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Current Procedural Terminology, 4th Edition

LECTURE SESSION

This text is updated and revised annually. The code numbers are added or deleted as new procedures are developed or existing procedures are modified. The CPT uses a basic five digit system for coding services rendered by physicians and a two digit add on modifier when needed which is used to indicate procedural changes or special circumstances. Procedural code numbers represent diagnostic and therapeutic services on all medical billing statements and insurance forms.

The following format and chapters are included in the CPT:

  1. Evaluation and Management (E/M)99201 - 99499
  2. Anesthesia00100 - 01999
  3. Surgery10040 - 01999
  4. Radiology, nuclear medicine

and diagnostic ultrasound70010 - 79999

  1. Pathology and Laboratory Tests80048 - 89399
  2. Medicine90281 - 99569
  3. Category II codes0001T - 0026T
  4. Appendix A – modifiers
  5. Appendix B – additions, deletions, revisions
  6. Appendix C – update of short descriptors
  7. Appendix D – clinical examples
  8. Appendix E – CPT Add-on codes
  9. Appendix F - codes exempt from modifier -51

Conventions

Any of the following symbols placed in front of a CPT code implies that a specific revision or edition has been made to the code:

a). STAR () = service includes surgical procedure only

b). PERIOD ( ) = new code

c). Triangle () = revised code

d). Double triangle () = new or revised text

e). PlusSIGN () = add on code

f). Circle (⊘) = modifier⊘ 56898 (50) (52) (99)

$125 $450

Consultations (evaluation and management section)

There are four basic consultation classifications:

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a). Office or other outpatient consultations 99241 – 99245

b). Initial inpatient consultations 99251 - 99255

c). Follow-up inpatient consultations 99261 - 99263

d). Confirmatory consultations 99271 - 99275

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specialty departments

Critical Care = A critical illness or injury is that occurs to one or more vital organ systems that makes a situation life-threatening and where there is deterioration in the patient’s condition. Critical care involves high complexity decision-making to make an assessment. Types of protocols for critical care include pulse oximetry 94760, blood gases, gastric intubation 43752, transcutaneous pacing and more.

Emergency Care = Emergency department is defined as an organized hospital-based facility for provision of unscheduled episodic services to patients who present for immediate medical attention.

Miscellaneous services

a). Prolonged evaluation and management service 99358

b). Prolonged evaluation and management service for each 30 minutes and above 99359

c). Physician standby service 99360

d). Medical conference by physician 99361

e). Telephone call my physician 99371

FEE SCHEDULES

Although Fee schedules and prices will vary from practice to practice or center to center, the following fee schedule definitions remain constant and universal:

  1. ACTUAL FEE = this is the amount that a physician bills a patient for a particular medical procedure or service.
  2. PREVAILING FEE = this is the charge or fee that falls within the range of charges most frequently used in a locality for a particular medical service or procedure.
  3. CUSTOMARY FEE = this fee is in the range of the fees charged by providers of similar training and experience in a
  4. given geographic area.
  5. REASONABLE FEE = this fee meets the criteria of the usual fee and is in the opinion of the medicalreview committee, justifiable, considering the special circumstances of the patient and case.

Factors to take into consideration when looking up CPT codes:

Categories and Subcategories:

  1. Main category = is the location an office or hospital
  2. Subcategory = is the patient new or established
  3. Key component = is there a history, physical, or medical decision being made
  4. Contributory factors = is there a counseling, coordination of care, nature of the problem, or face-to-face time with the patient.

Main Term and Subterms

The Main term is the subject of what is being sought in the CPT and the subterm is usually a descriptive term that describes the main term. It is often anatomical in nature. The CPT just like the ICD are both arranged within anatomical categories, and you have to bear in mind the 10 systems of the body when looking things up.

For example:

“Closed treatment of a patellar dislocation; no anesthesia”

Here the main term is a dislocation in the subterm which is descriptive of this is the kneecap or patella. The two basic ways for looking this up are: (a) to look in the index in the back of the book under dislocation, and under this category follow the part of the body from head to toe until you arrive at the lower extremities and kneecap. There you will see several categories with and without anesthesia and which send you to (b) the CPT chapter on surgery of the musculoskeletal system, for which again one can search from head to toe until arriving at the lower extremities and kneecap or go directly to the repair section of the lower extremities in this chapter. In either case, the code is 27560.

