HIT CPT

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ICD-9-CM / ICD-10-CM CPT ICD-10-PCS Body Systems Drugs




Current Procedural Terminology (CPT)

  • AMA is responsible for issuing Official Guidelines for CPT


Title Codes Notes
• Evaluation and Management (E/M) Services 99201-99499
• Anesthesia 00100-01999
• Surgery (10021-69990)
   • General 10021-10022
   • Integumentary System 10040-19499
   • Musculoskeletal System 20005-29999
   • Respiratory System 30000-32999
   • Cardiovascular System
     • Medicine
     • Radiology
33010-37799 Also
• Medicine (92950-93799)
• Radiology (75557-75574, 75600-75791)
   • Hemic and Lymphatic Systems 38100-38999
   • Mediastinum 3900-39499
   • Diaphragm 39501-39599
   • Digestive System 40490-49999
   • Urinary 50010-53899
   • Male Genital System 54000-55899
   • Reproductive System Procedures 55920
   • Intersex Surgery 55970-55980
   • Female Genital System 56405-58999
   • Maternity Care and Delivery 59000-59899
   • Endocrine System 60000-60699
   • Nervous System 61000-64999
   • Eye and Ocular Adnexa 65091-68899
   • Auditory System 69000-69979
   • Operating Microscope 69990
• Radiology 70010-79999
   • Nuclear Medicine 78000-79999
• Pathology and Laboratory 80047-89398
• Medicine 90281-99607

Contents

Level I Modifiers (CPT)

TOP

-22, Increased Procedural Services

• Valid for Code With Global Periods of 0, 10, or 90 days
• Overused and Results in an Increase in Payment of 20% to 30%
• NOT be Appended to
   • E/M service
   • Radiology
   • Laboratory
   • Pathology
   • Most Medicine codes
   • Cannot be Assigned to 99291, 99292 codes

-23, Unusual Anesthesia

• General Anesthesia Used when Normally Local or Regional
• eg. The patient is a 10-month-old boy who fell while trying to walk across the kitchen floor at his home. He suffered an open wound to his bottom lip. Sutures are necessary but due to patient's age and excessive movement general anesthesia is needed

-24, Unrelated Evaluation And Management Service by the Same Physician During A Postoperative Period

• CODING SHOT
   • Payment for an Unassociated E/M within Global Period
• With E/M codes

-25, Significant Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

• NCCI Note
• Medical Necessity

-26, Professional Component

• Ultrasound, X-ray
• Professional component
• Technical component

-32, Mandated Services

• Service required by some Third-party payers
• Not for Second Opinion
• Insurance certification
• Only assigned for mandated services, such as police, Worker's Compensation, etc., NOT for requests made by patient, family member, or another physician
• eg. A radiological examination of the GI tract was ordered by a third-party payer for a confirmation of Crohn's disease (regional enteritis) of the large bowel.

-33, Preventive Service

• Patient Protection and Affordable Care (PPACA)
• US Preventive Services Task Force (USPSTF)
   • Grade A (High certainty for substantial net benefit)
   • Grade B (High certainty for moderate net benefit)
• Preventive services
• Immunization

-47, Anesthesia by Surgeon

• Anesthesia by the Surgeon
• NCCI Note
• eg. Anesthesia provided by the ENT physician during a tympanoplasty for a repair of a tympanic membrane perforation

-50, Bilateral Procedures

• Mirror-Image Organ
• NCCI Note
   • Medicare Does NOT Accept Two Line Items for Bilateral Procedure
• eg. A patient is admitted and has bilateral arthroscopy of the knees due to Baker's cyst

-51, Multiple Procedures

1. Same Operation, Different Site
   • -51
2. Multiple Operations, Same Opportunity Site
3. Procedure Performed Multiple Times
   • eg. 27658 X 2
   • eg. 27658, 27658-51
 
   • HCPCS/National Level II Modifiers that indicate digits of foot and hand
      • Inside CPT front cover
      • -LT (Left side)
      • -RT (Right side)
      • -FA (Left hand, thumb)
      • -F1 (Left hand, second digit)
 
   • NCCI Note
      • Medicare: Modifiers Specifying Digit MUST be Reported
   • CODING SHOT
      • CPT Modifier First (High to Low), followed by HCPCS code (Ascending Alpha)
   • CODING SHOT
      • Payers dictate how providers are to submit for payment of services
   • Times Symbol (x) - each
   • CAUTION: NOT used with add-on codes that specify “each additional…”

-52, Reduced Services

• CODING SHOT
   • May or May Not Affect Reimbursement

-53, Discontinued Procedure

• NCCI Note
   • Use to Report a Failed or Terminated Colonoscopy

-54, -55, -56 (Modifiers-54,-55, and-56)

