Lesson 4 – CPT

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INTRO TO CPT

In Learn More About Medical Coding, we introduced you to Current Procedural Terminology, or CPT. This expansive, important code set is published and main­tained by the American Medical Association (AMA), and it is, with ICD, one of the most important code sets for medical coders to become familiar with. Note also that all the codes featured in this course, and every course that touches on CPT codes, are copyrighted by the AMA.

CPT codes are used to describe tests, surgeries, evaluations, and any other med­ical procedure performed by a healthcare provider on a patient. As you might imagine, this code set is extremely large, and includes the codes for thousands upon thousands of medical procedures.

CPT codes are an integral part of the billing process. CPT codes tell the insur­ance payer what procedures the healthcare provider would like to be reim­bursed for. As such, CPT codes work in tandem with ICD codes to create a full picture of the medical process for the payer. “This patient arrived with these symptoms (as represented by the ICD code) and we performed these procedures (represented by the CPT code).

Like ICD codes, CPT codes are also used to track important health data and measure performance and efficiency. Government agencies can use CPT codes to track the prevalence and value of certain procedures, and hospitals may use CPT codes to evaluate the efficiency and abilities of individuals or divisions within their facility.

FORMAT                  Let’s look a little closer at what these codes look like and how they’re organized.

Each CPT code is five characters long, and may be numeric or alphanumeric, depending on which category the CPT code is in. Don’t confuse this with the ‘category’ in ICD. Remember that in ICD codes the ‘category’ refers to the first three characters of the code, which describe the injury or disease documented by the healthcare provider.

With CPT, ‘Category’ refers to the division of the code set. CPT codes are divid­ed into three Categories. Category I is the most common and widely used set of codes within CPT. It describes most of the procedures performed by healthcare providers in inpatient and outpatient offices and hospitals. Category II codes are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimen­tal technologies, services, and procedures.

Note that while CPT codes have five digits, there are not 99,000-plus codes.

CPT is designed for flexibility and revision, and so there is often a lot of “space” between codes. Unlike ICD, each number in the CPT code does not correspond to a particular procedure or technology.

Here’s a closer look at the three categories of CPT codes.

FORMAT CATEGORY I

Medical coders will spend the vast majority of their time working with Category I CPT codes. For the sake of simplicity, we’ll refer to the CPT codebook when we’re describing the code set. This book, which is updated yearly by the AMA and the CPT Editorial Board, is an essential tool for every medical coder. In the next few minutes, you’ll learn the basic layout, format, and instruc­tions found in the CPT codebook. We’ll cover how to use CPT codes in the next course, Using CPT. Most of the Using CPT course will be focused on Category I CPT codes. (CMS.gov.,2021)

Like the ICD code set and its division into chapters by type of injury or illness, Category I CPT codes are divided into six large sections based on which field of health care they directly pertain to. The six sections of the CPT codebook are, in order:

  • Evaluation and Management
  • Anesthesiology
  • Surgery
  • Radiology
  • Pathology and Laboratory Medicine

CPT codes are, for the most part, grouped numerically. The codes for surgery, for example, are 10021 through 69990.

In the CPT codebook, these codes are listed in mostly numerical order, except for the codes for Evaluation and Management. This Evaluation and Manage­ment, or E&M, codes are listed at the front of the codebook for ease of access. Physician’s offices frequently use E&M codes for reporting a number of their services. The code 99214, for a general checkup, is listed in the E&M codes, for example. (medicalbillingandcoding.org.,2021)

Note also that some codes appear out of numerical sequence but near similar procedures. This may seems slightly confusing, but having these codes clus­tered near similar procedures prevents having to delete and resequence codes, and so is seen as a sort of necessary evil.

Here’s a quick look at the sections of Category I CPT codes, as arranged by their numerical range.

  • Evaluation and Management: 99201 – 99499
  • Anesthesiology: 00100 – 01999; 99100 – 99140
  • Surgery: 10021 – 69990
  • Radiology: 70010 – 79999
  • Pathology and Laboratory: 80047 – 89398
  • Medicine: 90281 – 99199; 99500 – 99607

Within each of these code fields, there are subfields that correspond to how that topic—say, Anesthesia—applies to a particular field of healthcare. For instance, the Surgery section, which is by far the largest, is organized by what part of the human body the surgery would be performed on. If you’d like to learn more about the anatomy and physiology terms used in the Surgery section, see the course on Human Anatomy and Medical Terminology later in Section 2. Likewise, the Radiology section is organized into sections on diagnostic ultrasound, bone and joint studies, radiation oncology, and other fields.

