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Current Procedual Terminology {CPT} is a listing of descriptive terms and indentifying codes for reporting medical services and procedures.

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OVERVIEW OF CPT

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It provides a uniform language that describes medical, surgical and diagnostic services to facilitate communication among providers, patients and insurers.

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CPT

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American Medical Association first published CPT in 1966 and subsequent editions expanded its descriptive terms and codes for diagnostic and therapeutic procedures.

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AMA

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were introduced in 1970, replacing the four-digit classification.

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Five-digit codes

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adopted as part of the Healthcare Common Procedure Coding System {HCPCS}, mandated for reporting MEDICARE Part "B" services.

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CPT

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are used to report services and procedures performed on patients:

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CPT Codes

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By providers in OFFICES, CLINICS and PRIVATE HOMES.

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CPT Codes {bullet 1}

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By providers in INSTITUTIONAL settings such as HOSPITALS, NURSING facilities and HOSPICES.

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CPT Codes {bullet 2}

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When the provider is employed by the HEALTHCARE facility (e.g. many of the physicians associated with VETERANS ADMINISTRATION MEDICAL CENTERS ARE EMPLOYEES OF THAT ORGANIZATION

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CPT Codes {bullet 3}

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By a hospital outpatient department (e.g. ambulatory surgery, emergency dept and outpatient laboratory or radiographic procedures).

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CPT Codes {bullet 4}

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Reporting and assist in the accurate identification of procedures and services for {THIRD-PARTY} payer consideration.

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CPT Codes simplifies reporting

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are based on consistency with CONTEMPORARY MEDICAL PRACTICE as performed by clinical providers throughout the country.

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CPT Codes and descriptions

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HIPAAA's requirements that code sets and classification systems be implemented in a COST-EFFECIVE manner includes: LOW-COST, EFFICIENT distribution, and application to all users

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CPT-5

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as a procedure coding standard for the reporting of physicialn services in 2000, the May 7th, 1998 Federal Register reported that CPT is not always precise or unambiguous teh CPT-5 project was the AMA's response.

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CPT IDENTIFIED

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CPT supports Electronic Data Inerchange {EDD} hte computer-based patient record (CPR) or Electronic Medial record (EMR), reference/research databases.

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Changes to CPT

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created to standarize definitions and differentiate teh use of synonymous terms: and searchable, Electronic CPT Index is under development, along with a computerized datebase to delinate relationships among CPT code descriptions.

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CPT glossary

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are underway to address the needs of hospitals, managed care organizations and long-term care facilities.

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CPT Improvements

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with changes phased in starting with CPT 2000 and concluding with CPT 2003; resulting in the establishment of (3) three categories of CPT Codes.

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CPT-5 Project

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procedures/services, identified by FIVE-DIGIT CPT code and descriptor nomenclature; these are codes traditionally associated with CPT and organized within (6) six sections.

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CPT Codes {bullet I}

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performance measurements tracking codes that are assigned an alphanumeric identifier with a letterin teh last field (e.g., 1234A) these codes will be located after the Medicine section, and their use is optional.

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CPT Codes {bullet II}

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contain "Emerging technology" temporary codes assigned for data collection purposes that are assigned an alphanumeric identifier with a letter in teh last field (e.g. 0001T); these codes are located after the Medicine section, and they will be archived after (5) five years unless accepted for placement within Category I sections of CPT

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CPT Codes {bullet III}

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Organizes Category I procedures/service within six sectons.

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CPT Sections

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99201 - 99499

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Evaluation and Management (E/M)

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00100 - 01999, 99100-99140

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Anesthesia

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10021-69990

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Surgery

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70010-79999

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Radiology

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80047-89356

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Pathology and Laboratory

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90281-99199, 99500-99607

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Medicine

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FIVE-DIGIT code number and a narrative description identify each procedure and service listed in CPT Most precedure/service contain stand-alone descriptions.

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CPT Code Number Format

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CPT contains appendices located between the Medicine section and the index. Insurance specialists should carefully review these appendices to become familiar with coding changes that affect the practices annually:

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CPT Appendices

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Clinical examples for Evaluation and Management (E/M) sectin codes.