• -54 Surgery (Intraoperative) ONLY
• -56 Preoperative Evaluation ONLY
• -55 Postoperative Care ONLY (Post-Operative)

-54, Surgical Care Only

• CODING SHOT
   • Usually Results in Reimbursement to the Surgeon for Intraoperative % of the Global Package Payment
• When there has been a Transfer of Responsibility
• Payment for the Surgery Portion of the Surgical Procedure is being requested

-55, Postoperative Management Only

• After Discharge from the Hospital

-56, Preoperative Management Only

• Physical Examination Before Surgery

-57, Decision for Surgery

• CAUTION: NOT to be Added to Surgical Section, ONLY E/M codes
   • Only E/M codes
   • Cannot be added to Surgery section codes
• CODING SHOT
   • Does NOT Indicate Diagnostic or Therapeutic, Minor or Major
• E/M codes
• The day the decision for surgery was made
• Day before
• Day of
• Major
• Minor
• NCCI Note
   • Medicare, Carrier to Pay for E/M Service Day Of or Day Before a Procedure

-58, Staged or Related Procedure or Service by the Same Physician during the Postoperative Period

• CAUTION: Some codes include Multiple codes in the Description
• CODING SHOT
   • Requests Full Payment for Subsequent Procedure
   • New Global Period

-59, Distinct Procedural Service

• Services that are Usually Bundled are Being Provided as Separate Services
• CODING SHOT
   • Same day
• Except E/M codes
   • Only appended to other than E/M codes
• NCCI Note
   • Medicare, codes that cannot be reported together: Edits

-62, Two Surgeons (Co-surgeons)

• CODING SHOT
   • 125% of fee schedule, half for each surgeon
• Two Surgeons, Different Specialties
• Two Physicians Working Together in the Completion of a Procedure When Each has the Same Level of Responsibility
• Cannot be Used if One Physician Assists Another Physician

-63, Procedure Performed on Infants Less Than 4 kg (8.8 lbs)

• 4kg
• 8.8 pounds

-66, Surgical Team (More than Two)

• When Several Physicians, with Technicians and Specialized Equipment,
  Work Together to Complete a Complicated Procedure
  and Each Physician has a Specific Portion of the Surgery to Complete
• CODING SHOT
   • Payment for Procedure Increased

-76, Repeat Procedure or Service by Same Physician

• CODING SHOT
   • Requests Payment for Repeated Service

-77, Repeat Procedure by Another Physician

• CODING SHOT
   • Requests Payment for Repeated Service

-78, Unplanned Return to the Operating/Procedure Room by the Same Physician
Following Initial Procedure for Related Procedure During The Postoperative Period

• CODING SHOT
   • Intraoperative Percent

-79, Unrelated Procedure or Service by the Same Physician during the Postoperative Period

• CODING SHOT
   • Request Payment for Full Fee, Unassociated with First Procedure

-80, Assistant Surgeon

• CAUTION: Physician Assistant, HCPCS modifier -AS
• CODING SHOT
   • Preauthorization Does NOT Guarantee Payment

-81, Minimum Assistant Surgeon

• Not Commonly Used

-82, Assistant Surgeon (When Qualified Resident Surgeon Not Available)

• CODING SHOT
   • Medicare Does NOT Pay for Assistant Surgeon if the Hospital has a Residency Program

-90, Reference (Outside) Laboratory
-91, Repeat Clinical Diagnostic Laboratory Test

• Same Day

-92, Alternative Laboratory Platform Testing

• Kit or Transportable Instrument

-99, Multiple Modifiers

• If Third-Party Payer Does NOT Accept Multiple Modifiers


+CPT Modifiers (Grouped)

