CPT – Flashcard

Testing Results Interpretation Reports

Time is measured as the face-to-face time with the patient Charting and reporting are not counted as part of the time Once time has hit 31 minutes or more it is counted as one hour If a patient is seen for 2 hours and 31 minutes it is coded as 3 hours If a patient is seen for 78 minutes it is coded as 1 hour

Procedure or service Organ or other anatomic site Condition Synonyms, Eponyms, and Abbreviations

Procedure name = code Special circumstances = modifier Modifier + code = complete description Reasons For:A service or procedure had both a professional and technical component A service or procedure was performed by more than one physician and/or in more than one location A service or procedure was increased or reduced Only part of a service was performed An adjunctive service was performed A bilateral procedure was performed A service or procedure was provided more than once Unusual events occurred

For use with procedure code Increased time Ex:increased intensity, time, difficulty of procedure, severity of patient's condition, physical/mental effort required by provider)

For use with procedure code Anesthesia is not routinely given for some procedures. When special circumstances require general anesthesia to be given in a case where no anesthesia or local anesthesia is typical, modifier 23 is appended to the basic procedure code.

For use with E/M Code- Modifier 24 is used in those cases where a patient has a procedure by a physician and is seen in the postoperative time frame by the same physician for a different reason.

For use with E/M Code Consider a patient who visits the physician's office because of a problem with severe headaches. The physician spends quite a bit of time evaluating the patient for the headache problem. The physician does a history, physical, and prescribes medication for the patient's headaches. The evaluation and management code for the patient's headache evaluation and management is 99202. Now let's assume the patient mentioned a bothersome skin tag during the physical exam and the physician and patient decide it's a good idea to remove the skin tag during this same visit. The physician performs the procedure (skin tag removal). The code for the procedure is 11200. When the claim is prepared, if the codes show evaluation and management and skin tag removal, it is not clear that evaluation and management was for a condition separate from the procedure performed (skin tag removal). Payment would be limited to evaluation, management, and care of a skin tag only instead of for evaluation and management of headache, skin tag and removal of a skin tag. Modifier 25 alerts the third-party payer of the two separate services: evaluation and management for a condition OTHER than the condition for which the procedure was performed procedure - removal of the skin tag Evaluation and management for headache, skin tag removal. 99202-25, 11200

Certain procedures are a combination of a physician component and a technical component. When the physician's component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.

Requests for second and third opinions by an insurance company or government agency are examples that require the addition of modifier 32 to the CPT® code.

Preventive services monitored by government Examples of preventive services with an A or B rating are screening for high blood pressure, screening for cervical cancer, screening for HIV, screening for cholesterol abnormalities, and more. When assigning a code for these preventive services and when these services are performed for preventive care, assign modifier 33.

The administration of a regional or general anesthesia by a surgeon instead of by an anesthesiologist is reported by adding the modifier 47 to the procedure code to indicate the surgeon administered the anesthesia Modifier 47 does not apply to local anesthesia—regional or general anesthesia only! Modifier 47 is appended to the PROCEDURE code and not to any anesthesia code.

are procedures performed on both sides of the body. When bilateral procedures are done during the same session, the modifier 50 is appended to the procedure code. The modifier 50 is not applicable to procedures that are bilateral by definition or procedures where the descriptions include the terminology bilateral or unilateral. See codes 58940, 61253, and 58605 in the Numeric Section of the CPT codebook.

Multiple Procedures During an operative session more than one procedure may be performed. When this occurs, it's described as multiple procedures. You have to be careful when coding multiple procedures because CPT® codes may include many different procedures bundled together as one code. However, if one code does not describe all the procedures performed, then each secondary procedure code may be reported with the modifier 51 appended. PROCEDURES PERFORMED: Total abdominal hysterectomy and anterior and posterior colporrhaphy. 58150, 57260-51

Modifier 52 is used when the procedure is terminated at the physician's discretion. Reduced services (52) modifier is used when results are less than optimal or the outcome is reduced from desired result For example: stopping colonoscopy because colon is not clear

Discontinued procedure is used when the service is terminated or stopped because of suboptimal conditions or at the physician's discretion. EX: physician doesn't go through with surgery because patient is vomitting Modifier 53 is NOT valid: For use with E/M service CPT® codes When used for elective cancellation of a procedure before the patient's anesthesia induction and/or surgical preparation in the operating suite When a laparoscopic or endoscopic procedure is converted to an open procedure When a procedure is changed or converted to a more extensive procedure

used when the surgeon provides the surgical care only and does not provide the preoperative and postoperative care. Modifier 54 is appended to the surgical code.