Each of these fields has its own particular guidelines when it comes to use. For example, the Surgery section has a guideline for how to report extra materials used (such as sterile trays or drugs) and how to report follow-up care in the case of surgical procedures.

Like ICD codes, many CPT codes are arranged by indentation. If a procedure is indented below another code, the indented procedure is an important or note­worthy variation on the above procedure and would replace the first code. Let’s take a look at an example of an indented code. (medicalbillingandcoding.org.,2021)

The code for “management of liver hemorrhage; simple suture of liver wound or injury” is 47350. This is a surgical procedure, and would be found in the surgery/ digestive system portion of the CPT book.

It’s helpful to look at a code like this in two parts. The first, which comes before the semicolon, is the general procedure. In this case, that’d be “liver manage­ment.” The phrase that comes after the semicolon is additional, specific infor­mation. In this example, we could read the code as “liver management, with a simple suture of liver wound or injury.”

If, however, a doctor performed a more complicated procedure on a patient’s liver, 47350 would no longer be the correct code to use. If we look in the CPT manual, we find the code 47360 below 47350. Code 47360 reads “complex suture of liver wound or injury, with or without hepatic artery ligation.” That phrase is meant to take the place of the phrase that comes after the semicolon in code 47350.

You could therefore read code 47360 as “liver management, with complex suture of liver wound or injury, with or without hepatic artery ligation.”

CPT codes also have a number of modifiers. These modifiers are two-digit addi­tions to the CPT code that describe certain important facets of the procedure, like whether the procedure was bilateral or was one of the multiple procedures per­formed at the same time. CPT modifiers are relatively straightforward, but are very important for coding accurately. For this reason, we’ll cover them in a CPT Modifiers later in Section 2.

Like ICD codes, many CPT codes also have additional instructions featured be­low the code. These instructions, which are in parentheses below the code you’ve looked up, tell the coder that, in certain situations, another code might be better suited than the present code. We’ll cover these commands in more depth in the next course Using CPT. For now, just recognize that the CPT code set has a number of instructions that inform the medical coder on how to best code the procedure performed. Remember that you always need to code to the highest level of specificity, and a miscoded procedure can be the difference between an accepted and rejected the claim.

The CPT code set also instructs coders on when to use multiple codes, when to use codes in tandem with one another (add-on codes), and which codes are “modifier exempt.”

This is an awful lot of information to take in regarding Category I CPT codes, so let’s review briefly.

Category I CPT codes are numeric, and are five digits long.

They are divided into six sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.

Each of these sections has its own subdivisions, which correspond to what type of procedure, or what part of the body, that particular procedure relates to.

The sections are grouped numerically, and, aside from Evaluation and Manage­ment, are in numerical order. That is, the codes for Anesthesia come before, or are “lower” than the codes for Pathology and Laboratory.

Each of these sections also has specific guidelines for how to use the codes in that section.

Certain codes have related procedures indented below them. These indented codes are important variations on the code above them, and denote different methods, outcomes, or approaches to the same procedure. For example, the code for the elevation of a simple, extradural depressed skull fracture is 62000. The code for the elevation of a compound or comminuted, extradural depressed skull fracture is 62005.

There are a few important CPT Modifiers, which provide additional informa­tion about the procedure performed. We’ll cover these in just a little bit.

Some codes have instructions for coders below them. These instructions are found in parentheses below the code, and they instruct the coder that there may be another, more accurate code to use.

These codes are five character-long, alphanumeric codes that provide additional information to the Category I codes. These codes are formatted to have four digits, followed by the character F. These codes are optional, but can provide important information that can be used in performance management and future patient care.

  • CATEGORY II NUMERICAL FIELDS
  • CATEGORY II EXAMPLE
  • FORMAT CATEGORY II

Here’s a quick example. If a doctor records a patient’s Body Mass Index (BMI) during a routine checkup, we could use Category II code 3008F, “Body Mass Index (BMI), documented.”

These codes never replace Category I or Category III codes, and instead, simply provide extra information. They are divided into numerical fields, each of which corresponds with a certain element of patient care. These fields are, in order:

Composite Codes – These codes combine a number of procedures that typically occur in conjunction with one main procedure.

