Chapter 6- Intro To Cpt, Hcpcs And Modifiers

Front 1

CPT I

Back 1

utilizes a 5 digit numeric code and is the most commonly used for medical procedures and services

Front 2

CPT II

Back 2

these codes are optional performance measurement codes used for PQRS. They are categorized by 4 numbers and the letter F . They have no RVU value

Can't be reported alone

Front 3

CPTIII

Back 3

Temporary codes assigned for emerging technology, services, and procedures

Has a T in the last position. Can be reported alone.

Front 4

; Semicolon and indented procedure

Back 4

used so that there is no need for a full description of every procedure

the words before the semicolon are considered the "common procedure"

The indented descriptor is dependent on the preceding "common procedure"

It is not necessary to report the main code when reporting the indented code.

Front 5

+ Add-on codes

Back 5

some of the procedures listed in CPT are carried out in addition to the primary procedure performed.

They are never reported alone.

Front 6

"bullet point" or red circle

Back 6

symbolizes new procedures and services added to the CPT book

Front 7

Blue "triangle"

Back 7

indicates that the description of the code has been revised

Turn to appendix B, look up the code, and read the revisions

Front 8

>< "triangles pointing at each other"

Back 8

indicate new and revised text other than procedure descriptors.
These symbols indicate CPT Editorial Panel Actions

Front 9

"forbidden symbol" (circle with a line through it)

Back 9

indicates codes that are exempt from the use of modifier 51

Front 10

a "bulls-eye symbol"

Back 10

identifies codes that include moderate sedation. (when this symbol appears moderate sedation is not reported separately.)

Front 11

the "lightening bolt symbol"

Back 11

identifies vaccines pending Food and Drug Administration approval.

Front 12

the # sign

Back 12

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

Front 13

Bundled procedure codes

Back 13

codes for proceedures and services deemed necessary to accomplish a major procedure. Bundled procedure codes are not reported separately.

Reporting bundled procedure codes in addition to procedure codes is characterized as unbundling and is considered fraud.

Front 14

NCCI chart rules

Back 14

Column 1/ Column 2 edits are for code pairs that should not be billed together because one service inherently includes the other, unless an appropriate modifier is used

Front 15

GPCI

Back 15

Geographical practice cost index

Front 16

EP

Back 16

Eligible professional

Front 17

RA

Back 17

Remittance Advice

Front 18

QDC

Back 18

Quality Data Code

Front 19

Major surgery global days

Back 19

1 day with 90 days of the postoperative period.

Front 20

Minor surgery global period

Back 20

the day of the surgery and either 0-10 days depending on the procedure

Front 21

Global period for endoscopic procedures

Back 21

There is none unless there is an incision

Front 22

MMM

Back 22

maternity codes; the usual global period concept does not apply

Front 23

XXX

Back 23

The global concept does not apply to this code

Front 24

YYY

Back 24

These are unlisted codes, and subject to individual pricing.

Front 25

ZZZ

Back 25

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

Front 26

Services included in the global period

Back 26

Preoperative visits
Intraoperative services
Complications following surgery (do not include additional trips to the O.R.)
Post operative visitis- follow-up visits
Post surgical pain-management
Supplies and Miscellaneous services

Front 27

Services not included in a global package

Back 27

Initial consultation or evaluation of the problem
Visits unrelated to the diagnosis (unless it is a complication of the surgery)
Treatment for an underlying condition or an added course of treatment that is not part of normal recovery
Diagnostic test and procedures
Clearly distinct surgical procedures during the postoperative period
Complications that require a trip to the O.R.
If a less extensive procedure fails and a more extensive procedure is needed
Certain services performed in the office
Immunosuppressant therapy
Critical Care Services
for minor surgeries no E/M service on same day

Front 28

Modifier 24

Back 28

Unrelated E/M by the same physician or other qualified health care professional during the postoperative period

i.e. a pt comes in for a post-op of a facial lesion and asks for sinus medication

Front 29

Modifier 25

Back 29

Significant, Separately Identifiable E&M Service by the same Dr. or other h.c. professional.

e.g. MVA and the pt has a laceration repair, but the patient is also evaluated for a head injury. Code the laceration repair and the E/M code

Front 30

Modifier 57

Back 30

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

e.g. a pt was seen in the ER with abdominal pain. The surgeon admitted the pt and performed a laproscopic cholecystectomy the same day.