TOP

  • Special Evaluation and Management (E/M) Services
    • -24 (Unrelated Evaluation And Management (E/M) Service by the Same Physician DURING A Postoperative Period)
    • -25 (Significant Separately Identifiable E/M Service by the Same Physician on the SAME DAY of the Procedure or Other Service)
    • -57 (Decision for Surgery)
  • Greater, Reduced, or Discontinued Procedures or Services
    • -22 (Increased Procedural Services)
    • -52 (Reduced Services)
    • -53 (Discontinued Procedure)
    • -73 (Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC)
      Procedure PRIOR to Anesthesia Administration)
    • -74 (Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC)
      Procedure AFTER Anesthesia Administration)
  • Global Surgery
    • -54 (Surgical Care Only)
    • -55 (Postoperative Management Only)
    • -56 (Preoperative Management Only)
    • -58 (Staged or Related Procedure or Service by the Same Physician DURING the Postoperative Period)
    • -59 (Distinct Procedural Service)
    • -60 (Altered Surgical Field)
    • -63 (Procedure Performed on Infants Less Than 4 kg (8.8 lbs))
    • -78 (Unplanned Return to the Operating/Procedure Room
      by the Same Physician FOLLOWING Initial Procedure
      for Related Procedure During the Postoperative Period)
    • -79 (Unrelated Procedure or Service
      by the Same Physician DURING the Postoperative Period)
Global Surgery, CPT Surgical Package
  • Bilateral and Multiple Procedures or Encounters
    • -50 (Bilateral Procedures)
    • -27 (Multiple Outpatient Hospital E/M Encounters on the Same Date)
    • -51 (Multiple Procedures)
  • Repeat Procedures
    • -76 (Repeat Procedure or Service by Same Physician)
    • -77 (Repeat Procedure by Another Physician)
    • -62 (Two Surgeons (Co-surgeons))
    • -66 (Surgical Team (More than two))
    • -80 (Assistant Surgeon)
    • -81 (Minimum Assistant Surgeon)
    • -82 (Assistant Surgeon (When Qualified Resident Surgeon Not Available))
    • -33 (Preventive Service)
  • Professional Components
    • -26 (Professional Component)
  • Mandated Services
    • -32 (Mandated Services)
  • Unusual Anesthesia or Anesthesia by Surgeon
    • -23 (Unusual Anesthesia)
    • -47 (Anesthesia by Surgeon)
  • Laboratory Services
    • -90 (Reference (Outside) Laboratory)
    • -91 (Repeat Clinical Diagnostic Laboratory Test)
    • -92 (Alternative Laboratory Platform Testing)
  • Multiple Modifiers
    • -99 (Multiple Modifiers)



+CPT Modifiers (Outpatient Use)

TOP

  • -25 (Significant Separately Identifiable E/M Service by the Same Physician on the SAME DAY of the Procedure or Other Service)
  • -27 (Multiple Outpatient Hospital E/M Encounters on the Same Date)
  • -50 (Bilateral Procedures)
  • -52 (Reduced Services)
  • -58 (Staged or Related Procedure or Service by the Same Physician DURING the Postoperative Period)
  • -59 (Distinct Procedural Service)
  • -76 (Repeat Procedure or Service by Same Physician)
  • -77 (Repeat Procedure by Another Physician)
  • -78 (Unplanned Return to the Operating/Procedure Room
    by the Same Physician FOLLOWING Initial Procedure
    for Related Procedure During the Postoperative Period)
  • -79 (Unrelated Procedure or Service
    by the Same Physician DURING the Postoperative Period)
  • -91 (Repeat Clinical Diagnostic Laboratory Test)



Anesthesia Physical Status Modifiers

See Anesthesia Section
TOP

CPT Manual Purpose

TOP

  • Current Procedural Terminology (CPT)
  • CPT-4
  • CPT-5
    • Unclear Terminology CPT will be Replaced with More Precise Definitions
  • American Medical Association (AMA) -1966
  • Category I (Majority)
  • Category II (Optional Performance Measures)
  • Category III (Temporary, New/Emerging Technologies)
  • Used by…
    • Clinics
    • Outpatient Hospital Departments
    • Ambulatory Surgery Centers (ASC)
    • Third-party payers
  • CMS-Healthcare Financing Administration (HCFA)
  • Healthcare Common Procedural Coding System (HCPCS)
    • Developed by Centers for Medicare and Medicaid Services (CMS)
      • Formerly HCFA
    • HCPCS developed in 1983
    • CPT Did Not Contain All Codes Necessary for Medicare Services Reporting
    • Level I   CPT codes (Professional services)
    • Level II   National Codes
      (HCPCS, Alphanumeric, Report Services, Supplies, Equipment to Medicare and Medicaid Patients When NO CPT Code Exists)



CPT Manual Updating

TOP

  • Updated annually
  • HIPPA
    • Secretary of Health and Human Services (HHS)
      • National uniform standards for electronic transmission of financial and administrative health information
  • Technologic advances
  • Editorial revisions
  • CMS 1500 Health Insurance Form
  • ASC X12N 837 electronic claim form



CPT Manual Format

TOP

  • Triangle ( ▲ ): New or Revised code
  • Bullet ( ● ) : New code
  • Left Triangle , Right Triangle ( ▶◀ ): New or Revised Text (Beginning and End of Change)
  • Plus ( ✚ ): Add-on code
  • Circle and Slash ( Ø ): Modifier -51 Exemption
  • Circle with Bullseye ( ◉ ): Moderate Sedation
  • Lightning Bolt ( ϟ ☇ ): FDA Approval Pending
  • Circle ( O ): Recycled or Reinstated code
  • Pound Sign ( # ): Out of Numerical Sequence code
  • Appendices (CPT Appendix) (CPT Manual Appendix)
    • A (Modifiers)
    • B (Additions, Deletions, Revisions)
    • C (Clinical Examples, Evaluation and Management (E/M) codes)
    • D (Add-on codes, +)
      • Identifies a code that is NEVER Used Alone
    • E (modifier -51 exempt, Circle With Line,
      -51 CANNOT Be Used With these Codes)
    • F (Modifier -61 Exempt,
      Infants less than 4Kg)
    • G (Moderate (Conscious) Sedation codes, Bullseye)
    • H (Alphbetic Index of Performance Measures by Clinical Condition or Topic, Category II codes)
    • I (Genetic Testing Code Modifiers)
    • J (Electrodiagnostic Medicine Listing of Sensory)
    • K (Product Pending FDA Approval, Lightning Bolt)
    • L (Vascular Families)
    • M (Crosswalked Deleted CPT Codes Summary)
    • N (Resequenced CPT Codes Summary)
      • Pound sign (#)


