Procedural Coding – CPT – Flashcards

Code identifying medical treatment or diagnostic services. When a patient sees a physician, each procedure and service performed is reported on a health care claim using a standardized procedure code. Procedure codes represent medical procedures, such as surgery and diagnostic tests, and medical services, such as an examination to evaluate a patient's condition.

Connection between a service and a patient's condition or illness. On correct insurance claims, each reported service is connected to a diagnosis that supports the procedure as necessary to investigate or treat the patient's condition in that health care setting. Health plans analyze this connection between the diagnostic and procedural information, called code linkage, to evaluate the medical necessity of the reported charges. Procedure codes must be verified and then used to report physician's services. Physician, a medical coder, clearinghouse coder, or a medical administrative assistant may be responsible for the selection of procedure codes. Note that it is the physician's responsibility to report the correct CPT code. To be sure that the procedure codes, and the diagnosis codes, are correctly linked and valid, a medical administrative assistant, coder, or clearinghouse would review the documentation in the patient's medical record to be sure it supports the codes. A query may be communicated to the physician to resolve outstanding questions. By verifying all information and following the rules of correct coding, medical administrative assistants ensure that the provider receives the maximum appropriate reimbursement for procedures and services.

Contains the standardized classification system for reporting medical procedures and services. The HIPAA-required set of procedure codes is the CPT, published by the American Medical Association (AMA) and is called the CPT. An updated edition of the CPT is available every year to reflect changes in medical practice. Newly developed procedures are added, some are changed, and old ones that have become obsolete are deleted. These changes are available in print and in an electronic file for medical offices that use a computer-based version of the CPT. New CPT codes are released on October 1 of each year and must be used for services dated the following January 1 or later. The CPT codes as of the date of service -- not the date of claim preparation -- are required by HIPAA. Encounter forms, the PMP, and any other computer systems that store CPT codes must also be updated.

Procedure codes found in the main body of the CPT. Category I codes -- which are most of the codes in the CPT -- are five-digit numbers with no decimals. They are organized into six sections: (1) Evaluation and Management (E/M); (2) Anesthesia; (3) Surgery; (4) Radiology; (5) Pathology and Laboratory; and (6) Medicine.

With the exception of the first section, Evaluation and Management (E/M), the CPT is arranged in numerical order from start to end. Codes for E/M are listed first, out of numerical order, because they are used most often. The six primary sections of the CPT Category I codes are divided into subsections. The subsections are further divided into headings according to the type of test, service, or body system. Code number ranges included on a particular page are found in the upper-right corner. This makes locating a code faster after using the index.

Usage notes at the beginnings of CPT sections. The CPT book as well as all sections opens with section guidelines that apply to its procedures. The section guidelines information should be read carefully before a procedure code is chosen.

A bullet (a solid circle) indicates a new procedure code. The bullet symbol appears next to the code only the year that it is added.

A triangle indicates that the code's descriptor has changed. It appears only in the year the descriptor is revised.

Facing triangles enclose new or revised text other than the code's descriptor.

Procedure performed and reported in addition to a primary procedure. A plus sign (+) next to a code in the main text indicates an add-on code. Add-on codes describe "secondary procedures" that are commonly carried out in addition to a primary procedure. Add-on codes usually use phrases such as "each additional" or "list separately in addition to the primary procedure" to show that they are NEVER used as stand-alone codes.

Moderate sedation is moderate, drug-induced depression of consciousness during which patients can respond to verbal commands. The bullet inside a circle, in CPT, next to a code means that moderate sedation is part of the procedure that the surgeon performs. This means that for compliant coding, moderate sedation is not billed in addition to the code.

The lightning bolt symbol is used with vaccine codes that have been submitted to the Federal Drug Administration (FDA) and are expected to be approved for use soon. The codes CANNOT be used until approved, at which point this symbol is removed.

CPT procedure codes that have been reassigned to another sequence. As new procedures are developed and widely adopted, CPT has encountered situations where there are not enough numbers left in a particular numerical sequence of codes to handle all new items that need to be included. Also, at times codes need to be regrouped into related procedures for clarity. The AMA decided to use the idea of Resequencing rather than renumbering and moving codes. Resequencing is the practice of displaying codes outside of numerical order in favor of grouping them according to the relationships among the code descriptions. This allows out-of-sequence code numbers to be inserted under the previous key procedural terms without having to renumber and move the entire list of related codes. Codes that are Resequenced are listed two times in CPT. First, they are listed in their original numeric position with the note that the code is now out of numerical sequence and referring the user to the code range containing the Resequenced code and description. Second, the Resequenced symbol # is shown in front of the code and its descriptor where it appears in the group of codes to which it is related.