Example #2:

“Jamie Lee was skating on the ice when she fell. On diagnostic arthroscopy, a torn medial meniscus tear was seen and repaired.”

The main term here is a “repair”, and from the medical term arthroscopy it is noted that the prefix Arthro/s refers to a joint and that particular joint is at the kneewith this being the subterm. Again, we can either look in the back index under the main term “repair” and follow anatomically until reaching the lower extremities and in particular the kneecap, or we can go directly to the musculoskeletal system and look within the section for “repairs “ for which the code found would be 27403.

Current procedural terminology code digit analysis

If we analyze the CPT code 99202, we can see that the first portion 99 refers to the EM section of the CPT while the zero refers to a second category new patient which is a type level II.

Surgical Packages = Surgical package will always include (a) the operation and (b) local infiltration or anesthesia

Coding procedures:

  1. Always read the introduction section at the beginning of the code book
  2. Read the guidelines at the beginning of each of the six sections of the book
  3. Read the notes and the special subsection information throughout the surgery section, radiology, medicine sections.
  4. Use the index at the back of the book in order to locate the specific term by generalized code numbers not by page numbers.
  1. If the procedure performed is not listed, check for an organ involved. If the procedure or organ is difficult to find then look at the condition and keywords such as synonyms, eponyms or abbreviations which can also help.
  1. Always identify and start with the main term when reading a description.
  1. When trying to locate a code, always identify the place or type of the service rendered; then identify whether the patient is new or established and locate the category or subcategory involved.

CODING TYPES

  1. Comprehensive Codes = a comprehensive code is a single code that describes or covers two or more component codes that are bundled together as one unit. For example, there is one comprehensive code that covers the entire anatomy in the female reproductive system including both fallopian tubes, uterus, ovaries and vaginal vestibule. Each structure also has its own individual CPT code number, and since there is a comprehensive code that covers all of them it is preferable to use this instead. It should also be noted that the use of a comprehensive code instead of the individual bundled codes will always yield more money in return than the individual codes separately. For example, individual coding for a hysterectomy would yield: 1 uterus (44678) ($465), 2 fallopian tubes (42578) ($350), and 2 ovaries (43789)($450) for a total of $1265; while if the same were submitted with a comprehensive code that includes these structures the return would be $2500, which is a significantly larger amount. These larger amounts are already pre-computed in all CPT submissions, but comprehensive codes do take time to find and also have pre-qualifications that also must be submitted from the patient record which are required for approval as well.
  1. Bundled codes = A Bundled code means a group of codes together that are related to a particular procedure.
  1. Unbundling = Unbundling is coding and billing numerous CPT codes to identify procedures that usually describe a single code. Unbundling is considered fraud when done intentionally to gain increased reimbursement.
  1. Downcoding = Downcoding occurs when the coding system used on a claim submitted to an insurance carrier does not match the coding system used by the company receiving the claim. For example, if a code has been deleted from the CPT and then submitted by a medical biller it would appear as a downcoding code.
  1. Upcoding = This term in coding is used to describe the deliberate manipulation of CPT codes for increased payments. For example, intentional upcoding is one in which physicians select one level of service codes for patient visits with the theory that these codes will even out eventually.

Code modifiers

A CPT code modifier is two digit add on that permits the physician to indicate circumstances in which a procedure will differ in some way from that originally described by the five digit code. These digits are always placed at the end of the CPT code in parentheses with a minus sign.

Code modifies can be used for any of the following:

(a) a service or procedure was performed as a professional component, (b) a service or procedure was performed by more than one physician or in more than one location, (c) a service or procedure has been increased to reduce patient symptoms, (d) a service or procedure was performed more than once, (e) only part of the service was performed, (f) or a group of services performed, (g) a bilateral service was performed (h) or unusual events occurred during the service or procedure.

The more common CPT code modifiers are: code (–26), for professional component, code (- 50) for bilateral procedure, and code (- 51) for multiple procedures. If multiple code modifiers being used you must begin with the code modifier number (-99), which is the coding for “multiple modifiers”; for example: 99346 (-99)(-50)(-51).

