CHAPTER

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5Procedural Coding: Introduction to CPT

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Learning Outcomes

When you finish this chapter, you will be able to:5.1 Discuss the purpose of the CPT code set.

5.2 Describe the organization of the index, the main text, and the appendixes in CPT.

5.3 Summarize the format and seven of the symbols that are used in CPT.

5.4 Describe the purpose and correct use of CPT modifiers.

5.5 List the six general steps for selecting correct CPT procedure codes.

5.6 Explain how the key components are used as the basis for selection of CPT Evaluation and

Management codes.

5-2

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Learning Outcomes (Continued)

When you finish this chapter, you will be able to:5.7 Describe the purpose and the physical status

modifiers used in the Anesthesia section of CPT Category I codes.

5.8 Recognize the concepts of the surgical package and of separate procedures in the Surgery section of

CPT Category I codes.

5.9 State the purpose of the Radiology section of CPT Category I codes.

5.10 Describe the correct use of codes for laboratory panels in the Pathology and Laboratory section ofCPT Category I codes.

5-3

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Learning Outcomes (Continued)

When you finish this chapter, you will be able to:5.11 Explain why two codes from the Medicine section

of CPT Category I codes are reported for immunizations.

5.12 Compare the purpose of Category II and Category III codes.

5-4

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Key Terms

• add-on code• ancillary services• bundling• Category I codes• Category II codes• Category III codes• conscious sedation• consultation• Current Procedural

Terminology (CPT)• descriptor

5-5

• E/M codes (evaluation and management codes)

• fragmented billing

• global period

• global surgery rule

• key component

• modifier

• outpatient

• panel

• physical status modifier

• primary procedure

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Key Terms (Continued)

• professional component (PC)

• resequenced• secondary procedure• section guidelines• separate procedure• special report• surgical package• technical component

(TC)• unbundling

5-6

• unlisted procedure

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5.1 Current Procedural Terminology,Fourth Edition (CPT)

5-7

• Procedure codes for physicians’ and other health care providers’ services are selected from the Current Procedural Terminology code set

• Category I codes—five-digit procedure codes found in the main body of CPT– Each code has a descriptor—a brief explanation of

the procedure

• Category II codes—optional CPT codes that track performance measures

• Category III codes—temporary codes for emerging technology, services, and procedures

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5.2 Organization 5-8

• CPT contains the main text, which has six sections of Category I codes:– Evaluation and Management– Anesthesia– Surgery– Radiology– Pathology and Laboratory– Medicine

• Category II and Category III codes have 14 appendixes and an index

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5.2 Organization (Continued) 5-9

• Section guidelines—usage notes at the beginnings of CPT sections

• Unlisted procedure—service not listed in CPT• Special report—note explaining the reasons for

a new, variable, or unlisted procedure or service

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5.3 Format and Symbols 5-10

• CPT uses a semicolon and indentions when a common part of a main entry applies to entries that follow

• Some codes and descriptors are followed by indented see or use entries in parentheses, which refer the coder to other codes

• Descriptors often contain clarifying examples in parentheses, sometimes with the abbreviation e.g.

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5.3 Format and Symbols (Continued) 5-11

• Seven symbols are used in CPT:1. ● (a bullet or black circle) indicates a new procedure

code

2. ▲(a triangle) indicates that the code’s descriptor has changed

3. ►◄ (facing triangles) enclose new or revised text other than the code’s descriptor

4. + (a plus sign) before a code indicates an add-on code that is used only along with other codes for primary procedures

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5.3 Format and Symbols (Continued) 5-12

• Seven symbols are used in CPT (continued):5. (a bullet in a circle) next to a code means that

conscious sedation is a part of the procedure that the surgeon performs

6. (a lightning bolt) is used for codes for vaccines that are pending FDA approval

7. # (a number sign) indicates a resequenced code

• Resequenced—CPT procedure codes that have been reassigned to another sequence

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5.3 Format and Symbols (Continued) 5-13