These codes are for physicians' services that are performed to determine the best course for patient care. The E/M codes are organized by place and/or type of service. Guidelines for E/M codes include new/established patients, other definitions, unlisted services, special reports, and selecting an E/M service level.

These codes are for anesthesia services by or supervised by a physician; and include general, regional, and local anesthesia. This section is organized by body site. Guidelines include time-based, services covered (bundled) in codes, unlisted services/special reports, and qualifying circumstances codes.

These codes are for surgical procedures performed by physicians. The surgery section is organized by body system, then by body site, followed by procedural groups. Guidelines include surgical package definition, follow-up care definition, add-on codes, separate procedures, subsection notes, and unlisted services/special reports.

These codes are for radiology services by or supervised by a physician. This section is organized by type of procedure followed by body site. Guidelines include unlisted services/special reports and supervision and interpretation (professional and technical components).

These codes are for pathology and laboratory services by physicians or by physician-supervised technicians. This section is organized by type of procedure. Guidelines include complete procedure, panels, and unlisted services/special reports.

These codes are for evaluation, therapeutic, and diagnostic procedures by or supervised by a physician. This section is organized by type of service or procedure. Guidelines include subsection notes, multiple procedures reported separately, add-on codes, separate procedures, and unlisted services/special report.

Some descriptions in CPT are indented to show that they include a common entry from above them. The parent code begins with a capital letter. Indented codes beneath the parent code begin with a lowercase letter. The indented codes refer to the parent code above them. The words in the description of the parent code that come before the semicolon are common to all the indented codes below it.

CPT listings may contain notes, which are explanations for categories and individual codes. Notes often appear in parentheses after a code. Many times, notes suggest other codes that should be considered before a final code is selected.

Service not listed in CPT. Some services or procedures occur infrequently. Others are too new to be included in the CPT. Therefore, each section provides codes to be used when a service or procedure is not listed. Codes for unlisted procedures are found in the guidelines at the beginning of each section, and usually under an "Other Procedures" subsection. Whenever a code for an unlisted procedure is used, a SPECIAL REPORT must be attached to the health care claim. The Special Report describes the procedure, its extent, and the reason it was performed. It also gives the equipment and amount of time and effort required. Be careful using unlisted codes. An unlisted procedure code should NOT be reported until a thorough search of the CPT, especially of the Category III codes, is done using different possibilities for the proper name of the procedure. Using a code for an unlisted service requires extra time to prepare the special report and extra attention by the insurance carrier's claims department. These efforts delay or often reduce payment, particularly if the unlisted code is assigned in error.

Optional CPT codes that track performance measures. The Category II codes are listed at the end of the regular Category I CPT codes section, and are used to track performance measures for a medical goal, such as reducing tobacco use. Reporting these codes on health claims is OPTIONAL, and they are NOT paid. They do help in the development of best practices and improve documentation. These codes have an alphabetic character for the fifth digit such as 4000F for tobacco use cessation counseling.

Temporary codes for emerging technology, services, and procedures. If a Category III code exists for a service, it rather than an unlisted code, MUST be used. these codes also have an alphabetic fifth digit such as 0184T. A temporary code may become permanent and part of the regular codes if the service it identifies proves effective and is widely performed. Both vaccine product codes and Category III codes are released twice a year and have a six-month period for implementation. Offices billing these services should check for updates at the CPT website. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

Number that is appended to a code to report particular facts. One or more two-digit CPT modifiers may be assigned to a five-digit main number. Modifiers are written with a space before the two-digit number. The use of a modifier shows that some special circumstance applies to the service or procedure the physician performed. There are more than 30 CPT modifiers. Appendix A of the CPT explains the proper use of each modifier. Some section guidelines also discuss the use of modifiers with the section's codes.

A five-digit number to which one or more two-digit CPT modifiers may be assigned.

Modifier 62 indicates that two surgeons worked together, each performing part of a surgical procedure, during an operation. Each physician will be paid part of the amount normally reimbursed for that procedure code.

Indicates that the services of a surgical assistant were used, and this person's fee are a part of the claim.

If a procedure has two parts, a technical component modifier (TC) is appended to show the work performed by a technician, such as a radiologist.

A professional component modifier (PC) is added to show the work that the physician performs, usually the interpretation and reporting of the results.

