CPT Coding

CPT coding system

Descriptive terms and identifying codes for reportingmedical services and procedures

Provides uniform language that describes medical,surgical, and diagnostic services

Published by the American Medical Association (AMA)

CPT codes

Five digits in length

Descriptions reflect health care services and proceduresperformed in modern medical practice.

Reviewed by AMA to update codes and descriptionsannually

Category I CPT codes

Five-digit CPT code and descriptor nomenclature

Organized in six sections

Category II CPT codes

Reported to track performance measurements

Use is optional.

Category III CPT codes

Contains "emerging technology" temporary codes

Assigned for data purposes

Archived after five years unless accepted for placement

CPT Category I Sections

Evaluation and Management (E/M)

Anesthesia

Surgery

Radiology

Pathology and Laboratory

Medicine

Stand-alone code

includes complete description of procedure or service

Indented code

appears below stand-alone code,requiring coder to refer back to common portion of code description located before semicolon

CPT Category II Codes

Tracking codes used for performancemeasurement in compliance with PQRS

Assigned for certain services or test resultsthat support performance measures

Alphanumeric and consist of four digitsfollowed by alpha character F

Reporting is optional.

CPT Category III Codes

Allow for utilization tracking of emerging:

Technology

Procedures

Services

Facilitate data collection/assessment aboutnew services/procedures during FDAapproval process

Alphanumeric and consist of four digitsfollowed by the alpha character T

CPT Appendices

Appendix A—CPT modifiers/descriptions

Appendix B—Added/deleted/revised codes

Appendix C—E/M clinical examples

Appendix D—Summary list of add-on codes

Guidelines

define and explain assignment of codes, procedures, and services in aparticular CPT section

Unlisted Procedures/Services

Assigned for procedure or service for which there is no CPT code

Special report (e.g., copy of procedure report) is attached to claim to describe:

Nature

Extent

Need for procedure or service

Time, effort, and equipment necessary

Notes

Instructional notes—appear throughout CPT to clarify assignment of codes

Blocked unindented note—located below subsection title and contains instructions that apply to all codes in that subsection

Indented parenthetical note—located below subsection title, code description, or a code description that contains an example

Descriptive Qualifiers

Terms that clarify assignment of CPT code

Can occur in middle of main clause or after the semicolon

May or may not be enclosed in parentheses

CPT Index

Organized by alphabetical main terms

Main terms represent:

Procedures or services

Organs or anatomic sites

Conditions

Synonyms, eponyms, and abbreviations

Modifying Terms

Main term

may be followed by subterms that modify main term and/or terms they follow.

Subterms

may also be followed by additional subterms that are indented

Single Codes and Code Ranges

Index code numbers are represented by:

Single code number

Range of codes, separated by:

Dash

Series of codes separated by commas

Combination of single codes and ranges of codes

Note: Review all listed codes before assigning a code for the procedure or service.

Boldface type

Main terms in the CPT index are printed in boldface type.

Note: CPT categories, subcategories, headings, and code numbers are also printed in boldface type.

Cross-reference term See

Directs coders to index entry under which code is listed

Italicized type is used for cross-reference term See.

Inferred words

used to save space when referencing subterms

CPT Modifiers

Modifiers indicate that description of service or procedure performed has been altered.

Clarify services and procedures performed by providers.

CPT code and description remain unchanged.

CPT Modifiers

Reported as two-digit numeric codes added to the five-digit CPT code

HCPCS level II (national)

two-character alphanumeric modifiers are added to CPT codes when reporting outpatient services.

Coding Procedures and Services

Step 1—Read introduction in CPT manual.

Step 2—Review guidelines at beginning of each section.

Step 3—Review procedure or service listedin the source document (e.g., patient record).

Code what is documented in source document.

Obtain clarification from provider if necessary.

Step 4—Refer to CPT index, and locate mainterm for procedure or service documented.

Main terms can be located by referring to:

Procedure or service documented

Organ or anatomic site

Condition documented in the record

Substance being tested

Synonym

Eponym

Abbreviation

Step 5—Locate subterms, and follow cross-references.

Step 6—Review descriptions of codes, and compare qualifiers to descriptive statements.

Step 7—Assign code number, applicable add-on or additional codes, and/or modifiers.

Evaluation and Management Section

Located at beginning of CPT because these codes describe services most frequently provided by physicians

Accurate assignment is essential to success of physician practice because most revenue is generated by these services.

E/M Level of Service

Reflects amount of work involved in providing care to patient:

Extent of history performed

Extent of examination performed

Complexity of medical decision making