CPT Symbols.jpg



CPT Sections (Chapters) (x6)

TOP

  1. Evaluation & Management (E/M)  99201-99499
  2. Anesthesia      00100-01999; 99100-99150
  3. Surgery             10021-69990
  4. Radiology            70010-79999
  5. Pathology & Laboratory     80047-89398
  6. Medicine      90281-99189; 99500-99607
  • Category II Codes
  • Category III Codes
  • Appendices A-M
  • Index


  • Section (x6, Top of page, eg. Surgery 2XXXX-2XXXX)
  • Subsection (Top of page, Body system, eg. Musculoskeletal System)
  • Subheading (Body part, eg. Neck (Soft Tissues) and Thorax)
  • Category (eg. Incision)


Category II Codes

TOP

  • These codes provide supplemental information and do not substitute for a Category I code.
  • Performance measurement
  • Physician Quality Reporting Initiative (PQRI) -Dec 2006
    • Voluntary Program -Medicare
    • Renamed to Physician Quality Reporting System (PQRS)
  • Systolic blood pressure
  • Diastolic blood pressure
  • Modifiers, Reason a performance measurement was not performed
    • 1P (medical reasons)
    • 2P (patient reason)
    • 3P (system reason)
    • 8P (not otherwise specified)
  • CPT E/M code or HCPCS G code
  • CMS-1500 insurance claim form (field 24D)
  • ASC X12N 837 electronic claim form (segment SV1)
  • NPI (National Provider Identification)


Category III Codes

TOP

  • New Technology, Emerging technology
  • Temporary code (5 years)
  • Format of Category III Codes
    • Four numbers and a letter
  • Publication of Category III Codes
    • Twice a year (Jan, Jul)
    • AMA


Special Reports

TOP

  • Category I Unlisted code or Category III code
  • When using an Unlisted or Category III code, third-party payers usually require the submission
  • Nature
  • Extent
  • Need
  • Time
  • Effort
  • Equipment



History of National Level Codes (HCPCS)

TOP

  • Promotes Uniform Reporting and Statistical Data Collection for Medical Procedures, Supplies, Products, and Services
  • Each CPT/HCPCS Code is Assigned to One APC

HCPCS Codes (Level I, Level II)

TOP

  • 2 (two) Groups: Level I, Level II
  • + Promotes Uniform Reporting and Statistical Data Collection
    for Medical Procedures, Supplies, Products, and Services
  • Level I (CPT-
    Category I: 99201-99607,
    Category III: 0017T-0259T)
    • AMA (American Medical Association)
    • Outpatient
    • Professional Services
    • Codes for wide variety of providers
      • Physicians
      • Dentists
      • Orthodontists
      • Temporary codes for Medicare
    • Codes for wide variety of services
      • Specific Drugs
      • Durable Medical Equipment (DME)
      • Ambulance Services
  • Level II (HCPCS, National Codes) (A0021-V5364)
    • Alphanumeric (5 digits, Letter+4 numbers)
      • Temporary Code Groupings: K, G, Q, S
    • Alpha-Numeric Workgroup
      (CMS, Health Insurance Association of America, Blue Cross/Blue Shield Association)
    • When NO CPT code exists
    • Physician and Non-Physician Services and Supplies that are NOT Represented in Level I
    • NOT Used for Inpatients
  • Level III (Phased out)
  • Codes and Descriptions Updated Annually by CMS in November
  • Allied Health Professionals (Dentists, Orthodontists, Ambulance)
    • NOT Specifically Reportable with CPT codes
  • NO CPT codes for Many Supplies used in Patient Care (Drugs, DME, Orthoses)
  • Reporting of National Codes is Mandatory on all Medicare and Medicaid forms


+Level II Codes (Partial)