The correct process for assigning accurate procedure codes has six steps: (1) review complete medical documentation; (2) abstract the medical procedures from the visit documentation; (3) identify the main term for each procedure; (4) locate the main terms in the CPT Index; (5) Verify the code in the CPT main text; and (6) determine the need for modifiers.

Review the documentation in the patient's medical record of the patient's visit and decide which procedures and/or services were performed and where the service took place (the place of service, which may be an office, a facility, or another health care setting. There are over 50 place of service codes.

After reviewing complete medical documentation, and based on knowledge of CPT and of each individual insurance payer's policies, a decision is made about which services can be charged and are to be reported on the insurance claim form.

Identify the main term for EACH procedure. Main terms may be based on the: (1) procedure or service (such as repair, biopsy, E/M, or extraction); (2) organ or body part (such as chest wall, prostate, or bladder); (3) condition or disease being treated; (4) common abbreviation (such as ECG or CT) or synonym; (5) eponym (the name of a person or place for which a procedure is named, such as Cotte operation); and (6) symptom (for example, fracture).

Locate the procedures using the main term in the index at the back of CPT. For each term a listing of a code or a code range identifies the appropriate heading and procedure code(s) in CPT. Some entries have a "See" cross-reference or a "See also" to point to another index entry. First, pick out a specific procedure or service, organ, or condition. find the procedure code in the CPT Index. Remember, the number in the index is the five-digit code, not a page number. Then, turn to the procedure code in the body of the CPT to be sure the code accurately reflects the service performed. When a code range is listed, read the code descriptions for all codes within the range indicated in the index in order to select the most specific code. If the main term cannot be located in the index, review the main term selection with the physician for clarification. In some cases, there is a better or more common term that can be used.

Review the possible codes in the CPT section that the index entries point to. Check section guidelines and any notes directly under the code, within the code description, or after the code description. Items that cannot be billed separately because they are covered under another, broader code are eliminated. The codes to be reported for each day's services are ranked in order of highest to lowest rate of reimbursement. The actual order in which they were performed on a particular day is NOT important. When reporting, the earliest date of service is listed FIRST, followed by subsequent dates of service.

The circumstances involved with the procedure or service may require the use of modifiers. The patient's diagnosis may effect this determination. Check section guidelines and Appendix A to find modifiers that elaborate on details of the procedure being coded.

Covers physicians' services performed to determine the optimum course for patient care. To diagnose conditions and to plan treatments, physicians use a wide range of time, effort, and skill for different patients and circumstances. The guidelines to the E/M section explains how to choose the correct codes for different levels of evaluation and management services.

Health plans want to know whether the physician treated a new patient or an established patient. Physicians often spend more time during new patient's visits than during visits from established patients, so many E/M codes for the two types of patients are separate.

Emergency patients are not classified as either new or established patients.

Administrative code indicating where medical services were provided. The place-of-service is also important to know, because different E/M codes apply to services performed in a physician's office, a hospital inpatient room, a hospital emergency room, a nursing facility, an extended-care facility, and a patient's home. Remember there are over 50 place of service codes.

A consultation occurs when a second physician, at the request of the patient's physician, examines the patient. The second physician usually focuses on a particular issue and reports a written opinion to the first physician. The physician providing a consultation ("consult") may perform a service for the patient but does not independently start a full course of treatment (although the consulting physician may recommend one) or take charge of the patient's care. Consultations require the use of the E/M CONSULTATION CODES (the range from 99241 to 99245). Consultation requests and reports must be written documents that are stored in the medical records. If the sending provider requests a consultation, this is asking for the opinion of another physician regarding the patient's care. The patient will be returned to the care of the original provider with the specialist's written consultation report containing an evaluation of the patient's condition and/or care. Coders remember the three R's of consults: request opinion, render service, and report back. Because of fraudulent use of consult codes by some physicians -- billing consults for what are new visits -- in 2010 Medicare announced it would stop paying for both the outpatient and inpatient consult codes; providers must report these visits using regular office E/M codes.

When a patient is "referred" to another physician, either the total care or a specific portion of care is transferred to that provider. The patient becomes a new patient of that doctor for the referred condition and may not return to the care of the referring physician until the completion of a course of treatment. Referrals require use of the regular office visit E/M service codes. Under a referral, the PCP, or other provider is sending the patient to another physician for specialized care. The amount that can be charged for a referral is different than the amount that can be charged for a consultation.