Front 31

Modifier 58

Back 31

Staged or related procedure or service by the same physician or provider during postoperative period.

e.g. a breast biopsy and then 5 days later a mastectomy

Front 32

Modifier 78

Back 32

Unplanned return to the operating room by the same dr or provider

e.g. a pt returns to surgery for possible abdominal bleeding on the same day following colon resection performed earlier by the same surgeon

Front 33

Modifier 79

Back 33

Unrelated procedure or service by the same physician or provider during the post operative period

Front 34

When a code exists in both HCPCS Level II and CPT code

Back 34

Medicare prefers HCPCS Level II

Front 35

c codes

Back 35

identify items that may qualify for pass through payments under the hospital outpatient prospective payment system (OPPS)

Front 36

G codes

Back 36

are used to identify professional healthcare procedures and services that would otherwise be coded in CPT but for which there are no CPT codes

Front 37

H Codes

Back 37

used by Medicaid agencies that are mandated by state law to establish separate codes for identifying mental health service such as alcohol and drug treatment

Front 38

K codes

Back 38

were established by the Durable Medical Equipment Medicare Administrative Contractors (DME MAC)

Front 39

Q codes

Back 39

services that would not be given a CPT code such as drugs, biologicals, and other types of medical equipment or services which are not identified by national level II codes but are needed for claims processing

Front 40

S codes

Back 40

are used by BCBSA and the HIAA to report drugs, services and supplies for which their are no national code but are needed by the private sector to implement policies, programs, or claims processing

Front 41

T codes

Back 41

are designated by state agencies for use by Medicaid state agencies to establish codes for items with no permanent national codes (T codes are not used by Medicare but can be used by private insurers)

Front 42

IA

Back 42

Intraarterial

Front 43

IT

Back 43

intrathecal- administrtion of the drug is given into the subdural space of the spinal cord.

Front 44

SC

Back 44

Subcutaneous adminstration

Front 45

INH

Back 45

administration by inhalation

Front 46

VAR

Back 46

various- commonly administered into joints, cavities, tissues, or topical applications

Front 47

OTH

Back 47

other routes of administration such as suppositories

Front 48

normal healthy patient- anesthesia code

Back 48

P1

Front 49

patient with mild systemic disease- anesthesia code

Back 49

P2

Front 50

patient with severe systemic disease

Back 50

P3

Front 51

patient with severe systemic disease that is constant threat to life

Back 51

P4

Front 52

a moribund patient who is not expected to survive the operation

Back 52

P5

Front 53

a declared brain-dead patient whose organs are being removed for donor purposes

Back 53

P6

Front 54

enteral feeding

Back 54

tube feeding

Front 55

parenteral

Back 55

provided intravenously

Front 56

BO

Back 56

Orally administered nutrition, not by feeding tube

Front 57

E2

Back 57

lower left eyelid

Front 58

NU

Back 58

new equipment

Front 59

TC

Back 59

Technical component

Front 60

LT

Back 60

left side

Front 61

If a category III code is available

Back 61

you must put the category III code instead of an unlisted code

Front 62

Separate Procedure

Back 62

s seen at the end of a code descriptor, it serves as a reminder to coders the separate procedure is ordinarily a component of a larger procedure and should only be reported separately when it is performed alone or when it is unrelated to the primary service.

Front 63

Appendix B of the CPT book

Back 63

Summary of Additions, Deletions, and Revisions (the codes with the bullet or red circle next to it.)

Front 64

Appendix E in the CPT book

Back 64

a list of all the codes modifier 51 exempt (those with a forbidden sign)

Front 65

Appendix G in the CPT book

Back 65

A summary of codes that include moderate sedation (those with a bulls eye)

Front 66

Appendix K in the CPT book

Back 66

list of codes pending FDA approval (those with a lightening bolt)

Front 67

Appendix N in the CPT book

Back 67

a list of codes that have been re-sequenced (those with a # sign next to it.)

Front 68

RBRVS is calculated based on

Back 68

on physician work value, practice expense, and a component based on the Professional liability insurance.

Front 69

Appendix A in the CPT book

Back 69

lists modifiers in separate categories.

Front 70

Appendix D in the CPT book

Back 70

summary of codes not reported as single or stand
alone codes. The codes listed in this appendix are identified throughout CPT with the plus symbol.