Example: 0001F: Heart failure assessed (includes all of the following): Blood pressure measured Level of activity assessed

Clinical symptoms of volume overload assessed Weight recorded

Clinical signs of volume overload assessed

Patient Management – Includes patient care provided for specific clinical purposes like pre- and postnatal care Example: 0503F: Postpartum care visit

Patient History -Describes measures for select elements of patient history or symptom review

Example: 1030F: Pneumococcus immunization status assessed

Physical Examination

Example: 2014F: Mental status assessed

Diagnostic/Screening Processes or Results –Includes results of tests ordered, including clinical lab tests and radiological procedures Example: 3006F: Chest X-ray documented and reviewed

Therapeutic, Preventive, or Other Interventions –

Describes pharmacologic, procedural or behavioral therapies

Example: 4037F: influenza immunization ordered or administered

Follow-up or Other Outcomes –These codes describe the review and communication of test results to a patient, patient satisfaction, patient functional status, and patient morbidity or mortality

Example: 5005F: patient counseled on self-examination for new or changing moles

Patient Safety- Includes codes that describe patient safety precautions Example: 6015F: Patient receiving or eligible to receive foods, fluids, or medication by mouth.

CATEGORY III EXAMPLE

FORMAT CATEGORY III

CATEGORY II NUMERICAL FIELDS (CONT’D)

Structural Measures-This short section includes codes that describe the setting of the delivered care, and also covers the capabilities of the healthcare provider

Example: 7025F: patient information entered into a reminder system with a target due date for the next mammogram

There are not nearly as many Category II CPT codes as there are in Category I, and in general, you will not use Category II nearly as much. Still, it is an import­ant element of the CPT code set, and you should be familiar with the basics of Category II codes as you prepare for a career in the field.

The third category of CPT codes is made up of temporary codes that represent emergent or experimental services, technology, and procedures. In certain cas­es, you may find that a newer procedure does not have a Category I code. There are codes in Category I for unlisted procedures, but if the procedure, technol­ogy, or service is listed in Category III, you are required to use the Category III code.

Category III codes allow for more specificity in coding, and they also help health facilities and government agencies track the efficacy of new, emergent medical techniques.

Think of Category III as codes that may become Category I codes, or that just don’t fit in with Category I. Category I codes must be approved by the CPT Edito­rial Panel. This Panel mandates that procedures or services must be performed by a number of different facilities in different locations, and that the procedure is approved by the FDA. Due to the nature of emerging medical technology and procedures, it’s not always possible for an experimental procedure to meet these criteria, and thus become a Category I code.

Whether a Category III code becomes a Category I code or not, all Category III codes are archived in the CPT manual for five years. If at the end of this five year period the code has not been converted to Category I, this procedure must be marked with a Category I “unspecified procedure” code. When flipping through the Category III section of the CPT manual, you’ll notice that each of the codes has a phrase listing its sunset date below the code. Think of the sunset dates as expiration dates on the code.

Like Category II, these codes are five characters long, and are comprised of four digits and a terminal letter. In this case, the last letter of Category III codes is T. For example, the code for the fistulization of sclera for glaucoma, through ciliary body is 0123T.

Now that you have a better idea of what CPT looks like, how it’s formatted, and when to use which category of codes, let’s dive a little deeper. We’ll take a look at CPT codes in action in the next course, and CPT Modifiers later in Section 2.

USING CPT

Now you’ve got a basic idea of what CPT is, how it’s organized, and what it’s used for. Let’s look at how to use CPT as a medical coder.

Two notes before we begin this course on the practical applications of the CPT code set. First, there are a number of modifiers which may be added to CPT codes and which provide important additional information about the proce­dure performed. Since it’s helpful to have a working knowledge of CPT in action before we learn about those modifiers, we’re going to learn about them after this course. See the next course, CPT modifiers for more information.

  • USING CPT EXAMPLE
  • CODING PROCESS
  • CATEGORY I

Category I is divided into six sections, which are grouped, for the most part, in numerical order. The sections are Evaluation and Management (E&M), Anesthe­sia, Surgery, Radiology, Pathology and Laboratory, and Medicine. These sec­tions, with the exception of E&M, are in loose numerical order, though you may find some codes from one section referenced in another section.

