 – Repeat Clinical Diagnostic Lab Test
Not used to confirm results
Not used to repeat a test due to equipment malfunction
92 – Alternative Lab Platform Testing
Single use
HIV testing
Modifiers 90, 91 and 92 are laboratory modifiers. Modifier 90 is used when lab procedures are performed by and individual other than the treating physician. The modifier is often used to bill for lab services purchased from an outside lab. Modifier 91 is used for a repeat clinical diagnostic lab test. If a test is performed more than once on the same day to obtain subsequent test results you would append 91 to the subsequent identical tests. Modifier 91 would be appropriate to use if we were testing multiple arterial blood gasses for a patient in a 24 hour period. However, you wouldn’t use it if the same test was performed to confirm the results of a previous test, or if it was repeated due to equipment malfunction. Modifier 92 is Alternative Lab Platform Testing which indicates tests that use a kit or transportable instrument that is of a single use. Examples are HIV testing These tests don’t require permanent dedicated space and may be hand carried or transported to the vicinity of the patient for immediate testing at that site.

66. Anesthesia Modifiers 23 - Unusual Anesthesia
47 – Anesthesia by Surgeon
Physical Status Modifiers
There are also some modifiers that are specific to anesthesia. These modifiers are 23, 47 and the Physical Status modifiers. These modifiers will be discussed in more detail in the Anesthesia Lecture.

67. HCPCS Level II Level I HCPCS is CPT® Level II HCPCS Maintained by AMA
Identify services and procedures
Level II HCPCS
Maintained by CMS
Identify products, supplies, and services not included in CPT®
Another book used to code medical services and supplies is the HCPCS Level II code book. The acronym HCPCS stands for Healthcare Common Procedure Coding System. HCPCS codes are divided into two principal subsystems referred to as Level I & Level II.
Level I HCPCS are known as CPT codes and are maintained by the American Medical Association which was discussed earlier in this lecture. They are used to identify services and procedures used by healthcare professionals. Level II HCPCS codes are maintained and distributed by the Centers for Medicare and Medicaid Services and are used to identify products, supplies and services not included in the CPT codes.

68. HCPCS Level II
A Codes ~ Transportation Services, Med/Surg Supplies, Admin
B Codes ~ Enteral and Parenteral Therapy
C Codes ~ Pass-Through Items
D Codes ~ Dental Procedures
E Codes ~ Durable Medical Equipment
G Codes ~ Procedures/Professional Services
H Codes ~ Alcohol and Drug Abuse Treatment Services
J Codes ~ Drugs Admin Other Than Oral Method/Chemotherapy Drugs
K Codes ~ DME Supplies
L Codes ~ Orthotic/Prosthetic Procedures
M Codes ~ Medical Services
P Codes ~ Lab/Path
Q Codes ~ Temporary Codes
R Codes ~ Diagnostic Radiology
S Codes ~ Temporary National Codes (Non-Medicare)
T Codes ~ Nat’l Codes for State Medicaid Agencies
V Codes ~ Vision/Hearing Services
The Table of Contents lists 17 alpha-numeric sections of Level II codes. The codes are categorized as either Permanent or Temporary.

69. HCPCS Level II Types of Level II Codes
Permanent National Codes maintained by the CMS HCPCS Workgroup
Responsible for additions, deletions, revisions
Updated annually
Temporary National Codes maintained by the CMS HCPCS Workgroup
Updated quarterly
The Permanent National Codes are maintained by the CMS HCPCS Workgroup who is responsible for the additions, deletions and revisions to the codes. National codes are updated annually and effective January 1st each year. The Temporary National Codes are also maintained by the CMS HCPCS Workgroup and may be added, changed or deleted on a quarterly basis.

70. HCPCS Level II Types of Temporary Codes G codes H codes
Professional health care procedures/services with no CPT ® codes
Example:
G0412 – G0415 – unilateral or bilateral
27215 – – unilateral only, use modifier 50 for bilateral
H codes
Used by State Medicaid Agencies for mental health services such as alcohol and drug treatment services
There are several types of temporary codes. Examples include the G codes and H codes. G codes are for identifying professional healthcare procedures and services for which there are no CPT codes. These codes are also created when CMS has a definition of a code that does not match that of the AMA.
An example of this would be HCPCS Codes G0412 through G0415, which consider the pelvis procedures as unilateral or bilateral. The same procedures in CPT, codes through which consider the same procedure as unilateral only. It may be helpful for you to identify these types of definition differences between AMA and CMS and cross reference them in each of the manuals.
H codes are used by State Medicaid Agencies for mental health services such as alcohol and drug treatment services.
Other temporary codes include C codes, K codes, Q codes, S codes, and T codes.