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CPT Appendice "C"

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add-on codes

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CPT Appendice "D"

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Codes exempt from modifier - 51 reporting rules

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CPT Appendice "E"

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CPT codes exempt from modifier -63 reporting rules.

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CPT Appendice "F"

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Summary of CPT codes that include moderate (conscious) sedation. CODING TIP: Codes that include moderate CPT symbol.

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CPT Appendice "G"

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Electodiagnostic medicine listing of sensory, motor and mixed nerves that are reported for motor and nerve studies codes. Also a table that indicates the "type of study and maximum number of studies" generally performed for needle electromyogram (EMG), nerve conduction studies and other MG studies. The AMA's CPT Changes 2006

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CPT Appendice "J"

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located throughout the CPT coding book ; EXAMPLE: CPT code 84145 was added. 84145 Procalcitonin (PCT)

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CPT Symbols {bullet}

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located to the left of the code number identifies a code description that has been revised. EXAMPLE CPT code 24150 was revised to change "for" to "of" - 24150 Radial resection of tumor; clavicle

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Triangle

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EXAMPLE: The special report guideline in each section of CPT: (Triangle) Concurrent Care and Transfer of Care.

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CPT Horizontal triangles

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used to save in CPT and some cold description are not printed in their entirety next to a code number.

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CPT Semicolon

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identifies add-on codes

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CPT Plus + symbol

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symbol indicatea procedure that includes moderate (conscious) sedation.

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CPT Bull's-eye

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indicates codes that classify products that are pending FDA aproval but have been assigned a cpt code.

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CPT Flash symbol

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precedes CPT CODES that appear out of numerical order

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CPT code # symbol

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define terms and explain the assignment of codes for procedures and services in a particular section.

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Guidelines

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code is assigned when the provider performs a procedure or service for which there is NO CPT code.

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Unlisted Procedures/Services

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must accompany the claim to describe the nature, extent and need for the procedure or service along with time, effort and equipment necesary to provide the service

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Special Report

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appear throughout CPT sections to clairfy the assignment of codes. Typeset in two patterns

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Instructional Notes

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located below a subsection title and contains instructions that apply to all codes in the subsection.

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Blocked unindented note

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located below a subsection title, code description, or code description that contains

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Indented parenthetical note

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clarify the assignment of a CPT code. They can occur in the middle of a main clause or after the semicolon and may or may not be enclosed in parenthesises.

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Descriptive Qualifiers

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CPT modifiers clarify services and procedures performed by providers. Although the CPT code and description remain unchanged, modifiers indicate that the description of the service/procedure performed has been altered. CPT modifiers are reported as (2) two-digit numeric codes added to the (5) five-digit CPT code.

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CPT MODIFIERS

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-25 significant, sparately identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Services.

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Special E/M cases -25

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Decision for surgery

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Special E/M cases -57

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increased Procedural Services

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Special E/M cases -22 (ABOVE/BEYOND)

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Read the introduction in the CPT coding Manual.

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STEP 1

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Review guidelines at the beginning of each section

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STEP 2

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Review the procedure/services listed in the source document (e.g. charge slip, progress note, operative report laboratory report, or pathology report). Code only what is documented in the source document; do not make assumptions about conditions, procedures/services not stated. if necessary, obtain clarification from the provider.

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STEP 3

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Refer to the CPT Index; and locate the main term for the procedure or service documented. Main terms can be located by referring to.

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STEP 4

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Locate subterms and follow cross references.

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STEP 5

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review descriptions of service/procedures codes, and compare all qualifiers to descriptive statements.

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STEP 6

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Assign the applicable code number and any add-on (+) or additional codes needed to accurately classify the statements.

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STEP 7

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(E/M) section (code 99201-99499) is located at the beginning of CPT because these codes describe services most frequently provided by physicians. Accurate assignment of E/M codes in essential to the success of a physician's practice because most of the revenue generated by the office is based on provision of these services. Before assigning E/M codes, make sure you review the guidelines (located at the beginning of the E/M section) and apply any notes (located below category and subcategory titles).