When you’re coding, you first want to think about what kind of procedure you’re looking at. Was it a patient visit? A surgical procedure? Did a physician admin­ister an X-ray? Did they prescribe medication to the patient? Using that infor­mation, you can start looking at higher and higher levels of specificity. Where on the patient’s body was the surgery performed? Where was the X-ray?

As a coder, your job is to use this information to find the best possible code for the procedure.

As with ICD codes, the process of procedure coding begins with a physician’s report. The coder reads these reports, makes notes of the important procedures and terms used in the report, and then uses this information to determine the best CPT code to input. Let’s take a look at a quick, simple example.

A patient breaks his arm and must go to the emergency room. His injury is seri­ous but is not a risk to the patient’s life or major physiological functions. Leav­ing aside the other procedures that a physician would undoubtedly perform in this situation, let’s look only at the hospital visit itself as a procedure code.

Since this is an instance of Evaluation and Management (E&M), we would turn to the first section of the CPT book. We’d find the “Emergency Department Services” subsection and look at the codes listed there. There are a number of codes for a trip to the ER, and so we have to pick the one that fits our situ­ation best. We’d select 99282 for an “Emergency department visit” of “low to moderate severity.” There are higher and lower levels of severity, but this code fits the visit best: the patient has a moderately severe injury but is in no serious danger.

Like ICD codes, when coding with CPT we always want to code to the highest level of specificity. We never want to stop coding at a CPT code that is simply “close enough” to the procedure performed. In E&M situations, this may be a bit of a judgment call, but as the procedures get more and more specific, there is less room for interpretation.

PARENT CODES

USING CPT EXAMPLE

Here’s a slightly more complicated example. A patient requires a biopsy of a deep, intramuscular cyst in his elbow. This is a surgical procedure, so we’d find the code in the surgery section of the CPT codebook. This is also a procedure related to the musculoskeletal system, which is the first subsection of the Sur­gery section, so we’d flip toward the front of the section. We’d locate the correct part of the body that the surgery is performed on, the humerus (upper arm) and elbow.

From there we’d look at excision codes. The first one that comes up is the excision of soft tissue of the upper arm.

Certain procedures, like the excision of soft tissue for a biopsy in the upper arm, have important variations. In our example, there are two options for this procedure: an excision of soft tissue on the skin of the upper arm, and excision of soft tissue deep in the arm. The latter procedure is indented below the former. The former is the parent code. The specification of the parent code comes after a semi-colon and describes where the excision takes place.

When using the indented code, we’d replace what comes after the semicolon with the procedure listed in the indented code.

Here’s the parent code:

  • – Biopsy, soft tissue of upper arm or elbow area; superficial.

And here’s the code we want:

  • – Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or in­tramuscular).

So we’d select the indented code (24066) and use that as the procedure code for the biopsy on the cyst in our patient’s elbow.

In certain cases, you may find that the procedure you’ve been asked to code cannot be found in the CPT code manual. Remember that we want to code as accurately as possible at all times. In cases where a procedure has not yet made it’s way into the CPT book, we use an unlisted procedure code and file an additional report. This may seem like a lot of extra work, but it’s your duty as a medical coder to maintain the highest level of accuracy.

USING CPT EXAMPLE

PARENTHESES EXAMPLE

GUIDELINES

OUT OF ORDER CODES

Sometimes you may find procedure codes that are out of order in the code man­ual. Placing codes out of numerical order allows for clustering of similar pro­cedures, and can help the medical coder find exactly the right procedure code. These out-of-sequence codes typically have a note instructing the coder to flip to the correct code elsewhere in the book. Think of these out-of-sequence codes as road signs.

The CPT codebook is full of guidelines. Each section of Category I has guidelines specific to that section. The Anesthesia section, for example, instructs coders on how to code the duration of the anesthetic procedure. The Medicine section, for another example, tells coders how to code medicinal services that commonly occur with other medical procedures.

Many codes also have guidelines or instructions, and this is where the CPT code set can get very complex. Certain procedures, like a “photodynamic therapy of second eye” (code 67225), must be used in conjunction with another procedure.

In this case, code 67225 must be coded along with code 67221, for “photodynamic therapy (includes intravenous infusion).”

Other codes may instruct you not to report this code in conjunction with a cer­tain other code. Those procedures may contradict one another or overlap.

