Chapter 4: Introduction to CPT, Surgery Guidelines, HCPCS Level II, and modifiers

Which anatomic site would you look under in the CPT Index to find carinal reconstruction?

A. Breast

B. Chest

C. Esophagus

D. Trachea

Trachea

When the entry point for a catheterization is the aorta, what order would the right brachial artery be considered when using Appendix L?

A. First Order

B. Second Order Branch

C. Third Order Branch

D. Beyond Third Order Branch

Third Order Branch

Which option below would be the appropriate way to report removal of 30 skin tags?

A. 11201 x 3

B. 11200, 11201

C. 11200, 11201 x 2

D. 11200, 11201 - 51 x 2

C. 11200, 11201 x 2

Rationale: CPT code 11200 is reported for the first 15 lesions; 11201 is an add-on code, used in addition to 11200. Code 11201 reports each additional 10 lesions, or part thereof. After reporting 11200, we have 15 skin tags remaining to report. Code 11201 reports another 10 lesions, leaving 5 lesions remaining. The "part thereof" statement tells us we do not have to have a full count of 10 remaining to report it. Code 11201 is reported twice. Modifier 51 is not appropriate when using an add-on code.

According to the National Correct Coding Initiative, what edit is placed on codes 11042 and 10060 (refer to the NCCI table provided in the chapter)?

A. CCM 0; a modifier will not bypass the edit

B. CCM 1; a modifier will bypass the edit

C. CCM 9; a modifier will not bypass the edit

D. CCM 9; a modifier will bypass the edit

B. CCM 1; a modifier will bypass the edit

The provider performed debridement of an open leg wound. Two days later, during the postoperative period, the provider performed a more extensive debridement of the same wound. What modifier would be reported for the second service?

A. 58

B. 78

C. 79

D. No modifier is required

58

When coding for a surgical service, which of the following is NOT included in the global surgical package?

A. Digital block

B. General anestesia

C. Talking with the family

D. E/M encounter on the date immediately prior to a major procedure

B. General Anesthesia

Rationale: A digital block or topical anesthesia, talking with family and other physicians, and the E/M prior to a major surgery and during the postoperative care are all considered included in a CPT surgical code. General anesthesia would be reported separately.

How often does CMS release updates for HCPCS Level II codes?

A. Monthly

B. Quarterly

C. Semi-Anually

D. Annually

B. Quarterly

When a service having both technical and professional component (e.g., X-ray) is performed in the hospital, which modifier would be used by the physician?

A. 26

B. 47

C. TC

D. AM

26

Excision of the inferior turbinate is reported with CPT code 30130. What CPT code is reported for excision of the middle turbinate?

A. 30117

B. 30130

C. 30130 - 52

D. 30999

30999

The separate reporting for use of mesh (+49568) during a hernia repair can be reported with which code?

A. 49507

B. 49520

C. 49560

D. 49587

49560

Current Procedural Terminology (CPT)

A compilation of guidelines, codes, and descriptions used to report healthcare services.

Category II CPT codes

Optional 'performance measurement' tracking codes used for the Quality Payment Program.

Category III CPT codes

Temporary codes assigned by the AMA for emerging technology, services, and procedures.

Semicolon and Indented Procedure

A CPT procedure or service code that is divided into two parts by a semicolon; the description before and after the semicolon.

Add-on Codes

Procedures, identified with a “+” symbol, are commonly carried out in addition to a primary procedure and must be used with their specified primary procedure.

Bullet Symbol

Indicates new procedures and services added to the CPT code book.

Triangle Symbol

Indicates that a code descriptor has been revised.

Opposing horizontal triangles (bowties)

Indicate new or revised guidelines or instructions.

"Forbidden" Symbol

Identifies codes that are modifier 51 exempt.

Lightning Bolt

Identifies vaccines pending Food and Drug Administration (FDA) approval.

Pound Sign

Identifies CPT codes that have been resequenced and are out of numerical order.

Star Symbol

CPT codes which can be reported when using synchronous telemedicine using both audio and video telecommunications.

Audio Icon

CPT codes which can be reported when telemedicine services are furnished using audio-only communications.

Main Term in CPT Index

The procedure or medical service documented (e.g., Removal, Suture, Fasciotomy).

Subterms

Clarify the main term by noting a condition, procedure, or anatomic site.

National Correct Coding Initiative (NCCI)

Promotes accurate and appropriate coding. NCCI identifies codes considered by CMS to be bundled, or not reported separately, because one code is included in the work of another code.