TOP

  • HCPCS/National Level II Alpha-Numeric Codes
A-codes Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental
(e.g. Radiopharmaceuticals)
B-codes Enteral and Parenteral Therapy
C-codes Temporary Hospital Outpatient Prospective Payment System
D-codes Dental Procedures
E-codes Durable Medical Equipment
G-codes Temporary Procedures & Professional Services
(e.g. Procedures and Procedures Combined with Supplies, Radiopharmaceuticals)
H-codes Rehabilitative Services
J-codes Drugs Administered Other Than Oral Method, Chemotherapy Drugs
(e.g. Drugs)
K-codes Temporary Codes for Durable Medical Equipment Regional Carriers
L-codes Orthotic/Prosthetic Procedures
M-codes Medical Services
P-codes Pathology and Laboratory
Q-codes Temporary Codes
(e.g. Contrast Agents)
R-codes Diagnostic Radiology Services
S-codes Private Payer Codes
T-codes State Medicaid Agency Codes
V-codes Vision/Hearing Services



+Level II Modifiers (Partial)

TOP

  • HCPCS/National Level II Alpha-Numeric Modifiers (Partial)
  • Inside CPT front cover
Q1 || Routine clinical service provided in a clinical research study that is in an approved clinical research study
*AA Anesthesia services performed by anesthesiologist
*AD Medical supervision by a physician, more than four concurrent

anesthesia procedures

AH Clinical Psychologist (CP) Services [Used when a medical group

employs a CP and bills for the CP’s service]

AI Principal Physician of Record
AJ Clinical Social Worker (CSW) [Used when a medical group employs a

CSW and bills for the CSW’s service]

AM Physician, team member service
AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist

services for assistant at surgery

AT Acute treatment [This modifier should be used when reporting a spinal

manipulation service (codes 98940, 98941, and 98942)]

BL Special Acquisition of blood and blood products
CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
CC Procedure code changed [This modifier is used when the submitted

procedure code is changed either for administrative reasons or because an incorrect code was filed]

CR Catastrophe/Disaster Related
E1 Upper Left, Eyelid
E2 Lower Left, Eyelid
E3 Upper Right, Eyelid
E4 Lower Right, Eyelid
EJ Subsequent claims for a defined course of therapy (example: EPO,

sodium hyaluronate)

EM Emergency reserve supply (for ESRD benefit only)
EP Service provided as part of Medicaid early periodic screening diagnosis

and treatment (EPSDT) program

F1 Left Hand, Second Digit
F2 Left Hand, Third Digit
F3 Left Hand, Fourth Digit
F4 Left Hand, Fifth Digit
F5 Right Hand, Thumb
F6 Right Hand, Second Digit
F7 Right Hand, Third Digit
F8 Right Hand, Fourth Digit
F9 Right Hand, Fifth Digit
FA Left Hand, Thumb
FB Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)
FC Partial credit received for replaced device
FP Service Provided as Part of Medicaid Family Planning Program
G1 Most recent urea reduction ratio (URR) reading of less Than 60
G2 Most recent urea reduction ratio (URR) reading of 60 to 64.9
G3 Most recent urea reduction ratio (URR) of 65 to 69.9
G4 Most recent urea reduction ratio (URR) of 70 to 74.9
G5 Most recent urea reduction ratio (URR) reading of 75 or greater
G6 ESRD patient for whom less than six dialysis sessions have been

provided in a month

G7 Pregnancy resulted from rape or incest or pregnancy certified by

physician as life threatening

G8 Monitored Anesthesia Care (MAC) for deep complex, complicated, or

markedly invasive surgical procedure

G9 Monitored Anesthesia Care (MAC) for patient who has history of severe

cardio- pulmonary condition

GA Waiver of Liability Statement on file (Effective for dates of service on or

after October 1, 1995, a physician or supplier should use this modifier to note that the patient has been advised of the possibility of noncoverage)

GB Claim being re-submitted for payment because it is no longer covered

under a global payment demonstration

GC This service has been performed in part by a resident under the

direction of a teaching physician

GE This service has been performed by a resident without the presence of

a teaching physician under the primary care exception

GG Performance and payment of a screening mammogram and diagnostic

mammogram on the same patient, same day

GH Diagnostic mammogram converted from screening mammogram on

same day

GJ "Opt Out" physician or practitioner emergency or urgent service
GM Multiple patients on one ambulance trip
GN Service delivered personally by a speech-language pathologist or

under an outpatient speech-language pathology plan of care

GO Service delivered personally by an occupational therapist or under an

outpatient occupational therapy plan of care

GP Service delivered personally by a physical therapist or under an

outpatient physical therapy plan of care

GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication systems
GV Attending physician not employed or paid under arrangement by the

patient’s hospice provider

GW Service not related to the hospice patient’s terminal condition
GY Item or service statutorily excluded or does not meet the definition of

any Medicare benefit

GZ Item or service expected to be denied as not reasonable and

necessary

KO Single drug unit dose formulation
KP First drug of a multiple drug unit dose formulation
KQ Second or subsequent drug of a multiple drug unit dose formulation
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LR Laboratory round trip
LS FDA-monitored intraocular lens implant
LT Left Side (Used to identify procedures performed on the left side of the

body)

Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q3 Live kidney donor - Services associated with postoperative medical

complications directly related to the donation

Q4 Service for ordering/referring physician qualifies as a service

exemption

Q5 Service furnished by a substitute physician under a reciprocal billing

arrangement

Q6 Service furnished by a locum tenens physician
Q7 One Class A Finding
Q8 Two Class B findings
Q9 One Class B and Two Class C findings
QA FDA investigational device exemption
QB Physician providing service in a rural Health Professional Shortage

Area (HPSA)

QC Single channel monitoring
QD Recording and storage in solid state memory by digital recorder
*QK Medical direction of two, three, or four concurrent anesthesia

procedures involving qualified individuals

QL Patient pronounced dead after ambulance called
QM Ambulance service provided under arrangement by a provider of

services

QN Ambulance service furnished directly by a provider of services
QP Documentation is on file showing that the laboratory test(s) was

ordered individually or ordered as a CPT-recognized panel other than automated profile codes 80002-80019, G0058, G0059, and G0060

QQ Claim submitted with a written statement of intent
QS Monitored anesthesia care service
*QT Recording and storage on a tape by an analog tape recorder
QU Physician providing service in an urban Health Professional Shortage

Area (HPSA)

QV Item or service provided as routine care in a Medicare qualifying clinical

trial

*QW Clinical Laboratory Improvement Amendment (CLIA) waived test

(modifier used to identify waived tests)

*QX CRNA service with medical direction by a physician
*QY Anesthesiologist medically directs one CRNA
QZ CRNA service without medical direction by a physician
RC Right coronary artery
RT Right Side (used to identify procedures performed on the right side of

the body)

*SF Second opinion ordered by a Professional Review Organization (PRO)

per Section 9401, P.L. 99-272 (100% reimbursement - no Medicare deductible or coinsurance)

SG Ambulatory Surgical Center (ASC) facility service
T1 Left Foot, Second Digit
T2 Left Foot, Third Digit
T3 Left Foot, Fourth Digit
T4 Left Foot, Fifth Digit
T5 Right Foot, Great Toe
T6 Right Foot, Second Digit
T7 Right Foot, Third Digit
T8 Right Foot, Fourth Digit
T9 Right Foot, Fifth Digit
TA Left Foot, Great Toe
*TC Technical Component. Under certain circumstances, a charge may be

made for the technical component alone
Under those circumstances adding modifier TC to the usual procedure number identifies the technical component charge
Note: The TC modifier should not be appended to procedure codes that represent the technical component (example: 93005)

*UN Two patients served
*UP Three patients served
*UQ Four patients served
*UR Five patients served
*US Six patients or more served
VP Aphakic Patient

(*) Denotes modifiers which are valid for the first modifier field only

Table of Drugs

TOP

  • Physician’s Desk Reference (PDR)
  • J codes
  • Routes of administration
    • INJ
    • IT
    • IV
    • IM
    • SC
    • INH
    • VAR
    • OTH



Routes of Administration of Drugs

TOP

  • VAR
  • OTH



Durable Medical Equipment (DME)

TOP

  • CMS-848
  • CMS-484 (Certification of Medical Necessity, Oxygen)



Status Indicator (SI)

TOP
Each CPT and HCPCS Level II Code is Assigned a Status Indicator (SI) as a Payment Indicator to Identify How Each Code is Paid (or Not Paid)

APC Status Indicators
Value Description
A Services Paid under Fee Schedule or other prospectively determined rate
AA Ambulance Fee Schedule Item
AD DMEPOS Fee Schedule Item
AL Clinical Laboratory Fee Schedule Item
AM National Fee Schedule Item
AR Physician Fee Schedule Item
AX Other Fee Schedule Item
B Service not allowed under OPPS on Hospital Outpatient Claim
C Inpatient service, not paid under OPPS
E Non-Covered Service, not paid under OPPS
F Corneal, CRNA and Hepatitis B
G Drug/Biological pass-through
H Pass-through device, brachytherapy source, radiopharmaceuticals
J New drug/biological, transitional pass--through (prior to April 1, 2002 only)
K Non-pass-through drugs and biologicals
L Influenza virus or pneumococcal pneumonia vaccine (PPV)
M Service not billable to the fiscal intermediary
N Packaged/Incidental service, no additional payment
P Partial hospitalization service
Q Packaged, separately paid under OPPS
Q1 STVX - Packaged Codes
Q2 T - Packaged Codes
Q3 Codes that may be paid through a composite APC
S Significant procedure, not subject to discounting
T Significant procedure, subject to discounting
V Clinic or Emergency department visit
W Invalid HCPCS, or blank HCPCS and invalid revenue code
X Ancillary service
Y Non-implantable DME
YD DMEPOS Fee Schedule Item
Z Valid revenue code with blank HCPCS and no other status indicator assigned