Front 71

Modifier 63

Back 71

appended to CPT codes to indicate the procedure was
performed on infants weighing less than 4kg

Front 72

Appendix F

Back 72

contains a summary of CPT® codes exempt from the use of Modifier 63

Front 73

Appendix J

Back 73

provides a summary that assigns each sensory,
motor, and mixed nerve with its appropriate nerve conduction study code in order to enhance
accurate reporting of codes. This appendix also contains a table showing the reasonable maximum
number of studies for a physician to arrive at a diagnosis.

Front 74

Appendix L

Back 74

important for coding vascular procedures. Turn to appendix L. Based on the
assumption that a vascular catheterization has a starting point of the aorta, Appendix L illustrates
vascular “families” emerging from the aorta using brackets to identify the order of vessels: First, Second, Third, and Beyond Third Order of vascular branches.
The largest “First Order Branch” emerges from the aorta. The “Second Order Branch” emerges from the “First Order Branch”, and so on to include the vessel‟s “Third Order Branch” and “Beyond Third Order Branches”. If the starting point of the catheterization is other than the aorta, the orders might change.

Front 75

Appendix M

Back 75

contains a crosswalk noting the deleted CPT codes and descriptors from the previous year to the current year. This is an essential tool when updating charge m
asters, charge capture documents, and any system or process using CPT codes.

Front 76

Modifiers 54 through 56

Back 76

indicate a provider has performed only a portion of the global service. 54 represents surgical care only, 55 the postoperative management only, and 56 represents the preoperative management only.

Front 77

Modifier 22

Back 77

Increased Procedural Service. When the usual work to perform a procedure is significantly greater than typically required, you would add this modifier. The
documentation in the operative report must support the additional work and the reason for the additional work which may be increased time, technical difficulty, severity of patient‟s condition, etc. This modifier is not used on an evaluation and management service codes.

Front 78

Modifier 50

Back 78

indicates Bilateral Procedure. The CPT definition for modifier 50 is “unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier
Pay close attention to the code descriptions as some codes include in their description,unilateral or bilateral‟. When you see codes with “bilateral” in the descriptor, you would not append modifier 50.

Front 79

Modifier 51

Back 79

Used when multiple procedures are performed during the same session by the same
provider. The primary procedure would be reported as listed and the additional procedure(s)
identified with modifier 51. An example would be an orthopedic surgeon who performed a closed
treatment of a femoral shaft fracture on the left leg and a closed treatment of a right knee dislocation during the same operative session.
Modifier 51 isn't used on E/M services, Physical Medicine or Rehabilitation Services, the provision of
supplies such as vaccines or codes designated as 'add-on' codes

Front 80

Modifier 52

Back 80

indicate reduced services. If a procedure is partially reduced or eliminated at the provider's discretion

If a bilateral service is performed unilaterally, modifier 52 would be appended to the procedure code.

Front 81

Modifier 53

Back 81

Discontinued procedure. If a procedure is terminated due to extenuating circumstances and/or circumstances that threaten the well-being of the patient, you would use this modifier with the procedure code.

DO NOT to use 53 to report the elective cancellation
of a procedure prior to the induction of anesthesia and/or surgical prep in the OR suite.

Front 82

Modifier 59

Back 82

Distinct procedural service. You might use it in these instances: for procedures not normally reported together; a different site or organ system; a separate
incision/excision; a separate lesion.

An example would be a patient who had a colonoscopy and a lesion is removed proximal to the
splenic flexure. During the same colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure.

Front 83

Modifier 76

Back 83

used to report a Repeat procedure or service by the same physician or other qualified health care professional. An example would be a patient who goes to the Emergency Room with trauma to the chest.
A two-view chest X-ray is taken that shows a pneumothorax. After a chest tube is placed a repeat two-view chest X-ray is taken to verify the placement of the chest tube. You would report 71020 and 71020-76.

Front 84

Modifier 77

Back 84

Repeat procedure by ANOTHER physician or OTHER qualified health care professional. An example is a patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG. The second EKG would
be reported with modifier 77.

Front 85

Modifier 62 and 66

Back 85

multiple surgeon modifiers. Modifier 62 is used when two surgeons work together as primary surgeons performing distinct parts of a single surgical procedure. Each surgeon would dictate an operative report of their distinct operative work and each would submit the same CPT code and append modifier 62.

Modifier 66 indicates a surgical team was used for the procedure

Front 86

modifiers are 80, 81 and 82

Back 86

Assistant surgeon modifiers

Front 87

Modifiers 90, 91, and 92

Back 87

laboratory modifiers