Some codes will also have instructions, listed in parentheses, that instruct the coder to look elsewhere for a procedure. Let’s say a coder receives a medical report that a patient had his the ACL in his knee reconstructed during a surgi­cal procedure. That coder would turn to the Surgery section of the code book, then to the musculoskeletal subsection. The coder would find the section on the femur and knee joint, and look at code 27407 – “repair, primary, torn ligament and/or capsule, knee; cruciate.”

The coder would then look at the instructions below this code and see a note: “For cruciate ligament reconstruction, use 27427.” The medical coder needs to describe a reconstruction, not a repair, and so the first code—27407—would be incorrect. The coder would go to 27427, check that it is the correct procedure, and then use that code.

You can think of these instructions and guidelines a little like the “includes,” “excludes,” and “see” commands that you find in the ICD codes. They help guide the coder to the correct spot.

These guidelines and instructions may seem redundant, highly specific, or needlessly complicated, but insurance companies need as much information as possible in order to properly gauge the authority of a medical claim. When in doubt, always follow the rules laid out by the CPT code set (guides.com.,2021)

CODE SYMBOLS – Now that we’ve talked a little bit about using the CPT codebook, it’s time to get into some finer detail. A lot of CPT codes come with important distinctions about their use, placement, or history.

In an effort to save space, and save you from having to read tedious notes on each and every code, the CPT Editorial Board has instituted a number of sym­bols within the codebook. These symbols will tell you important information about the code. Each codebook will have a key that explains these symbols.

We won’t dive fully into all of these symbols, but you should know about a few of the more common ones.

Part of the purpose of the code symbols included in the CPT manual is to tell coders which codes are new, resequenced, or revised procedure codes. The new procedures are marked with a red dot. Heavily revised procedures are marked with a blue triangle. New and revised procedure descriptions are marked with green triangles.

These code symbols also illustrate which codes must be, or cannot be, used in conjunctions with other codes. Certain codes are always paired with other codes. These are called “add-on” codes and are noted with a boldfaced plus sign. Other codes are incompatible with the -51 modifier, and are marked with a circle with a diagonal line through it. We’ll cover what a -51 modifier is in the next section—or now, just know that a procedure marked like this cannot be part of a “multiple procedure” report.

Finally, procedures that require mild sedation are marked with a circle with a dot in the center. This helps remind coders that they should be coding for an anesthesia procedure, in addition to the primary procedure.

APPENDICES When you’re using a code set as large and complicated as CPT, it helps to have a place to turn to for information specific to certain parts of the code set. The appendices at the back of the CPT manual allow you to search newly added codes, CPT modifiers, and a list of CPT add-on codes.

The manual comes with appendices A through O. You should look through these appendices, and pay special attention to Appendix A, the list of CPT modifiers, and Appendix C, which gives clinical examples for particularly confusing codes. (medicalbillingandcoding.org.,2021)

INDEX  Finally, we come to the index. The CPT Index can be used like any other index.

You can use it to track down hard-to-code procedures, services, and tests, and you can search it by both procedure and body part.

For instance, if you weren’t sure how to code exploration of the carotid artery, you Could turn to the index and look up carotid artery. The index would then re­direct you to “Artery, Carotid.” Upon flipping to that section, you’d find the code for an exploration of the carotid artery, 35701. As with ICD, you always flip to the code and examine it before entering it (www.billing-coding.com.,2021)

A trained medical coder never codes from the index. It is merely a tool for find­ing the right information.

Let’s close this course with a quick example of a coder using the index the right way.

MOVING FORWARD

INDEX EXAMPLE

A patient receives an X-ray of both their femoral arteries. The medical report is passed to the coder. The coder knows this is a radiology code, but isn’t sure which procedure to code. She turns to the index and finds Artery, Femoral, but can’t find the proper procedure. The coder is looking for the code for a venogra­phy, which is an invasive procedure that uses a catheter filled with dye, which is injected and traced through the body via X-ray.

The coder turns instead to Venography in the index and finds the code range for venographies in the leg: 75820-75822. The coder turns to this section and finds a number of venographies, each for a specific part of the body. The coder chooses the first one, 75822, for a bilateral venography of the extremities, with radiological supervision and interpretation. In the next course, we’ll learn how CPT modifiers can help us code more accurately, and with a wider range of information.