Amount of work, time, and decision making involved in an encounter. CThe final item to decide in assigning the right E/M code is the level of service -- how much work, time, and decision making were involved in the patient encounter. These key components (factors documented in the patient's medical record for various levels of evaluation and management services) help determine the level of service: (1) the extent of the patient history taken; (2) the extent of the examination conducted; and (3) the complexity of the medical decision making.

To select the correct E/M code, use the following eight steps: 91) determine the category and subcategory of service based on the place of service and the patient's status; (2) determine the extent of the history that is documented; (3) determine the extent of the examination that is DOCUMENTED; (4) determine the complexity of medical decision making that is DOCUMENTED; (5) analyze the requirements to report the service level; (6) verify the service level based on the nature of the presenting problem, time, counseling, and care coordination; (7) verify that the documentation is complete; and (8) assign the code.

Determine the category and subcategory of service based on the place of service and the patient's status. The list of E/M categories, such as office visits, hospital services, and preventive medicine services, is used to locate the appropriate place of service or type of service in the index. In the main text of the selected category, the subcategory -- such as new patient or established patient -- is then chosen. For most types of service, such as initial hospital care for an established patient, between three to five codes are listed. To select an appropriate code from this range, three key components are considered: (1) the history that the physician documented; (2) the examination that was documented, and (3) the medical decisions the physician documented. The exception to this guideline is selecting a code for COUNSELING or COORDINATION OF CARE, where the amount of time the physician spends may be the only key component in some situations.

Determine the extent of the history that is documented. History for a patient is the information the physician received by questioning the patient about the chief complaint and other signs or symptoms, about all or selected body systems, and about pertinent past history, family background, and other personal factors. If the patient is incapacitated, the history may be taken from a family member. The history is documented in the patient medical record as follows: (1) History of Present Illness (HPI); (2) Review of Systems (ROS); (3) Past Medical History (PMH); (4) Family History (FH); and (5) Social History (SH).

The history of the illness is a description of the development of the illness from the first sign or symptom that the patient experienced to the present time. It includes everything related to the illness or condition. These points about the illness or condition may be documented: (1) Location (body area of the pain/symptom); (2) Quality (type of pain/symptom, such as sudden or dull; (3) Severity (degree of pain/symptom); (4) Duration (how long the pain/symptom lasts and when it began); (5) Timing (time of day pain/symptom occurs); (6) Context (any situation related to the pain/symptom, such as occurs after eating); (7) Modifying Factors (any factors that alter the pain/symptom); and (8) Associated Signs and Symptoms (things that also happen when the pain/symptom occurs, such as the severity, location, and timing of pain, and other signs and symptoms).

The review of systems is an inventory of body systems. These systems are: (1) Constitutional Symptoms (such as fever or weight loss); (2) Eyes; (3) Ears, Nose, Mouth, and Throat; (4) Cardiovascular (CV); (5) Respiratory; (6) Gastrointestinal (GI); (7) Genitourinary (GU); (8) Musculoskeletal; (9) Integumentary; (10) Neurological; (11) Psychiatric; (12) Endocrine; (13) Hematologic/Lymphatic; and (14) Allergic/Immunologic.

The past history of the patient's experiences with illnesses, injuries, and treatments contains data about other major illnesses and injuries, operations, and hospitalizations. It also covers current medications the patient is taking, allergies, immunization status, and diet.

The family history reviews the medical events in the patient's family. It includes the health status or cause of death of parents, brothers and sisters, and children; specific diseases that are related to the patient's chief complaint or the patient's diagnosis; and the presence of any known hereditary diseases.

The facts gathered in the social history, which depend on the patient's age, include marital status, employment, and other factors. The histories documented after the HPI are sometimes referred to as PFSH, for past, family, and social history.

The history that the physician decides to obtain is then categorized as one of four types on a scale from lesser to greater extent of amount of history obtained: (1) Problem Focused (determining the patient's chief complaint and obtaining a brief history of the present illness; (2) Expanded Problem Focused (determining the patient's chief complaint and obtaining a brief history of the present illness, plus a problem-pertinent system of review of the particular body system that is involved); (3) Detailed (determining the chief complaint; obtaining an extended history of the present illness; reviewing both the problem-pertinent system and additional systems; and taking pertinent past, family, and/or social history; and (4) Comprehensive (determining the chief complaint and taking an extended history of the present illness, a complete review of systems, and a complete past, family, and social history.

