CHAPTER 1

INTRODUCTION TO THE CPT

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MEDICAL CODING
Transforms services/procedures/ supplies/drugs into CPT/HCPCS codes Transforms diagnosis and procedures into ICD-9-CM codes

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Three Levels of Service Codes

Level I CPTText, Chapters 1-13 Level II HCPCS, National Codes Text, Chapter 13

Level III Local Codesphased out

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Diagnosis Codes
ICD-9-CM, Volumes 1 & 2 International Classification of Diseases, 9th Ed., Clinical Modification

Text, Chapters 14 and 15

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ICD-9-CM
Classification system Changes diagnoses into codes Diabetes becomes 250.XX

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Why Codes?
Computers understand numbers Specific descriptions attached to each code

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CPT-4
Developed by the AMA in 1966 Five-digit codes Updated in November for use January 1

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Examples of Types of CPT Codes

Medical Surgical Diagnostic services

Anesthesia, etc.

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CPT Codes Allow For

Communication that is both effective and efficient

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Consider
Renal endoscopy through nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction, and insertion of endopyelotomy stent) OR 50575

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Codes Are
Used to tell third-party payers about services/procedures provided Often used as basis of payment

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Incorrect Coding
Results in providers being paid inappropriately
Either too much or too little

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Codes Are Used By

Clinics Hospitals Rehabilitation units

Wherever health care services are provided

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Outpatient Services
Reported on the insurance form CMS-1500 = universal form

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CMS-1500

Figure: 1.1
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CPT Format
Seven symbols

Used to convey information

Bullseye (New in 2005) Moderate (conscious) sedation included
Example 45391, Colonoscopy with ultrasound examination

Lightening Bolt (New in 2006) Pending FDA approval

Example, 90736, Zoster (shingles) vaccine, live, for subcutaneous injection
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Bullet = New Code Symbol

Figure 1.2

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Triangle = Description Change

Figure: 1.3

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 Right and Left Triangles = Beginning and Ending of Text Change

Figure: 1.4

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+ Plus = Add-On Code

Figure 1.5

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Add-On
(Contd)

Can only be used with another specific code

Never used alone Full list in Appendix D of CPT

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=Circle With Line, -51 Cannot Be Used With these Codes

(Contd)
Figure: 1.6

CPT Appendix E contains a listing of - 51 exempt codes

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Six CPT Sections (like chapters)

1. Evaluation & Management (E/M) 2. Anesthesia 3. Surgery

4. Radiology
5. Pathology & Laboratory

6. Medicine
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Categorized By
Sections Subsections Subheadings

Categories

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Categorized By
(Contd)

Anatomy
Knee or Shoulder

Description
Cast or Strap

Procedure
Incision or Excision

Surgical Approach
Anterior Cranial Fossa or Middle Cranial Fossa

Condition
Fracture or Dislocation

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Categorized By, Example

Figure: 1.8
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Guidelines
Figure: 1.9

Section-specific information begins each section

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Notes

Figure: 1.10

Must-reading located throughout the CPT

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Two Types of Codes

Stand-alone: Full description Indented: Dependent on preceding stand-alone

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Types of Codes, Example

Figure: 1.12

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Semicolon
Indicates full description in preceding code You must return to the stand-alone for full description

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Modifiers Add Information

CPT Modifier Two digits
62 Two surgeons performed a surgical procedure

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Level II HCPCS Modifiers

-AS Physicians Assistant -F1 Left hand, second digit All modifiers used on CPT or HCPCS

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Example of Modifier
43820 gastrojejunostomy
-62 two surgeons -43820-62 two surgeons performed a gastrojejunostomy

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Modifier on the CMS-1500

Modifiers are placed in 24D

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Unlisted Services
Codes ending in 99 = no specific code Equals = Miscellaneous Used if no more specific code

Written report must accompany

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Written Report Indicates:

Nature Extent Need

Time
Effort

Equipment Used
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Category III Codes New Technology

Temporary codesup to 3 years Identify emerging technology, services, and procedures

Located after Medicine section Alphanumeric (0062T)

May or may not receive future Category I code status

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Category III Codes New Technology

(Contd)

Category I codes (0010099602)

Approved by AMA and Food and Drug Administration

Proven clinical effectiveness

Category III codes have not been approved and have no proven clinical effectiveness

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Category III Codes

(Contd)

Use Category III code instead of unlisted code

Use unlisted code if no Category III code

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Category III Codes

Supplemental and optional Tracking codes for performance measurements

Five digits

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The Index!
Used to locate service/procedure terms and codes Speeds up code location

Like a dictionary
First entries and last entries

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CPT Index
(Contd)

Figure 1.16

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Presentation of Codes in Index

Single code: 38115 Multiple codes: 26645, 26650
Note comma

Range of codes: 22305-22325

Note hyphen

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REMEMBER!
Do not code directly from index Always reference main portion of CPT

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Location Methods With Examples

1. Service/procedure: repair, excision 2. Anatomic site: medial nerve, elbow 3. Condition or disease: cleft lip, clot

4. Synonym: toe and interphalangeal joint

5. Eponym: Jones Procedure, Heller Operation

6. Abbreviation: ECG, PEEP (Pressure Breathing, Positive)

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Always
Reference index Locate code in main portion of CPT Read the entire description and any notes

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See in Index
Cross-reference terms
Look here for code

Index: Stem, Brain: See Brainstem

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Appendices of CPT
Appendix A: Modifiers Appendix B: Additions, Deletions, Revisions Appendix C: Clinical Examples, E/M Codes

Appendix D: Add-On Codes

Appendix E: -51 Exempt Codes

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Appendices
(Contd)

Appendix F: Exempt from Modifier -63

Appendix G: Include Moderate (Conscious) Sedation Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I: Genetic Testing Modifiers Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves

Appendix K: Product Pending FDA Approval

Appendix L: Vascular Families
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The End CHAPTER 1

INTRODUCTION TO THE CPT

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