Misc. Notes

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  • Multiple Lesions
    • Most Complex Lesion Procedure first, followed by the others, using -51
    • If the Code Description includes Multiple Lesions (a stated number),
      Modifier -51 is not required
  • Size is Taken from Physician Notes
    • NOT Pathology Report (storage solution shrinks tissue)
      • Margins (healthy tissue)
        are also Taken for Comparison with Unhealthy Tissue
    • It is Very Important to get the Proper Dimensions of the Excision
      for Correct Coding and Correct Reimbursement
    • NEVER take the Dimensions from a Pathology Report
      (Tissue tends to shrink in the preservative solution)
  • Repair Factors (Wound Repair Criteria) (x3)
    1. Length
    2. Complexity (Simple, Intermediate, Complex)
    3. Site of Repair
  • Salpingo- (Tube)
  • Oviduct (Fallopian Tube)
  • Laparoscopy (58660-58679)
    • Fulguration of Oviducts (Fulguration of Obstructed Oviducts)
  • Two Lacerations, Arm, Simple Closure
    • One CPT Code, Adding Lengths Together
  • Chief Complaint (CC)
    Concise Statement Describing the Symptom, Problem, Condition, Diagnosis, or Other Factor That Is the
    Reason for the Encounter, Usually Stated in the Patient’s Words
  • Endoscopy That is Undertaken to the Level of the Midtransverse Colon
    Would be Coded as Colonoscopy
  • HCPCS Level I
    Healthcare Common Procedure Coding System Level I (HCPCS Level I)
    • Current Procedural Terminology (CPT)
    • Official Code Set Used to Report Procedures and Services
      Provided by Healthcare Professionals and Outpatient Institutions
    • American Medical Association (AMA)
  • HCPCS Level II
    Healthcare Common Procedure Coding System Level II (HCPCS Level II)
    • HCPCS National Codes
    • Official Code Set Used by Healthcare Professionals and Outpatient Institutions
      to Report Products, Supplies, and Services NOT Included in the CPT Code Set
    • Centers for Medicare and Medicaid Services (CMS)
  • Category II Codes
    • Supplemental Tracking Codes That Can Be Used for Performance Measurement


Healthcare Common Procedure Coding System (HCPCS)

  • HCPCS Used to Report Physician Services to Medicare for Reimbursement
  • Codes Procedures, Supplies, Products and Services
  • Required Because of Gaps in CPT
    • Example: CPT does not have Durable Medical Equipment (DME)
  • Used to Promote Uniform Reporting and Statistical Data Collection
  • HCPCS Levels
    • HCPCS Level I: AMA CPT codes
      • Cover Physician Services but are Used for Hospital Outpatient Services too
    • HCPCS Level II: National codes
      • Maintained by CMS
      • Updated Annually on January 1
      • Temporary Codes Update Throughout Year
      • Modifiers
      • Code Services, Equipment and Supplies NOT in CPT


Current Procedural Terminology, Version 4 (CPT-4)