Modifier 55 is used when the provider provides only postoperative care. Rayshad underwent an incision and drainage of an ischiorectal abscess. The surgeon did not perform the postoperative care; the patient's primary care doctor performed it.

Modifier 56 is used when the provider provides only preoperative care. Austin's primary care physician provided Austin with preoperative care prior to Austin's surgery for laryngoscopic removal of a foreign body. Austin was admitted to the surgery center at the hospital, where he underwent a laryngoscopic removal of a foreign body by direct visualization through the scope by the ENT surgeon. Austin followed up with the ENT surgeon for postoperative care.

Modifier 57 is appended to the E/M code for the encounter where the decision is made to perform a major surgical procedure and the provider spends extra time explaining risks, benefits, alternatives, and potential outcomes for the surgery.

Procedures done in stages Consider a patient who has mammography performed, then a procedure to biopsy a lump, then a mastectomy to remove cancerous tissue, then a breast reconstruction surgery. The treatment is in stages. Another example would be a burn victim requiring debridement procedures, graft harvest procedures, skin grafting, and so forth. Procedures are related and/or done in stages.

modifier 59 is sort of a "code of last resort." If a more descriptive modifier is available, it should be used first. If you are thinking about using modifier 59, review other modifiers first to make sure it's the best choice. In order to report modifier 59, two (or more) procedures must be performed at separate sites or at separate patient encounters on the same date of service.Modifier 59 is appended to a procedure code NOT to an E/M code. Felicity has two basal cell carcinomas removed, one from the ear that is 1 cm with a simple closure and the other from the nose requiring closure by adjacent tissue transfer. These procedures were both performed by Dr. Fipmar during the same session.Basal cell carcinoma removal from ear (simple closure) and nose (closure with adjacent tissue transfer). 14060, 11641-59

two primary surgeonsTwo primary surgeons working together are different than one primary surgeon working with an assistant. When both surgeons are working as primary surgeons, they are each performing distinct operative work.

Procedure Performed on Infants Less Than 4 kg

surgical team instead of 1 surgeon

Repeat Procedure or Service by Same Physician or Other Qualified Health Care ProfessionalIn order to use modifier 76, the procedure must be the SAME procedure/service performed in a separate session by the SAME physician or other qualified healthcare professionalLizette was admitted with a pleural effusion and the physician performed a thoracentesis. Later in the day, her lungs filled up again with fluid and Lizette returned to the operative suite for a second thoracentesis by the same physician.

Repeat Procedure by Another Physician or Other Qualified Health Care Professional _same as 76 but with a different physician

Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period. Must be related to original procedure Must be done in the postoperative period of the initial procedure Requires use of operating/procedure room Must be unplanned (not staged or planned) Direct complication of the original procedureRyan had surgical repair of a fracture of the tibia. Dr. Roseburg examined the fracture site two weeks later and found the fracture was not healing properly. Ryan was taken to the operating room for repair of the malunion of the tibia fracture.

79 - Unrelated Procedure During Postoperative, Same Physician for reporting unrelated procedures by the same physician during the postoperative period. To use modifier 79, the subsequent surgery must be unrelated to the initial surgery and must be in the postoperative period of the initial surgeryGordon had a hernia repair two weeks ago. He now returns to the hospital with complaints of right lower quadrant abdominal pain. Suspecting appendicitis, Dr. Felix admits Gordon and performs an emergency appendectomy

Assistant SurgeonModifier 80 is appended by a surgeon who provides assistance during surgery. Don't mix this up with surgical team (66) or two surgeons (62). Assistance at surgery is not the same as "performing a distinct part(s) of a procedure." Assistant surgeon provides full assistance to the primary surgeon.

Modifier 81 is used when a surgeon provides minimal assistance to the primary surgeon during surgery.Lindsay underwent a partial colectomy. Due to the complex nature of this procedure an assistant surgeon, Dr. Abbott, stood by during the procedure to assist Dr. Royal. The surgery went smoothly and without complication; Dr. Abbott was not called on to perform any significant surgical duties.