Determine the extent of the examination that is documented. The physician may examine a particular body area or organ system or may conduct a multisystem examination. The body areas are divided into the head and face; chest, including breasts and axilla (underarm/armpit); abdomen; genitalia, groin, and buttocks; back; and each extremity. The organ systems that may be examined are the eyes; the ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; and hematologic/lymphatic/immunologic. The examination that the physician documents is categorized as one of four types on a scale from lesser to greater extent: (1) Problem Focused (a limited examination of the affected body area or system; (2) Expanded Problem Focused (a limited examination of the affected body area or system and other areas; (3) Detailed (an extended examination of the affected body area or system and other related areas; and (4) Comprehensive (a general multisystem examination or a complete examination of a single organ system).

Determine the complexity of medical decision making that is documented. The complexity of the medical decisions that the physician makes involves how many possible diagnoses or treatment options were considered; how much data information (such as test results or previous records) was considered in analyzing the patient's problem; and how serious the illness is, meaning how much risk there is for significant complications, advanced illness, or death. The decision-making process that the physician documents is categorized as one of four types on a scale from lesser to greater complexity: (1) Straightforward (minimal diagnoses options, a minimal amount of data, and minimum risk); (2) Low Complexity (limited diagnoses options, a low amount of data, and low risk); (3) Moderate Complexity (multiple diagnoses options, a moderate amount of data, and moderate risk); and (4) High Complexity (extensive diagnoses options, an extensive amount of data, and high risk).

Analyze the requirements to report the service level. The descriptor for each E/M code explains the standards for its selection. For office visits and most other services to new patients, and for initial care visits, all three of the key components must be documented. This is stated in CPT as: To select code 99203 Office or other outpatient visit for the evaluation and management of a new patient, which require these three key components: (1) a detailed history; (2) a detailed examination; and (3) medical decision making of low complexity. The medical record must show that a detailed history and examination were taken, and medical decision making was at least at the level of low complexity. For most services for established patients, and for subsequent care visits, two of three of the key component requirements must be met. This means that to select code 99213, the medical record must show that two of the three factors (expanded problem focused history, expanded problem focused examination, and medical decision making of low complexity) are documented.

Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination. Many descriptors mention two additional components: (1) how severe the patient's condition is, referred to as the "nature of the presenting problem," and (2) how much time the physician typically spends directly treating the patient. These factors, while not the key components, help in selecting the correct E/M service level. Counseling is a discussion with a patient regarding areas such as diagnostic results, instructions for follow-up treatment, and patient education. It is mentioned as a typical part of E/M service in the descriptor, but it is NOT required to be documented as a key component. If a patient's visit is mainly about counseling and/or coordination of care regarding symptoms or illness, the length of time the physician spends is the controlling factor. If over 50 percent of the visit is spent counseling or coordinating care, time is the MAIN factor.

Verify that the documentation is complete. Meeting the requirements means that the documentation must contain the record of the physician's work. When an E/M code is assigned, the patient's medical record MUST contain the clinical details to support it. The history, examination, and medical decision making must be adequately documented, so that the medical necessity and appropriateness of the service can be understood.

After verifying the procedure code, it is then assigned. If the patient has more than one diagnosis for a single claim, the primary diagnosis is listed first. Likewise, the corresponding primary procedure is listed first. The physician may perform additional procedures at the same time or in the same session as the primary procedure. If additional procedures are performed, match up each procedure with its corresponding diagnosis. If this is not done, the procedures will not be considered medically necessary, and the claim will be denied. the need for any modifiers, based on the documentation of special circumstances, is also reviewed.

Two sets of guidelines for documenting evaluation and management codes have been published by CMS and the AMA: the 1995 Documentation Guidelines for Evaluation and Management Services and a 1997 version. CMS and most payers permit providers to use EITHER the 1995 or the 1997 E/M guidelines. A medical practice must be clear about which set of guidelines it generally follows for E/M coding and reporting.

Office and other outpatient services are the most often reported E/M services. When a patient is evaluated and then admitted to a health care facility, the service is reported using the codes for "initial hospital care" (99221-99223). The admitting physician uses the initial hospital care services codes. Only one provider can report these services; other physicians involved in the patient's care, such as a surgeon or radiologist, use other E/M service codes or other codes from appropriate sections. Codes for "initial hospital observation care" (99218-99220), "initial hospital care" (99221-99223), and "initial inpatient consultations" (99251-99255) should be reported by a physician only once for a patient admission.

An emergency department is hospital based and is available to patients twenty-four hours a day. When emergency services are reported, whether the patient is new or established is not applicable. Time is NOT a factor in selecting the E/M service code. The code ranges are 99281 to 99288.