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EVALUATION AND MANAGEMENT SYSTEM

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CPT 1992 introduced the E/M level of service codes, replacing the brief, limited office visit codes included in the Medicine section of past CPT revisions.

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OVERVIEW OF EVALUATION & MANAGEMENT

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organized according to place of service (POS) - hospital, home, nursing facility [NF], emergency dept [ED] or critical care), type of service [TOS]

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E/M Evaluation and Management System

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reflects the amount of work involved in providing health care to a patient, and correct coding requires determining the extent of history and examination performed as well as the complexity of medical decision making. Between (3) three and (5) five levels of service are included in E/M categories and documentation in the patient's chart must support the level of service reported.

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E/M Level of Service

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[POS] - refers to the PHYSICAL location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, NFs, home health care, or EDs).

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Place of Service

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[TOS] - refers to the kind of healthcare services provided to patients. It includes critical care, consultation, initial hospital care, subsequent hospital care, and confirmatory consultation.

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Type of Service

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is one who has not received any professional services from the physician, or form another physician of the same speciality who belongs to the same group practice, within the PAST THREE YEARS.

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New patient

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one who has received professional services from the physician, or from another physcian of the same specialty who belongs to hte same group practive. within the PAST THREE YEARS.

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Established Patient

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Providers are responsible for reporting the CPT (and HCPCS level II) code that most comprehensively describes the services provided. NCCI edits determine appropriateness of CPT code combinations for claims submitted to Medicare administrative contractors {NCCI} edits are designed to detect unbundling, which involves reporting multiple codes for a service when a single comprehensive code should be assigned.

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Unbundling CPT Codes

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occurs because: Provider's coding staff unintentionally reports multiple codes based on misinterpreted coding guidelines.

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PRACTICE UNBUNDLING (bullet I)

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Reporting multiple codes is intentional and is done to maximize reimbursement.

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PRACTICE UNBUNDLING (bullet II}

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read this textbook chapter, and highlight key concepts.

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STUDY CHECKLIST - No. 1

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create an index card for each key term

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STUDY CHECKLIST - No. 2

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Access the chapter internet links to learn more about concepts.

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STUDY CHECKLIST - No. 3

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Complete the chapter review, verifying answers with your instructor.

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STUDY CHECKLIST - No. 4

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Complete WEBTUTOR assignments and take online quizzes.

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STUDY CHECKLIST - No. 5

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complete workbook chapter assignments, verifying answers with your instructior.

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STUDY CHECKLIST - No. 6

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complete the StudyWare activities to receive immediately feedback.

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STUDY CHECKLIST - No. 7

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Form a study group with classmates in discuss chapter concepts in preparation for an exam.

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STUDY CHECKLIST - No. 8

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problem-focused examination (limited examination of the affected body area or organ system).

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Extent of Examination No. 1

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Expanded problem-focused examination (limited examination of the affected body area or organ system and other symptomatic or related organ systems.

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Extent of Examination No. 2

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Detailed examination (extended examination of the affected body area(s) and other symptomatic or related organ systems.

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Extent of Examination No. 3

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Comprehensive examination (general multisystem examination or a complete examination of a single organ system.

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Extent of Examination No. 4

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Number of diagnoses or management options.

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Complexity of Medical Decision Making #1

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Amount and/or complexity of data to be reviewed

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Complexity of Medical Decision Making #2

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Risk of complications and/or morbidity or mortality.

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Complexity of Medical Decision Making #3

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Laboratory imaging, and other test results that are significant to the management of the patient's care.

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Complexity of Medical Decision-making #1

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List of known diagnoses as well as those that are suspected

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Complexity of Medical Decision Making #2

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Opinions of other physicians who have been consulted.

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Complexity of Medical Decision Making #3

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Planned course of action for the patient's treatment (plan of treatment)

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Complexity of Medical Decision Making #4

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Review of patient records obtained from other facilities.