Correct Coding Modifier (CCM) indicator

Determines whether, under appropriate conditions, you may override a code pair edit.

CPT® Assistant

Provides additional information, clarification, and guidance for proper use of codes which cannot be found in the CPT® code book.

CPT Category II Codes

Codes used voluntarily to report performance measures, and to make up the Quality Data Codes (QDCs) for the Quality Payment Program established by CMS.

CPT® Category III Codes

Temporary codes used for data collection in the FDA approval process regarding new and emerging technology, services, and procedures.

Appendix A

Lists modifiers categorized as : CPT Level 1 Modifiers, Anesthesia Physical Status Modifiers, CPT Level I Modifiers approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use,Commonly used Level II (HCPCS/National) Modifiers

Appendix B

Contains the actual changes and additions to the CPT® codes from the previous year to the current publication.

Appendix D

These codes are not reported as single or stand-alone codes. The codes listed are identified throughout CPT® with the + symbol throughout the numeric section of CPT®.

Appendix E

This listing is a summary of CPT codes that are exempt from the use of modifier 51. The codes are identified in the CPT code book with the symbol.

Appendix J

Provides a summary that assigns each sensory, motor, and mixed nerve with its appropriate nerve conduction study code to enhance accurate reporting of codes.

Appendix L

Illustrates vascular 'families' and identifies the 'order' of vessels.

Appendix O

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

Appendix P

Summary of the CPT® codes that may be used for reporting real-time telemedicine services when appended by Modifier 95.

Appendix R

Provides a taxonomy and definitions for services that can be provided as digital medicine.

Appendix S

Provides guidance for classifying various artificial intelligence (AI) applications for medical services and procedures into one of three categories: assistive, augmentative, and autonomous.

Appendix T

Lists CPT codes that are reportable using audio-only telemedicine services.

Global Package

Payment for surgical procedures includes a standard package of preoperative, intraoperative, and postoperative services.

Global Surgery Indicators

Each CPT® is assigned a global period status indicator per the CMS payment policies

HCPCS Level II

The Healthcare Common Procedure Coding System used when filing health plan claims for medical devices, medications, transportation services, and other items and services.

Permanent National Codes

Codes updated annually and describe products and services grouped in alphanumeric sections.

Miscellaneous Codes

Codes used when there is no existing national code that describes the item or service being billed.

Temporary National Codes

Codes used at the discretion of CMS and are developed to meet specific operating needs, such as newly issued coverage policies or legislative requirements.

K Codes

Used by Durable Medical Equipment Medicare Administrative Contractors (DME MACS).

Q Codes

Identify services that would not be given a CPT code or are not identified by national level II codes but are needed by CMS to facilitate claims processing.

Add-on Code

A CPT® code used to report a supplemental or additional procedure appended to a primary procedure (stand-alone) code.

The Centers for Medicare & Medicaid Services (CMS)

The agency within the U.S. Department of Health & Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid and state Children's Health Insurance Programs (CHIP).

Global Package

The period (0-10 days, or 0-90 days as determined by the health plan) and services provided for a surgery inclusive of preoperative visits, intraoperative services, post-surgical complications, postoperative visits, post-surgical pain management by the surgeon, and several miscellaneous services as defined by the health plan, regardless of setting.

Global Surgery Status Indicator

An assigned payment indicator, which determines classification for a minor or major surgery, based on RVU calculations.

Healthcare Common Procedure Coding System (HCPCS) Level II

HCPCS Level II is the national procedure code set for healthcare practitioners, providers, and medical equipment suppliers when filing insurance claims for medical devices, medications, transportation services, and other items and services.

Major Surgery

Surgeries classified as major have a global surgical period that includes the day before the surgery, the day of surgery, and any related follow-up visits with the provider 90 days after the procedure.

Minor Surgery

Surgeries classified as minor have a global surgical period that includes the preoperative service the day of surgery, surgery, and any related follow-up visits with the provider 0-10 days after the surgery.

Resource-Based Relative Value Scale (RBRVS)

The physician payment schedule established by Medicare.

Relative Value Units (RVU)

CMS reimburses physicians for Medicare services using a national payment schedule based on the resources used in furnishing physician services.

National Correct Coding Initiative (NCCI)

Used by professional coders to determine codes considered by CMS to be bundled codes for procedures and services deemed necessary to accomplish a major procedure.

Substitute Physician

Substitute physicians who takes over the professional practice of a physician who is absent for reasons such as illness, pregnancy, vacation, or continuing medical education.

Modifier 76

The physician or other qualified healthcare professional may need to indicate a procedure or service was repeated.