71. HCPCS Level II Dental Codes Current Dental Terminology or CDT®
Separate category of national codes
Used for billing dental procedures and supplies
Copyright by the American Dental Association
Additions, deletions and revisions made by the ADA
The dental codes are a separate category of national codes. These codes are used for billing dental procedures and supplies. D codes are no longer listed in the HCPCS coding manual. The codes should be obtained from the American Dental Association.

72. HCPCS Level II Coding Conventions Bullet indicates new code
Triangle indicates code description has been revised
X with line through code and code description means code has been deleted
Color Coded Symbols
As with your other coding books, Level II codes have coding conventions. The bullet indicates a new code; the triangle means that the code description has been revised. An x next to a code with a line through the code and code description means it has been deleted. The color-coded symbols represent Medicare coverage and payment authority for each item or service.

73. HCPCS Level II Format: Alphabetic Index Tabular Index
Divided into different alpha-numeric sections
Table of Contents
List of alpha sections with code ranges and page numbers
Your Level II book has an Alphabetic and Tabular Index. The Tabular Index is divided into different alpha-numeric sections. The Table of Contents has a list of the separate alpha-numeric sections with code ranges and page numbers.

74. HCPCS Level II Appendices: Appendix A Appendix B Appendix C Appendix D
Level II modifiers
May be used with some CPT® codes, i.e., LT/RT
Appendix B
Table of Drugs
Names of Drugs, dosage, delivery method, J code
Appendix C
Medicare References
Appendix D
Jurisdiction List
Appendix E
Deleted Code Crosswalk
There are 5 Appendices. It is important to note that not all HCPCS code books are the same. They may vary depending on the publisher, but should all contain the basic information of HCPCS codes.
Appendix A is a listing of HCPCS Level II Modifiers, Appendix B is the Table of Drugs, Appendix C is Medicare References, Appendix D is a Jurisdiction List and Appendix E is the Deleted Code Crosswalk.
The modifiers in Appendix A are a combination of two alphas or one alpha and one numeric. The number of Level II modifiers is quite large compared to CPT modifiers. Most of them are specific to the Level II codes; however some are also used with CPT codes such as the modifiers for laterality – RT/LT. It might be helpful to go through the modifiers and bracket like modfiiers, such as F1 to F9 to identify the specific fingers and thumbs.
The Table of Drugs in Appendix B is in alpha order by Drug name. The table also gives the additional name or names of the drug, the dosage, the delivery method and the J code.
Depending on the type of practice or specialty you work in, the use of the Level II codes may be limited to only a few sections. One section with frequent use in the outpatient setting is the J codes. These codes are used for drugs administered other than oral method – with the exception being the oral immunosuppressive drugs. There are 2 different methods of looking up J codes. You can use the Table of Drugs in Appendix B or you can use the Alphabetic Index.

75. HCPCS Level II Finding a Code Two ways to find it
Depo Provera 150mg IM for contraception
Two ways to find it
Table of Drugs
Alphabetic Index
J Depo Provera 150 mg IM
If a physician administers an IM injection of 150mg of Depo Provera for contraceptive use - what code would you use for the drug? One way to find the code is by going to Appendix B, Table of Drugs. I’ll give you some time. In the Table of Drugs you’ll find Depo Provera under the column Drug Name. The generic name is in the column called Additional Name(s). The next column is the dosage; then the Delivery Method and the last column is the HCPCS code. The code for 150 mg of Depo Provera given IM is J When you look in the J code section for J1055 you’ll see the description say ‘injection, medroxyprogesterone acetate for contraceptive use, 150mg IM. Had you started by looking in the Alphabetic Index you would have been given a choice of J1051 or J At that point you would need to look in the section of J codes to identify the correct code.

76. HCPCS Level II Finding a Code Two ways to find it
Orthopedic Shoes
Two ways to find it
Table of Contents
Alphabetic Index
L High-top orthopedic shoe with pronator for an infant
Another example of coding with a HCPCS Level II code would be a podiatrist who prescribes orthopedic shoes. You can look in the Table of Contents for Orthotic Procedures to be referred to a section – or you can look in the Alphabetic Index for Orthopedic Shoes. If you choose the Alphabetic Index you will see a list of footwear and supplies associated with Orthopedic shoes. Lets say the podiatrist prescribed a high-top orthopedic shoe with pronator for an infant. If you look in the Orthopedic Footwear code range beginning with L3201 and scroll down the list you’ll see L3204 is the correct code.

77. HCPCS Fewer codes than CPT® and ICD-9-CM Smaller textbook
Care still needs to be taken when making a code selection
As you can see there are fewer Level II codes than CPT and ICD-9-CM codes, however Level II brings its own challenge to coding. You’ll want to make sure you have all the information necessary for accurate code selection and utilize the Table of Contents and/or Alphabetic Index to help in finding the code.

78. The End
Understanding your coding manuals and how to use them properly will help you be a more efficient and accurate coder. Be sure you take the time to learn the conventions and details of your coding manuals each year.