Assistant Surgeon (When Resident Unavailable) In many hospitals and surgical settings, resident surgeons (surgeons-in-training employed by the facility) are available to assist during surgeries. The services of resident surgeons are not billed separately from the facility charges. If a qualified, independent surgeon stands in for a resident surgeon as an assistant, modifier 82 would be appended to the procedure code for the stand-in surgeon to indicate their services were provided because no resident surgeon was available.

Modifier 90 is reported when an outside entity other than the treating or reporting physician performs laboratory procedures on behalf of the physician. This modifier indicates that the outside entity has been paid by the physician for the performance of the procedure and the physician is now billing the patient or the applicable third party payer to be reimbursed for the procedure even though the physician did not actually perform the procedure themselves. Physicians can still bill for the procedure used in the acquisition of the specimen, such as a venipuncture, and would not append the -90 modifier to that related procedure since it was performed in the physician's office. Marvin's employer requested he have a drug screen for opiates. Marvin's physician's office performs a venipuncture to obtain a specimen which is sent to Gentle Laboratory for a qualitative drug screening. Gentle Laboratory performs the test and forwards the result to Marvin's physician.

Repeat Clinical Diagnostic Laboratory Test Modifier 91 is not for use in cases where tests are re-run to confirm initial results, re-run because of problems with specimens or equipment, or re-run for any other reasons in a case where a normal, one-time, reportable result is all that is required. n medicine, it is not at all unusual to track a patient's condition through the use of serial (repeated) laboratory tests to monitor the effect of illness, injury, or treatment on the body. When the same laboratory services (same CPT® code) are performed for the same patient on the same day, modifier 91 should be used to indicate repetitive laboratory tests were done in the course of treatment. Aaron has a potassium serum level drawn, which shows a low value. Aaron's physician prescribes potassium chloride to try to correct his low potassium level. A repeat potassium serum level is ordered later in the day after the potassium chloride dose to see Aaron's response to treatment. Modifier 91 is only used when the same test is performed on the same day. If a test is done one day and then repeated the following day, there is no need to add modifier 91.

Alternative Laboratory Platform Testing Modifier 92 is reported with the HIV testing codes 86701-86703, 87389. Turn to the codes 86701-86703, 87389 in the "Numeric Section" and read the note following the description for 86703. In order to report modifier 92, the testing method has to consist of a disposable single use instrument. An example of this type of instrument is the OraQuick ADVANCE Rapid HIV-1/2. This test is manually performed, visually read, and consists of a single-use device and a single-use vial containing a pre-measured amount of a buffered developer solution. Since this course is not designed to make you a phlebotomy expert on all manners of drugs and drug administration methods, being aware of modifier 92 and the note in the Numeric Section should remind you to do additional research or seek additional clarification if administration method is not clear. The use of modifier 92 is not tied to a "place" like a physician office or stand-alone laboratory; it is only connected to testing method.

Modifier 99 is appended to a service/procedure code when two or more modifiers are necessary to describe the service performed. In practice, however, modifier 99 is rarely used Repair of an umbilical hernia and bilateral repair of an inguinal hernia. 49585, 49505-99 (-50, -51)

Multiple Outpatient Hospital E/M Encounters on Same Date

Discontinued Procedure Prior to Anesthesia When an outpatient surgery is canceled after the patient has been admitted and prepared for surgery, the hospital still incurs costs: nursing services, supplies, and so forth. Coding and billing with modifier 73 allows hospitals to recover some of those costs. A 65-year-old man was brought to the operating room for repair of a recurrent inguinal hernia. The patient was prepped and positioning was carried out. Before the administration of anesthesia, the patient complained of chest pain with cardiac monitor revealing ST segment changes. The procedure was cancelled.

Discontinued Procedure After Anesthesia A 45-year-old man was taken to the operating room for a laparoscopic cholecystectomy. After making the portal entry incision, the anesthesiologist noticed the patient having ventricular fibrillation on the cardiac monitor. Defibrillation effort was tried two times, finally the arrhythmia abated. The procedure was cancelled pending further cardiac consultation.

a diagnosis or diagnostic study of a physical or mental condition.

the whole system of care and treatment of a disease or a sick individual.

Only medical coding specialists billing for physicians (or individual providers) would code E/M services. Medical coding specialists working for a healthcare facility such as a surgery center, hospital, or nursing home would bill facility charges, not E/M services

Refers to a specific location of the problem. Examples: pain in the groin, elbow pain, headache, etc. Example: The patient is a 57-year-old white male who has metastatic malignant melanoma with disease in his abdomen, lungs, and chest wall.