• Add-on code—procedure performed and reported in addition to a primary procedure

• Primary procedure—most resource-intensive CPT procedure during an encounter

• Secondary procedure—additional procedure performed

• Conscious sedation—moderate, drug-induced depression of consciousness

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5.4 CPT Modifiers 5-14

• A CPT modifier is a two-digit number that may be attached to most five-digit procedure codes– Modifiers communicate special circumstances

involved with procedures

• A procedure has two parts:1.Technical component (TC)—reflects the technician’s

work and the equipment and supplies used in performing it

2.Professional component (PC)—represents a physician’s skill, time, and expertise used in performing it

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5.5 Coding Steps 5-15

• The six general steps for selecting correct CPT procedure codes:

Step 1. Review complete medical documentation

Step 2. Abstract the medical procedures from the visit documentation

Step 3. Identify the main term for each procedure

Step 4. Locate the main terms in the CPT index

Step 5. Verify the code in the CPT main text

Step 6. Determine the need for modifiers

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5.6 Evaluation and Management Codes 5-16

• E/M codes (evaluation and management codes)—cover physicians’ services performed to determine the optimum course for patient care

• Key component—factor documented for various levels of evaluation and management services

• Key components for selecting E/M codes:– The extent of the history documented– The extent of the examination documented– The complexity of the medical decision making

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5.6 Evaluation and Management Codes(Continued)

5-17

• Consultation—service in which a physician advises a requesting physician about a patient’s condition and care

• Outpatient—patient who receives health care in a hospital setting without admission

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5.7 Anesthesia Codes 5-18

• The codes in the Anesthesia section are used to report anesthesia services performed or supervised by a physician

• Two types of modifiers are used with anesthesia codes:1. Modifier that describes the patient’s health status

2. Standard modifiers

• Physical status modifier—code used with procedure codes to indicate a patient’s health status

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5.7 Anesthesia Codes (Continued) 5-19

• Patient’s physical status is selected from this list:– P1: Normal, healthy patient– P2: Patient with mild systemic disease– P3: Patient with severe systemic disease– P4: Patient with severe systemic disease that is a

constant threat to life– P5: Moribund patient who is not expected to survive

without the operation– P6: Declared brain-dead patient whose organs are

being removed for donation purposes

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5.8 Surgery Codes 5-20

• Codes in the Surgery section are used for surgical procedures performed by physicians

• Surgical package (or global surgery rule)– combination of services included in a single procedure code– Global period—days surrounding a surgical

procedure when all services relating to the procedure are considered part of the surgical package

– Separate procedure—descriptor used for a procedure that is usually part of a surgical package but may also be performed separately

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5.8 Surgery Codes (Continued) 5-21

• Reporting surgical codes:– Bundling—using a single payment for two or more

related procedure codes– Unbundling—incorrect billing practice of breaking a

panel or package of services/procedures into component parts

– Fragmented billing—incorrect billing practice in which procedures are unbundled and separately reported

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5.9 Radiology Codes 5-22

• The Radiology section of CPT contains codes reported for radiology procedures either performed by or supervised by a physician

• Radiology codes follow the same types of guidelines as noted in the Surgery section– Contain a technical component and a professional

component

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5.10 Pathology and Laboratory Codes 5-23

• Cover services provided by physicians or by technicians under the supervision of physicians

• Panel—single code grouping laboratory tests frequently done together– To report a panel code, all the indicated tests must

have been done, and any additional test is coded separately

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5.11 Medicine Codes 5-24

• Codes for the many types of evaluative, therapeutic, and diagnostic procedures that physicians perform– Immunizations require two codes from the Medicine

section, one for administering the immunization and the other for the particular vaccine or toxoid that is given

• Ancillary services—services used to support a diagnosis

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5.12 Category II and Category III Codes 5-25

• Category II and Category III codes both have five characters—four numbers and a letter– Category II codes are for tracking performance

measures to improve patients’ health– Category III codes are temporary codes for new

procedures that may enter the Category I code set if they become widely used in the future