Medical Coding and Billing: CPT Outpatient Coding

A set of vocabulary flashcards based on the lecture notes about Current Procedural Terminology (CPT) coding, including categories, modifiers, and outpatient billing principles.

CPT (Current Procedural Terminology)

The standardized code set used to report many outpatient procedures and professional services in physician offices, clinics, and other outpatient departments in the United States.

American Medical Association (AMA)

The organization responsible for maintaining and annually updating the CPT code set, including new, revised, and deleted codes.

Category I Codes

The main body of CPT, consisting of $5$-digit numeric codes arranged into sections such as Evaluation and Management, Surgery, and Medicine.

Category II Codes

Optional tracking codes used for performance measurement and quality reporting, documenting actions like blood pressure measurement or tobacco use screening.

Category III Codes

Temporary codes used for data collection regarding emerging technology, services, and procedures.

PLA Codes (Proprietary Laboratory Analyses)

Specific CPT codes used to identify certain proprietary laboratory tests.

Evaluation and Management (E/M)

Professional services where a provider evaluates a patient's condition and manages care, selected based on Medical Decision Making or total time on the date of the encounter.

Medical Decision Making (MDM)

A criteria for E/M selection involving the complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications, morbidity, or mortality.

Separate Procedure

A descriptor phrase signifying that a code is typically part of a comprehensive service and is reported separately only when performed independently and distinctly.

Add-on Codes

Codes describing additional work related to a primary service, often signaled by the phrase "each additional," which cannot be reported alone.

HCPCS Level II

A coding set that works alongside CPT to report items like supplies, durable medical equipment, biologicals, and certain medications.

Modifiers

$2$-character additions appended to CPT or HCPCS codes to communicate that a service was altered in a defined way without changing the basic meaning of the code.

Modifier $25$

Used to report a significant, separately identifiable Evaluation and Management service performed by the same physician on the same day as a procedure or other service.

Modifier $59$

Indicates a distinct procedural circumstance, used when two services usually bundled together are truly separate due to a separate site, lesion, or encounter.

Modifier $26$

Used to report only the professional component of a service, such as the interpretation and report of a diagnostic test.

Modifier TC

Used to report the technical component of a service, including equipment, staff, and supplies.

NCCI (National Correct Coding Initiative)

A system of edit logic provided to prevent unbundling and other coding patterns that would overstate the services performed.

Bundling

The coding rule where one service is considered part of another more comprehensive service and is not reported separately.

Unbundling

The incorrect practice of reporting components of a comprehensive service separately even though policy considers them included in a single code.

Unlisted Codes

Codes used when no existing CPT code accurately describes a service, requiring supporting documentation such as an operative report for claim submission.

Global Package

A reimbursement concept that includes related services provided before, during, and after a procedure as part of a single payment.

Medical Necessity

The requirement that a service is reasonable and necessary for a patient's condition, demonstrated by linking the CPT code to a supported diagnosis code.