Ch.7 Intro To CPT, HCPCS and Modifiers

Category I CPT

Utilizes a 5 digit numeric code. Most commonly used codes for medical services, procedures, and professional services by physicians and other qualified healthcare professionals.

Category II CPT

Optional performance measurement tracking codes designed to minimize administrative burdens because they facilitate data collection about quality of care per the AMA. Alphanumeric code, with letter F in last position. May be used in additional to E/M or clinical services CPT.

Category III CPT

Temporary codes assigned by the AMA for emerging technology, services and procedures. Alphanumeric structure with letter T in the last position. Can be reported alone, without a Category I code.

Separate Procedure

When performed alone, the separate procedure is reported. However, when reported with another procedure or service on the same patient during the same encounter, and is related, it may be considered inclusive to that procedure and not reported separately.

Procedure to procedure

PTP

Resource Based Relative Value Scale

RBRVS

Resource Based Relative Value Scale

System established by Medicare to reimburse physicians based on the CPT code submitted for reimbursement. Each code as a relative value unit assigned, which when multiplied by a conversion factor and geographic region adjustment allowance, creates the reimbursement for the medical service represented by the CPT code.

Relative Value Unit

Configured using 3 components: physician work (time, skill training and intensity of service), practice expense (reflects the cost of ancillary personnel, supplies and office overhead), and professional liability/malpractice insurance.

Physician Expense

PE

Malpractice

MP

GPCI

Geographic practice cost index

Conversion Factor

CF

Place of Service Codes (POS)

2 digit numeric codes placed on all healthcare professional claims that denote the setting in which the service was provided. Each service must link to the place where it was provided.

CPT Category II Modifiers

1P, 2P, 3P (exclusion modifiers) and 8P (reporting modifier)

Exclusion Modifier

Appended to indicate that an action specified in Category II code was not provided because of medical, patient or system reasons.

Reporting modifier

Modifier that indicates when an action in the measure is not performed and the reason is not documented.

Appendix A

Lists modifiers categorized as CPT Level I Modifiers, Anesthesia physical status modifiers, CPT Level I modifiers approved for ASC, and a selection of HCPCS modifiers.

Appendix M

Renumbered CPT Codes- Citations Crosswalk. An essential toll when referencing citations regarding coding for specific procedures.

Appendix N

Summary of resequenced CPT codes. A summary of CPT codes not appearing in numeric sequence.

Major Surgery

Preoperative period is 1 day with 90 days for the postoperative period.

Minor Surgery

Preoperative period is the day of the procedure, with a postoperative period of either 0 or 10 days depending on the procedure.

Endoscopic Procedures

There is no postoperative period for these procedures (except for procedures requiring an incision).

Global Surgery Status Indicator

Determine classification for a minor or major surgery as determined by RVU calculations.

000

Status indicator for endoscopies or minor procedures with a pre-op and post-op relative values on the day of the procedure are reimbursable. E/M services on the same day of the procedure are generally not payable.

010

Status indicator for minor procedures with pre-op relative values on the day of the procedure and post-op relative values during a 10-day post-op period are reimbursable services. E/M services on the day of the procedure during the 10 day post-op are not reimbursable.

090

Status indicator for major procedures with 1 day pre-op period and 90 days post-op period are considered to be a component of global package of the major procedure. E/M services on the day prior to the procedure and during the 90 day post-op period are not reimbursable.

MMM

Status indicator for maternity codes. The global period concept does not apply.

XXX

Status indicator for the global concept does not apply to this code.

YYY

Status indicator for unlisted codes subject to individual pricing.

ZZZ

Status indicators that represent add-on codes. They are related to another service and are always included in the global period of the primary service

Modifier 24

Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a post-op period. Reports an unrelated E/M during a post-op period.

Modifier 25

Significant separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.

Modifier 57

Decision for surgery. An E/M service provided the day before or the day of surgery that resulted in the initial decision to perform the surgery.

Modifier 58

Staged or related procedure or service by the same physician or other qualified healthcare professional during the post-op period. May be necessary to indicate that the surgery was planned prospectively at the time of the original procedure, more extensive than the original procedure, or for therapy following a diagnostic surgical procedure.

Modifier 78

Unplanned Return to the OR by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the pre-op period.

Modifier 79

Unrelated procedure or service by the same physician or other qualified healthcare professional during the post-op period.

HCPCS level II

Created by CMS to report supplies, material, injections, and certain procedures and services that may not be defined in the CPT code book.

Permanent National Codes

Representative from BCBSA, HIAA, and CMS maintain these HCPC codes. Updated once a year on 1/1 but codes and be added or deleted throughout the year.

Miscellanoues codes

Used when no existing national code describes the item or service being billed. Claims with these codes are manually reviewed, the item or service being billed must be clearly described, and pricing information must be provided along with documentation to explain why the beneficiary needs the item or service.

Temporary National Codes

Codes that allow insurers to establish codes needed before the next 1/1 annual update for permanent national codes or until consensus can be achieved on a permanent national code. Updated quarterly and usually implemented within 90 days. Includes: C, G, H, K, Q, S, and T codes.

Table of Drugs

Directs coder to drug names and their corresponding codes based on an alphabetic list of drugs with cross references to generic and commercial names.

IA

Intra-arterial Adminstration

IV

Intravenous adminstration

IM

Intramuscular adminstration

IT

Intrathecal- administration of the drug is given into the subdural space of the spinal cord.