(-25) Separate evaluation and management service by the same Dr. on the same day

(-26) professional component

(-50) bilateral procedure

(-51) multiple procedures

UPDATE

CPT CONDITIONAL METHOD FOR LOOKING UP CODES

EXAMPLE:

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  1. A patient underwent “closed treatmentof femoral shaft fracture, without manipulation”. Using the “Condition” Location

Method, which of the following will be used to locate the code in the index of the CPT manual?

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  1. Femur
  2. Fracture
  3. Treatment
  4. Manipulation

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The most common method of finding a CPT code is by way of looking up the main term. In this case, the main term is “fracture”,

and so by looking in the index under fracture, the next step would be to locate the part of the body onto which the fracture

occurred. Since the fracture here is in the lower extremities, and particularly in the femur or femoral bone, the code can

easily be found.

The conditional method relies on identifying the type of condition that has occurred as stated in the sentence. In this case,

the condition being stated is a “treatment”, and specifically, the “type” of treatment is one that is accomplished without

“manipulation”. So that, the same code can also be obtained by first looking up the term “manipulation” in the index of the

CPT in the back, and once this is found and then going to the part of the body to which this manipulation refers to, specifically,

the lower extremities and femoral region.

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EXAMPLE #2: “OPEN REPAIR OF A CLOSED MANDIBULAR FRACTURE”

HCPCS LEVEL II (2011)

Description:

HCPCS - Level II is the Healthcare Common Procedure Coding System, established by CMS's Alpha-Numeric Editorial Panel. HCPCS primarily represents items, supplies, non-physician services not covered by the AMA's CPT-4 codes. Medicare, Medicaid and private insurers use HCPCS procedures and modifier codes for claims processing.

The HCPCS level II coding system is a comprehensive and standardized system that classifies similar products that are medical in nature into categories for the purpose of efficient claims processing. For each alphanumeric HCPCS code, there is a descriptive terminology that identifies a category of like items. These codes are used primarily for billing purposes. For example, suppliers use HCPCS level II codes to identify items on claim forms that are being billed to a private or public health insurer.

In summary, the HCPCS level II coding system has the following characteristics:

  • This system ensures uniform reporting on claims forms of items or services that are medical in nature. Such a standardized coding system is needed by public and private insurance programs to ensure the uniform reporting of services on claims forms by suppliers and for meaningful data collection.
  • The descriptors of the codes identify a category of like items or services rather than specific products or brand/trade names.
  • The coding system is not a methodology for making coverage or payment determinations. Each payer makes determinations on coverage and payment outside this coding process.

HCPCS LEVEL II (2011)

STAT!Ref Overview

Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures

Introduction

A. HCPCS BACKGROUND INFORMATION

B. HCPCS LEVEL II CODES

C. TYPES OF HCPCS LEVEL II CODES

D. REQUESTING A REVISION TO THE HCPCS LEVEL II CODES

E. HCPCS Updates

Alphabetic Index to HCPCS Codes

Drug Index to HCPCS Codes

Tabular List of HCPCS Codes

Transportation Services Including Ambulance [A0021 - A0999]

Medical and Surgical Supplies [A4206 - A8004]

Administrative, Miscellaneous and Investigational [A9000 - A9999]

Enteral and Parenteral Therapy [B4034 - B9999]

Pass-Through Items [C1300 - C9728]

Durable Medical Equipment (DME) [E0100 - E8002]

Procedures/Professional Services (Temporary) [G0008 - G9140]

Alcohol and Drug Abuse Treatment Services [H0001 - H2037]

Drugs Administered Other than Oral Method [J0120 - J8999]

Chemotherapy Drugs [J9000 - J9999]

DME Supplies [K0001 - K0899]

Orthotic Procedures [L0112 - L4398]

Prosthetic Procedures [L5000 - L9900]

Medical Services [M0064 - M0301]

Laboratory and Pathology [P2028 - P9615]

Temporary Codes [Q0035 - Q9967]

Diagnostic Radiology Services [R0070 - R0076]

National Codes Established for State Medicaid Agencies [T1000 - T5999]

Vision and Hearing Services [V2020 - V5364]

Tabular List of HCPCS Modifiers