Introduction to CPT and HCPCS Coding

Who maintains and copyrights the CPT code set?

The American Medical Association (AMA).

What are the three main categories of CPT codes?

Category I (standard services), Category II (performance measurement), and Category III (temporary codes).

What is the format and update frequency of Category I CPT codes?

Five-digit numerical codes, reviewed and updated annually.

What are the six main sections of Category I CPT codes?

Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology and Laboratory, and Medicine.

What is the purpose of Category II CPT codes?

Optional performance measurement tracking codes, denoted by an alphanumeric format ending in the letter 'F'.

What is the purpose of Category III CPT codes?

Temporary codes for emerging technologies, services, and procedures, denoted by an alphanumeric format ending in 'T'.

How is a semicolon (;) used in CPT code descriptions?

It divides the stand-alone common portion of a procedure code from indented dependent descriptors.

What does the add-on code symbol (+) indicate?

It identifies codes that describe secondary services and can never be reported alone.

What do the red circle and blue triangle symbols represent in CPT?

A red circle indicates a new procedure code, and a blue triangle indicates a code description revision.

What does the symbol of a circle with a line through it (W) indicate?

The CPT code is exempt from the use of modifier 51 (multiple procedures).

What does the number symbol (#) indicate in the CPT code book?

Resequenced codes that appear out of numerical order.

What is the purpose of the National Correct Coding Initiative (NCCI)?

Implemented by CMS to promote correct coding methodologies and control improper code assignment.

What three components make up the Resource-Based Relative Value Scale (RBRVS)?

Physician Work, Practice Expense, and Professional Liability/Malpractice Insurance.

What is the main difference between HCPCS Level I and Level II?

Level I is CPT maintained by the AMA; Level II is maintained by CMS to identify products, supplies, and services not in CPT.

What are HCPCS Level II J codes used for?

Drugs administered other than by oral method, such as injections or chemotherapy.

When is Modifier 22 (Increased Procedural Service) used?

When services required to perform a procedure are significantly greater than usually required, requiring an operative report.

How should Modifier 50 (Bilateral Procedure) be reported?

According to payer guidelines, either as a single line with modifier 50, two lines with modifier 50 on the second, or using RT/LT modifiers.

What is Modifier 51 used for?

Multiple procedures performed at the same session by the same provider (not used on E/M, physical medicine, vaccines, or add-on codes).

When should Modifier 53 (Discontinued Procedure) NOT be used?

Do not use for elective cancellations prior to the administration of anesthesia.

What are the four subset characters for Modifier 59 (Distinct Procedural Service)?

XE (Separate Encounter), XS (Separate Structure), XP (Separate Practitioner), and XU (Unusual Non-Overlapping Service).

What does Modifier 63 indicate?

Procedures performed on infants less than 4 kg, reflecting increased work intensity and physiological maintenance.

What is included in the CPT Global Surgical Package?

A standard bundle of preoperative, intraoperative, and normal postoperative services.

What are the global periods for major versus minor surgery under CMS rules?

Major surgery has 1 pre-op day and 90 post-op days; minor surgery has 0 or 10 post-op days depending on the procedure.

When is Modifier 24 appended to an E/M service?

For an unrelated E/M service by the same physician during the postoperative period of a previous procedure.

What does Modifier 25 indicate when appended to an E/M code?

A significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service.

When is Modifier 57 (Decision for surgery) appended?

To an E/M service performed on the day before or day of a major procedure that resulted in the decision to perform surgery.

What is the difference between Modifier 26 and Modifier TC?

Modifier 26 covers the professional component (interpretation/report), while Modifier TC covers the technical component (equipment/supplies).

What does CPT Appendix A cover?

Modifiers categorized into CPT modifiers, anesthesia physical status modifiers, ASC/hospital outpatient modifiers, and HCPCS Level II modifiers.

What is the purpose of CPT Appendix B?

A summary of additions, deletions, and revisions to CPT codes from the previous year.

What does CPT Appendix D list?

A summary of CPT add-on codes.

What does CPT Appendix E identify?

CPT codes that are exempt from the use of modifier 51 (multiple procedures).

What does CPT Appendix F identify?

CPT codes that are exempt from the use of modifier 63 (procedures performed on infants less than 4 kg).

What is contained in CPT Appendix J?

Electrodiagnostic medicine listing of sensory, motor, and mixed nerves with their appropriate nerve conduction study codes.

What does CPT Appendix K indicate?

Products pending FDA approval, identified throughout the CPT code book with a lightning bolt symbol.

What is the focus of CPT Appendix L?

Vascular families illustrating vessels emerging from the aorta using brackets to identify order.

What does CPT Appendix M provide?

A renumbered CPT codes citations crosswalk for CPT Assistant references for deleted codes.

What is summarized in CPT Appendix N?

A summary of resequenced CPT codes that appear out of numerical sequence.

What does CPT Appendix O contain?

A listing of administrative codes for Multianalyte Assays with Algorithmic Analyses (MAAA) procedures.

What does CPT Appendix P list?

A summary of CPT codes that may be used for synchronous telemedicine services when appended by modifier 95.

What information is found in CPT Appendix Q?

A table linking individual COVID-19 vaccine product codes to immunization administration codes, NDC codes, and dosing intervals.

What is defined in CPT Appendix R?

Taxonomy and definitions for services that can be provided as digital medicine.

What does CPT Appendix S classify?

Artificial intelligence (AI) applications for medical services into assistive, augmentative, and autonomous categories.

What does CPT Appendix T list?

CPT codes used for reporting synchronous real-time interactive audio-only telemedicine services, reported with modifier 93.

HCPCS Level II A Codes

Transportation Services, Med/Surg Supplies, and Administration.

HCPCS Level II B Codes

Enteral and Parenteral Therapy.

HCPCS Level II C Codes

Pass-Through Items for Hospital Outpatient Departments and ASCs.

HCPCS Level II E Codes

Durable Medical Equipment.

HCPCS Level II G Codes

Procedures and Professional Services.

HCPCS Level II H Codes

Alcohol and Drug Abuse Treatment Services used by State Medicaid Agencies.

HCPCS Level II K Codes

DME Supplies.

HCPCS Level II L Codes

Orthotic and Prosthetic Procedures and Services.

HCPCS Level II M Codes

Medical Services.

HCPCS Level II P Codes

Pathology and Laboratory Services.

HCPCS Level II Q Codes

Temporary Codes.

HCPCS Level II R Codes

Diagnostic Radiology.

HCPCS Level II S Codes

Temporary National Codes (Non-Medicare).

HCPCS Level II T Codes

National Codes for State Medicaid Agencies.

HCPCS Level II U Codes

Coronavirus Diagnostic Panel.

HCPCS Level II V Codes

Vision and Hearing Services.