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Complexity of Medical Decision Making #5

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Anesthesia services are associate with the ADMINISTRATION of ANALGESIA and/or anesthesia as provided by an anethesiologist (physcian) or certified registered nurse anesthetist {CRNA} services include the administration of local, regional, epidural, general anesthesia, Monitored Anethesia Care {MAC},

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Anesthesia Section

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Adminisration of ANXIOLYTICS (drug that relieves anxiety) or amnesia-inducing medications.

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{MAC} MONITORED ANESTHESIA CARE

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Qualifying Circumstances code form CPT Medicine section (in addition to the anesthesia code).

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Qualifying Circumstances for Anesthesia

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99100 (Anesthesia for patient of extreme age, under one year and over 70)

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QUALIFYING CIRCUMSTANCES CODES #1

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99116 (Anesthesia complicated by utilization of total body hypothermia)

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QUALIFYING CIRCUMSTANCES CODES #2

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99135 (Anesthesia complicated by utilization of controlled hypotension

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QUALIFYING CIRCUMSTANCES CODES #3

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99140 (Anesthesia complicated by emergency conditions (specity). (An emergency condition results when a delay in treatment of the patient would lead to a significant increase in threat to life or body part).

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QUALIFYING CIRCUMSTANCES CODES #4

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Physical status modifiers

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Anesthesia Modifiers #1

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HCPCS Level II modifiers

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Anesthesia Modifiers #2

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CPT modifiers

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Anesthesia Modifiers #3

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is added to each reported anesthesia code to indicate the patient's condition at the time anesthesia was administered. THe modifier also serves to identify the complexity of services provided. The physical status modifier is determined by the anestheasiologist or CRNA and is documented as such.

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Physical Status Modifiers

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-23 (unusual anesthesia) (When a patient's circumstances warrant the administration of general or regional anesthesia instead of the usual local anesthesia, add modifier -23 to the anesthesia code (extremely apprehensive patients, mentally handicapped individuals, patients who have a physical condition, such as spasticity or tremors).

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CPT Modifiers #1 {-23}

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-53 (discontinued procedure}

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CPT Modifiers #2 {-53}

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-59 (distinct procedural service)

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CPT Modifiers #3 {-59}

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-74 (discontinued outpatient hosptial/ambulatory surgery center procedure after anesthesia administration).

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CPT Modifiers #4 {-74}

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-99 (multiple modifiers).

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CPT Modifiers #5 {-99}

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when reporting Anesthesia codes, be sure to report the time units in "Block 24G of the CMS-1500. (An anesthesia time unit is ONE 15 MINUTE INCREMENTS)

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Anesthesia Time Units

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Examination and evaluation of the patient by the anesthesiologist or CRNA prior to administration of anesthesia (if surgery is canceled, report an appropriate code from the CPT evaluation and management section. Usually, a consultation code is reported.

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Anesthesia Time Units #1

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Non-monitored interval time (e.g. period of time when patient does not require monitored anesthesia care, period of time during which anesthesiologist or CRNA leaves operating room to assist with another procedure).

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Anesthesia Time Units #2

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Recovery room time. (The anesthesiologist or CRNA is responsible for monitoring patient in the recovery room as part of the anesthesia service provided.

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Anesthesia Time Units #3

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Routine postoperative evaluation by the anesthesiologist or CRNA. When post-operative evaluation and management services are significant, separately identifiable services, such as postoperative pain management services or extensive unrelated ventilator management, report an appropriate code from the CPT evaluation and management section. I

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Anesthesia Time Units #4

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The surgery section contains subsections that are organized by body system. Each subsection is subdivided into categories by specific organ or anatomic, site. Some categories are further subdivided by procedure subcategories in the following order:

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SURGERY SECTION

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incision

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SURGERY SECTION #1

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Excision

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SURGERY SECTION #2

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introduction or Removal

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SURGERY SECTION #3

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Repair, Endoscopy

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SURGERY SECTION #4

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Revision or Reconstruction

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SURGERY SECTION #5

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Destruction

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SURGERY SECTION #6

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Grafts

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SURGERY SECTION #7

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Suture

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SURGERY SECTION #8

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Other Procedures

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SURGERY SECTION #9

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