Preventive medicine services are used to report routine physical examinations in the absence of a patient complaint. These codes, in the range 99381-99397, are divided according to the AGE of the patient. Counseling is coded from code range 99401-99429. Immunizations and other services, such as lab tests that are normal parts of an annual physical, are reported using the appropriate codes from the Medicine and the Pathology and Laboratory sections of the CPT.

Codes in the Surgery section represent groups of procedures that include all routine elements. The combination of services is called a surgical package. According to the Surgery section guidelines in the CPT, the procedure codes for surgical procedures include the following: (1) after the decision for surgery, one related E/M encounter on the date immediately before or on the date of the procedure; (2) the operation: preparing the patient for surgery, including injection of anesthesia by the surgeon (local infiltration, metacarpal/metatarsal/digital block or topical anesthesia), and performing the operation, including normal additional procedures, such as debridement; (3) immediate postoperative care, including dictating operative notes, talking with the family and other physicians; (4) writing orders; (5) evaluating the patient in the postanesthesia recovery area; and (6) typical postoperative follow-up care. A complete procedures includes the operation, the use of a local anesthetic, and post-operative care, all covered under a single code.

Combination of services included in a single procedure code.

Two types of services are not included in surgical package codes. These services are reported separately and reimbursed in addition to the surgical package fee: (1) Complications or recurrences that arise after therapeutic surgical procedures; and (2) Care for the condition for which a diagnostic surgical procedure is performed. Routine follow-up care included in the code refers only to care related to recovery from the diagnostic procedure itself, not the condition.

Procedure code for a surgical package that covers a group of services that should not be listed individually. Insurance payers assign a fee that reimburses all the services provided under a bundled code. When such services are billed, physicians MUST report the bundled code and not each of the other codes separately.

Incorrect billing practice of breaking a panel or package of services/procedures into component parts. Reporting anything that is included in the bundled code is considered unbundling, or fragmented billing. Doing this causes denied claims and may result in an audit. It could also be considered fraudulent.

Days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package. The period of time that is covered for follow-up care is referred to as the global period. After the global period ends, additional services that are provided can be reported separately for additional payment.

When health insurance plans pay for more than one surgical procedure performed on the same day for the same patient, they pay the full amount of the first listed surgical procedure, but they often pay less than the full amount for the other procedures. for maximum payment when multiple procedures are reported, the most complex or highest-level code -- the procedure with the highest reimbursement value -- should be listed first. The other procedures are listed with the modifier 51 or the modifier 59. Modifier 51 is used for multiple procedures at the same body site or system. Modifier 59 indicates distinct procedures, each fully reimbursed, rather than multiple procedures. It is usually used when the surgeon performs procedures on two different body sites or organ systems.

Descriptor used for a procedure that is usually part of a surgical package but may also be performed separately. Some procedural code descriptors in the Surgery section are followed by the words "separate procedure" in parentheses. Separate procedure means that the procedure is usually done as an integral part of a surgical package -- usually a larger procedure -- but that in some situations it is not. If a separate procedure is performed alone or along with other procedures but for a separate purpose, it may be reported separately.

Single code grouping laboratory tests frequently done together.

Organ or disease-oriented panels listed in the Pathology and Laboratory section of the CPT include tests frequently ordered together. A comprehensive metabolic panel, for example, includes tests for albumin, bilirubin, calcium, carbon dioxide, chloride, glucose, and other factors. Each element of the panel has its own procedure code in the Pathology and Laboratory section. However, when the tests are performed together, the code for the panel must be used, rather than listing each test separately.

Injections and infusions of immune globulins, vaccines, toxoids, and other substances require TWO codes: (1) one code for giving the injection and (2) one code for the particular vaccine or toxoid that is given. These codes are selected from the Medicine section of CPT. Note: An E/M code is NOT used along with the codes for immunizations unless a significant separate evaluation and management service is also done.

Procedure codes for Medicare claims. HCPCS was developed by the Centers for Medicare and Medicaid Services (CMS) for use in coding services for Medicare patients. The HCPCS coding system has two levels: Level I codes duplicate those from the CPT and Level II codes are issued by CMS in the Medicare Carriers Manual. Level II codes are called national codes and cover many supplies, such as sterile trays, drugs, and DME (durable medical equipment). Level II codes also cover services and procedures not included in the CPT. Level II HCPCS codes have five characters. HCPCS modifiers, either two letters with a letter and a number, are also available for use. These modifiers are different from the CPT modifiers. For example, HCPCS modifiers may indicate social worker services or equipment rentals.