SC

Subcutaneous

INH

Administration by inhaled solution

VAR

Various routes of adminstration.

OTH

Other routes of adminstration

ORAL

Administered orally

CMS Internet Only Manual (IOM) references

Contains CMS regulations and rulings concerning coverage for procedures, services and supplies, and includes the NCD manual.

HCPCS Modifiers

2 alpha characters or an alpha character followed by a digit. They may be used on CPT codes for services related to anatomy, transportation, anesthesia, coronary arteries, ophthalmology, professional service, ESRD, and dental care.

D

HCPCS modifier for diagnostic or therapeutic site other than P or H when these codes are used as origin codes.

E

HCPCS modifier for residential, domiciliary, custodial facility (other than 1819 facility).

G

HCPCS modifier for Hospital based dialysis facility (hospital or hospital related).

H

HCPCS modifier for hospital.

I

HCPCS modifier for site of transfer (eg airport or helicopter pad between modes of ambulance transport).

J

HCPCS modifier for freestanding ESRD facility

N

HCPCS modifier for SNF

P

HCPCS modifier for physicians’ office

R

HCPCS modifier for residence

S

HCPCS modifier for scene of accident or acute event.

X

HCPCS modifier for intermediate stop at physician’s office on the way to the hospital. Destination code only.

A codes

Transportation codes, medical and surgical supplies and administrative, miscellaneous and investigational services, equipment, and supplies.

B codes

Enteral and parenteral therapy

C codes

Temporary codes for use with Outpatient Prospective Payment System (OPPS) (pass-through). Report use of goods that Medicare will pay in addition to the APC for a procedure. Only facilities using APCs can use C codes.

E codes

Durable medical equipment

G codes

Procedures/ professional services (temporary)

H codes

Temporary national codes for governmental entities other than Medicare

J codes

Drugs administered other than oral method and injectable chemo drugs.

K codes

Assigned to DME MAC

L codes

Orthotic procedures and services and prosthetic procedures

M codes

Medical services

P codes

Pathology and lab services

Q codes

Procedures, services and supplies on a temporary basis.

R codes

Diagnostic radiology services

S codes

Temporary national codes (non-Medicare)

T codes

National codes established for state Medicaid agencies.

U codes

Coronavirus Diagnostic Panel

V codes

Vision services and hearing, which also includes speech-language pathology services.

Functional modifiers

Aka pricing modifier. Considered by payers when determining reimbursement. Entered immediately after the code when there are more than 1 modifiers.

Informational modifiers

Clarify aspects of the procedure or service provided for the payer. Reported after functional modifiers.

Modifier 22

Increased procedural services. When service provided is greater than that usually required for the listed procedure.

Modifier 23

Unusual Anesthesia. When a procedure usually requires no anesthesia or local anesthesia and due to unusual circumstances the procedure must be performed under general anesthesia. Anesthesiologists or CRNAs only use this modifier. Key words: unable to tolerate without general anesthesia, etc.

Modifier 24

Unrelated Evaluation and Management service by the same physician or other qualified healthcare professional during a post-op period. Key words: unrelated, outside of, not related to, etc.

Modifier 25

Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure of other service. Key words: unrelated, outside of, not related to, etc.

Modifier 26

Professional Component. Certain procedures are a combination of a physician component and a technical component. When the physician is reported separately, the service may be identified by adding this modifier. Key words: independent radiologist, performed in a hospital, etc.

Modifier 32

Mandated Services. Services related to a mandated consultation and/or related services. Keywords: second opinion, required by insurance, etc.

Modifier 47

Anesthesia by surgeon. Keywords: surgeon administered anesthesia, anesthesiologist not available, ect.

Modifier 50

Bilateral procedure- performed at the same operative session. Keywords: bilateral, both sides, left and right, etc.

Modifier 51

Multiple procedures. When multiple procedures, other than E/M services, Physical Medicine, and Rehab services or provision of supplies are performed at the same session by the same provider. Keywords: a different procedure, separate from, etc.

Modifier 52

Reduced services. Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s or other qualified healthcare professionals’ discretion. Keywords: partially, to be reduced, part of procedure not completed.

Modifier 53

Discontinued procedure. Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Keywords: procedure stopped before completion, no need to complete procedure, etc.

Modifier 54

Surgical care only. When one physician performs a surgical procedure and another provides pre-op and/or post-op management. Keywords: only performed the surgical procedure, no post-op management, ect.

Modifier 55

Post-op management only. When one physician performs post-op management and another performed the surgical procedure. Keywords: post-op follow-up only, post-op care turned over to, transfer of care, etc.

Modifier 56

Pre-op management only. When one physician performs the pre-op care and evaluation, and another performs the surgical procedure. Keywords: pre-op evaluation only, covering for surgeon, etc.

Modifier 57

Decision for surgery. An E/M that resulted in the initial decision to perform the surgery. Keywords: decision to perform surgery, will need to go to OR, etc.

Modifier 58

Staged or Related procedure or service by the same physician or other qualified healthcare professional during the post-op period. Keywords: return to OR, will proceed with additional services in the next procedure, etc.

Modifier 59

Distinct procedural service. Used to identify services not normally reported together but it appropriate under the reported circumstances. Keywords: separate procedure, needed additional services, etc.

XE

Separate encounter, a service that is distinct because it occurred during a separate encounter. Subset of modifier 59.