Severity: Description of the severity of the presenting problem. Examples: mild, severe, 7 on a scale of 10. Example: He underwent CT scan earlier today, which revealed that the pancreatic head appears to be about the same as what it had been back in ___ [DATE]. Aorta is somewhat dilated and along the liver, there is a papillary process versus portal lymphadenopathy. Otherwise, no discreet masses were noted. Patient relates that he does have some upper abdominal pain approximately once per day, rated 5/10.

Timing: Refers to a measurement of when or what frequency the patient notices the problem. Examples: every night, in the middle of the night, constant pain, comes and goes, intermittently. Example: This established patient is here with complaints of a right inguinal hernia that has been bothering him and sometimes it is painful with walking. He has also had a history of orally controlled type 2 diabetes. He is otherwise doing well.

Modifying factors: Information about how other factors make the problem better or worse. Examples: pain is relieved by standing erect, headache somewhat better after taking aspirin. Example: This is a 90-year-old established patient being seen again for follow up of rectal bleeding. The patient underwent repair of rectal prolapse about 5 weeks ago. Two weeks ago she had rectal bleeding secondary to bleeding at the anastomosis site. This is under good control with argon plasma coagulator. The patient underwent sigmoidoscopy on ______ [DATE] and she was noted to have active bleeding at the anastomosis site. Some of the staples fell off. After prolonged attempt with argon plasma coagulator to stop the bleeding, finally the bleeding was under good control.

Quality: Description of the problem's characteristic, such as how it looks or feels. Examples: dull, sharp, aching, stinging, etc. Example: The patient is a 67-year-old white male who comes in complaining of gross hematuria this evening. He states he has had some blood in his urine before but not as much as he is having today. He states he went to urinate and mostly what came out was blood followed by a few clots. He urinated again and there was still some blood and a few clots. He has had an IVP to evaluate this, which was normal. He also states that he had a little bit of burning when he urinated that was similar to pain he had when he had a TURP in the past. He denies any dizziness, nausea, vomiting, fevers, or chills. He does have chronic low back pain but states that is not any worse today.

Duration: The patient's description of the approximate duration of the symptoms. Examples: last week, since yesterday, began when I fell this morning. Example: This new patient complains of a pruritic rash for several weeks.

Context: Description of how the symptoms began. Examples: after an auto accident, after eating out at a restaurant, after bumping my head, when I sit down. Example: This is a pleasant 79-year-old white male who was a consult for a scrotal nodule. He had an ultrasound of the scrotum ___ [DATE] of this year. The nodule measured 1.2 x 1.2 x 1.2 cm. It was in the left inferior sac. It was likely to be a granulomatous reaction rather than a malignancy. The patient states that he was going mushroom hunting and stepped on a stick, which hit his scrotum; this was done in ____[MONTH]. He noticed this nodule at that time and thinks that the size is now smaller.

Significant signs or symptoms that the patient feels are related to the injury or illness or a documented lack thereof. Examples: some dizziness with nausea, swelling with an ankle injury, double vision with a headache or eye redness with no associated swelling or discharge. Example: A 44-year-old male who has a pain localized to his right upper gum line and right rear molar. The patient has a very small abscess on the right gum line and significant swelling involving the right side of his face in the area of the maxillary and zygomatic arch areas.

patient has been seen for the problem before and the problem requires ongoing management and is currently under treatment

E881.0, E016.9, E849.0, E000.8The selection of the appropriate E code is guided by the "Index to External Causes." An E code can never be a primary (first-listed) diagnosis. To locate the cause of the injury turn in the "Index to External Causes" to the main term fall, falling and the sub-terms from, off and ladder. The code listed is E881.0; fall from ladder. To locate the activity code turn in the "Index to External Causes" to the main term activity and the sub-term property maintenance NEC. The code listed is E016.9: other activity involving property and land maintenance, building and construction. To code the place where the injury occurred turn in the "Index to External Causes" to the main term accident(to) and the sub-terms occurring and home. The code listed is E849.0; place of occurrence, home.To locate the external cause status code turn in the "Index to External Causes" to the main term external cause status and the sub-term specified NEC. The code listed is E000.8; other external cause status.

