CPT Coding Overview and Exam Preparation

CPT codes

These are updated annually and the new codes become effective January 1 of each year and are 5 characters in length.

Category I codes

These are CPT codes listed in the main section or body of the CPT manual; these codes are the CPT codes that are used to report services and procedures.

Category I codes

5-character numeric codes.

Category II codes

Used for statistical purposes to track and measure performance and the quality of care provided in a healthcare facility.

Category II codes

5 characters: 4 numbers followed by the letter F.

Category III Codes

Used for emerging technology, services, and procedures that are innovative, but not widely used or accepted as a standard of care; also known as temporary codes.

Category III codes

5 characters: 4 numbers followed by the letter T.

Unlisted codes

Codes shown at the end of each subsection of the CPT used as a catch-all for procedures not represented by an existing code.

Plus sign (✚)

Identifies an add-on code; this is a procedure that is done in addition to or associated with the main procedure.

Bullet symbol (●)

Identifies a new code that wasn't included in the previous year's manual.

Triangle symbol (▲)

Distinguishes a code whose description has been changed or revised since the last edition of the CPT.

Double sideways triangle symbol (▶◀)

Marks the beginning and end of text that has been revised or is being shown for the first time in the current CPT manual.

Star symbol (★)

Indicates codes that are permitted to be reported as synchronous telemedicine service.

Forbidden symbol (Ø)

Identifies codes that aren't permitted to be appended with modifier 51.

Number sign/hashtag (#)

Identifies a code that has been added and placed into the code set out of numeric order.

Open circle (O)

Identifies a recycled or reinstated code that was previously deleted and has been added back in.

Modifiers

Two-character code that affects the meaning of another code; a code addendum that provides more meaning to the original code.

CPT Modifiers

2 characters that may be appended to a code from the main portion of the CPT manual.

Anesthesia Physical Status Modifiers

Consist of 2 characters and are alphanumeric which are used to report the condition of a patient at the time anesthesia is administered.

P1

A normal healthy patient.

P2

A patient with mild systemic diseases.

P3

A patient with severe systemic disease.

P4

A patient with severe systemic disease that is a constant threat to life.

P5

A moribund patient who is not expected to survive without the operation.

P6

A declared brain-dead patient whose organs are being removed for donor purposes.

HCPCS Level II modifiers

2 characters that are either alphabetic or alphanumeric; may be appended to a code from the main section of the CPT manual or the HCPCS manual.

Personnel modifiers

explains special circumstances relating to the healthcare professionals involved in the treatment of the patient.

Anatomical site modifier

Provide additional specific detail about the target of the service or procedure not provided by the code.

E/M Codes

Report and reimburse physicians for their expertise and thought processes involved in diagnosing and treating patients.

E/M Codes Usage

Used for physician encounters with the patient, including time spent directly with the patient face-to-face, discussing items with the patient/family, and even telehealth visits.

Selecting E/M Codes - Step 1

Determine the place of service and locate that heading.

Selecting E/M Codes - Step 2

Determine if patient is new or established (if applicable for the specific place of service).

Selecting E/M Codes - Step 3

Identify the type of service which helps to identify the subsection for the care provided to the patient (if applicable).

Selecting E/M Codes - Step 4

Determine the level of service based upon the documentation to include history/physical exam and level of MDM.

Level of MDM

As of January 1, 2023, this is the determining factor of level of service

Time-Based E/M Codes

Some E/M codes' level of service is based upon time spent with the

Straightforward MDM

Small number of possible diagnoses, small number of treatment or management options, little to no data or research to be reviewed, low to no risk for complications.

Low-level MDM

Limited number of possible diagnoses, limited number of treatment or management options, limited amount of data to be reviewed, low risk for complications.

Moderate-level MDM

Multiple number of possible diagnoses, multiple number of treatment or management options, moderate amount of data to be reviewed, moderate level risk for complications, possible due to other existing diagnoses or medications currently being taken.

High-Level MDM

Large number of possible diagnoses, large number of treatment or management options, large amount of data to be reviewed, high level risk for complications, possible due to other existing diagnoses and/or medications currently being taken.

Topical Anesthesia

Application of a drug to the skin to reduce or prevent sensation in a specific area temporarily.

Local Anesthesia

Injection of a drug to prevent sensation in a specific portion of body, includes local infiltration anesthesia, digital blocks, and pudendal blocks.

Regional Anesthesia

Prevents a section of the body from transmitting pain and includes epidural, caudal, spinal, axillary, stellate ganglion blocks, regional blocks, and brachial anesthesia.

General Anesthesia

Administration of a drug in order to induce a loss of consciousness in the patient, who is unable to be aroused even by painful stimulation; also known as surgical anesthesia.

Anesthesia Codes

Located by looking up 'Anesthesia' in the Index and then locating the anatomical site of the procedure, which determines the anesthesia code; pay attention to type of anesthesia.

Time Reporting for General Anesthesia

May be used for billing general anesthesia services in certain areas or by certain third-party payers instead of CPT codes.

Time

this is measured in 15-minute increments.

Physical Status Modifiers

Must be appended to general anesthesia codes; these include P1-P6 to note the condition of the patient at the time anesthesia is administered.

Modifier 47: Anesthesia by Surgeon:

appended for regional and general anesthesia codes when the surgeon administers the anesthesia versus an anesthesiologist.

Moderate (Conscious) Sedation

Use of a drug to reduce stress and/or anxiety; this is an ultralight form of general anesthesia that affects the entire body.

Administration of Moderate Sedation

Services of an anesthesiologist aren't required, so the provider performing the procedure or their staff may administer this type of anesthesia prior to the procedure.

Coding for Moderate Sedation

This service is not coded from the Anesthesia section of CPT but is coded from the Medicine section, codes 99151-99157, unless the sedation is administered by an anesthesiologist.

Intraservice Work Measurement

Measured in an initial 15-minute increment, with add-on codes for additional 15-minute increments, reported separately.

Qualifying Circumstances Codes

Cause the anesthetic process to be more complicated than usual; in these cases an add-on code is used to identify the circumstance.

Prophylactic procedure or treatment

Performed to prevent a condition from developing.

Diagnostic procedure (or test)

Performed to gather more details about a condition or concern at issue to get closer to an accurate diagnosis.

Therapeutic procedure

Provided to correct or fix a problem.

Separate procedure

The CPT manual will include notations within the code descriptions of: 'separate procedure'; this means these services and treatments are generally performed with a group of other procedures.

Noninvasive or external procedure

One that does not enter the patient's body; ex: shave biopsy on the surface of the skin.

Minimally invasive procedures

Becoming more and more available as healthcare researchers continue to find methods to diagnose and correct problems with the least amount of trauma to the patient.

Percutaneous approach

Uses instruments inserted into the body by way of a puncture or small incision to access the intended anatomical site.

Percutaneous endoscopic approach

Uses instruments inserted into the body by way of a puncture or small incision to access and visualize the intended anatomical site.

Via natural or artificial opening approach

Involves instrumentation entered into the body through a natural or an artificial opening to visualize the intended anatomical site.

Via natural or artificial opening endoscopic approach

Involves insertion of a scope through a natural or artificial opening to visualize and aid in the performance of a procedure on the intended anatomical site.

Open approach procedures

Are fully invasive, as the surgeon cuts through the skin, membranes, and body layers to access the intended anatomical site.