  • Maintained by American Medical Association (AMA)
  • Comprehensive Descriptive Listing of Terms and Codes for
    Reporting Diagnostic and Therapeutic Procedures and Medical Services
  • Updated Annually by the AMA CPT Editorial Panel
  • Purpose and Use (CPT)
    • Standard Terminology and Coding for Medical Procedures and Services
    • Used to Develop Guidelines for Medical Care Review
    • Collect Data for Medical Education and Research Purposes
    • Used for Medicare Part B Services
    • Used for Hospital Outpatient Surgical Procedures
  • Overview of Structure (CPT)
    • Sections (x8)
      1. Evaluation and Management (E/M) (E&M)
      2. Anesthesia
      3. Surgery
      4. Radiology
      5. Pathology
      6. Laboratory
      7. Medicine
      8. Category II and Category III Codes
        • Category II Codes
          • Supplemental Tracking Codes that can be
            Used for Performance Measurements
        • Category III
          • Temporary Codes for New Technology and Services
    • Index
      • Lists Main Terms Alphabetically
      • Main Term Types
        • Procedure or Service
        • Organ or Other Anatomic Site
        • Condition
        • Synonym, Eponym, or Abbreviation
  • Evaluation and Management (E/M) (E&M)
    • Follow Hospital Internal Guidelines
  • Each CPT/CPCS Code is Assigned to One APC
  • Endoscopy That is Undertaken to the Level of the Midtransverse Colon
    Would be Coded as Colonoscopy
  • A Surgeon Performs a Colonoscopy with Biopsy of Three Lesions
    Found in the Transverse Colon. What CPT code is assigned?
    45380. Colonscopy; endoscopy with biopsy, single or multiple.
  • Repair of a Laceration That Includes Retention Sutures
    Would be Considered What Type of Closure?
    • Complex
  • Immunization Reporting Requires Two Codes (x2)
    1. Administration (performing the injection) (90460-90474)
    2. Substance Administered (90476-90749)
  • Esophagoscopy (43200-43232)
  • Limited to Esophagus only
  • Scope May Be Advanced Into Stomach But Is Short Of Pylorus
  • If scope Transverses Pyloric Channel becomes an EGD (43234-43259)
    • Esophagogastroduodenoscopy (EGD)
    • Endoscopy, Gastrointestinal, Upper
    • Examine
      • Esophagus
      • Stomach
      • Duodenum
      • Sometimes jejunum
  • If Scope Passes Beyond Second Portion of Duodenum,
    Report Endoscopy, Small Intestine (44360-44379)
  • Must Report Substance Injected
    • Example: Botulinum toxin (J0585)
  • Patient Was Seen for Excision of Two Interdigital Neuromas from the Left Foot
    • 28080 Excision, interdigital (Morton) neuroma, single, each
    • 64774 Excision of neuroma; cutaneous nerve, surgically identifiable
    • 67476 Excision of neuroma; digital nerve, one or both, same digit
  • Operative Report
    • Preoperative Diagnosis: Breast mass right
      Postoperative Diagnosis: Infiltrating ductal carcinoma
    • Operation: Excisional Biopsy
      Procedure: The patient was brought to the operating room. Under general anesthesia,
      the right breast was prepped and draped n the usual manner.
      Through an elliptical incision in the upper outer quadrant, a small nodule was excised.
      Bleeders were electrocoagulated. The deep layer was closed with interrupted 3-0 Vicryl.
      The skin was closed with clips, a dry sterile dressing was applied and
      the patient returned to the recovery room in good condition.
    • 19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure).
    • 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion, open, male or female, 1 or more lesions
    • 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion.
    • 19101 Biopsy of breast; open, incisional.
  • Endoscopy Report
    • EGD Esophagus: This area was well visualized in its entirety and appeared macroscopically normal. A 1.5-cm to 2-cm hiatal hernia was present. No macroscopic abnormalities were noted in the distal esophagus. A biopsy was taken approximately 5 cm proximal to the macroscopic gastroesophageal junction.
      Stomach: The antrum was normal. The body of the stomach was normal and biopsies were taken from the antrum to the body of the stomach.
      Duodenum: There was a moderate degree of duodenitis in the bulb. The postbulbar and descending duodenal areas appeared normal. A biopsy was taken from the bulb.
    • 43202 Esophagoscopy, rigid or flexible; diagnostic, with biopsy, single or multiple.
    • 43239 Upper gastrointestinal endoscopy with biopsy, single or multiple
    • 43234 Upper gastrointestinal endoscopy, simple primary examination (eg with small diameter flexible endoscope) (separate procedure)
  • A Laparoscopic Tubal Ligation is undertaken. Which of the following is the correct CPT code assignment?
    • 49320 Laparoscopy, surgical; with bx (single or multiple)
    • 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic visera, or peritoneal surface by any method.
    • 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transaction)
    • 58671 Laparoscopy, surgical; with occlusions of oviducts (with or without transaction)
  • Insertion of a Dual Chamber Permanent Pacemaker
    • 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular.
    • 33211 Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure).
    • 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial.
    • 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
  • Subcutaneous Administration of the conjugate measles, mumps,and rubella (MMR).
    • 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid). (Do not report 90467 in conjunction with 90473)
    • 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
    • 90472 Same as 90471 - in addition, each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) (Use 90472 in confunction with 90471 or 90473)
  • Operative Report
    • Preoperative Diagnosis: Vocal cord polyp
      Postoperative Diagnosis: Same
      Operation: Laryngoscopy, vocal cord stripping
      The patient was given general anesthesia and placed in the supine position. The laryngoscope was inserted with the use of operating microscope, the vocal cords were well visualized. There were polypoid chnages and whitish lesions on the right cord. The right cord was stripped and care was taken to preserve the commissure. The scope was withdrawn and the patient was taken to the recovery room in satisfactory condition.
    • 31541. Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope.
  • If a Patient has an Excision of a Malignant Lesion of the Skin, the CPT code is Determined by the Body Area from which the excision occurs and which of the following?
    • Diameter of the Lesion
      as Well as the Margins Excised as Described in the Operative Report
  • The Surgeon Performs an Initial, Strangulated Ventral Hernia Repair. What is the correct CPT code assignment?
    • 49561. Repair initial incisional or ventral hernia; reducile; incarcerated or strangulated
  • A Surgeon Performs a Colonoscopy with Biopsy of Three Lesions
    Found in the Transverse Colon. What CPT code is assigned?
    • 45380. Colonscopy; endoscopy with biopsy, single or multiple.



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