Description of the development of the patient's present illness from the first sign and/or symptom to the present.

performance and interpretation of diagnostic test

When the physician administers regional or general anesthesia and performs the surgery, the modifier 47 (anesthesia by surgeon) is appended to the appropriate procedure code. Modifier 47 is added to the surgical code, not the anesthesia code. You may remember this from your study of Modifiers back a few units.

The codes 99143-99145 are reported when a physician provides both the moderate conscious sedation and the procedure. However, if the moderate conscious sedation is included in the procedure, these codes may not be reported separately. (See Appendix G of the CPT® codebook.) In fact, don't just see Appendix G, read the details under Appendix G. When a second physician provides the moderate conscious sedation in a facility setting, then the second physician may report the codes 99148-99150. However, when services are provided by the second physician in a non-facility setting, these codes are not reported.

Unusual forms of monitoring (e.g., intra-arterial, central venous, and Swan-Ganz) are reported with the use of additional codes.The code for basic anesthesia service, 01173, would be augmented by the codes for unusual forms of monitoring—central venous line (36556) and arterial catheterization (36620). These codes fall under the category of excluded services and not under the bundled general anesthesia code. Anesthesia services, surgical repair of open acetabular wall fracture with central venous line and arterial catheter placement. 01173, 36556, 36620

Physician's Services is a reminder to the coder to use E/M codes when appropriate and use anesthesia codes when appropriate. Just because an anesthesiologist is providing the service does not mean the report is assigned an anesthesia code. If the service provided by the anesthesiologist is not administering anesthesia or under the umbrella of administering anesthesia (pre-/post-operative visits, administration of anesthesia, anesthesia care during procedure, administration of fluids, etc.), then an E/M code would be the appropriate code and not an anesthesia code.

Materials supplied by the physician works the same for coding and billing anesthesia services as for coding and billing other physician services. If an anesthesiologist uses materials and supplies provided by the facility, the facility bills those materials and supplies. However, if the anesthesiologist uses materials and supplies provided by the anesthesiologist, he or she may code and bill for those supplies using the appropriate CPT and HCPCS codes. Find code 99070 in the "Numeric Section" and read the detailed code description. Additional HCPCS codes may also be reported if appropriate

When multiple procedures are performed during the same operative session under the same type of anesthesia, the anesthesia code associated with the most complex procedure is assigned. Separate anesthesia codes do not need to be assigned for each procedure. The amount of time reported when multiple procedures are performed is the combined time for all the procedures. The record will document an anesthesia start time and anesthesia stop time. The anesthesia time encompasses the entire process—from the induction of anesthesia to the transfer of patient from anesthesia care to postoperative care.

Anesthesia is unique because ALL anesthesia services are reported by use of a code + a modifier Physical Status Modifiers P1: A normal healthy patient P2: A patient with mild systemic disease P3: A patient with severe systemic disease P4: A patient with severe systemic disease that is a constant threat to life P5: A moribund patient who is not expected to survive without the operation P6: A declared brain-dead patient whose organs are being removed for donor purposes

the reporting of anesthesia codes is different than any other type of coding because anesthesia services are reimbursed using an anesthesia reimbursement formula. The formula is basic units + time units + modifying units (B + T + M) x anesthesia conversion factor. Each of these elements will be discussed in detail. Anesthesia Formula: basic units + time units + modifying units (B + T + M) = total units total units x anesthesia conversion factor = reimbursement

Anesthesia services are provided based on the amount of minutes and hours the anesthesia was administered. The time begins when the anesthesiologist begins preparing the patient to receive anesthesia and ends when the patient is no longer under the care of the anesthesiologist. The total time (minutes and hours) the anesthesia was administered must be recorded in the patient's medical record. Insurance companies determine the amount of time in units. Most insurance companies use 15 minutes as 1 unit. Total minutes = 90 90 minutes/15 minutes = 6 units Time Units = 6

TRUE

(in HSPC book) AA Anesthesia services performed personally by anesthesiologist AD Medical supervision by a physician for more than four concurrent anesthesia services QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QS Monitored anesthesia services QX Certified registered nurse anesthetist (CRNA) service with medical direction by a physician QY Certified registered nurse anesthetist (CRNA) and anesthesiologist are involved in a single procedure and the physician is performing the medical direction QZ Certified registered nurse anesthetist (CRNA) service without medical direction by a physician

Add on code for under age 1 and over age 50