Chapter 6 - Introduction To CPT, Surgery Guidelines, HCPCs, And Modifiers

Question 1

Category I CPT codes

Answer 1

5 numeric digits for each code. These codes are commonly used for medical services, procedures and professional services.

Question 2

Category II CPT codes

Answer 2

Optional performance measurement tracking codes designed to minimize administrative burden because they facilitate data collection about quality of care. Listed near the back of the CPT book. Alphanumeric codes with the letter F in the last position. Can be reported in addition to category I codes

Question 3

Category III CPT codes

Answer 3

Temporary codes for emerging technology, services or procedures. Alphanumeric with T in the last position. Can stand alone if a category III code fully represents a case

Question 4

; semicolon and indented procedure

Answer 4

Used so the common portion of a procedure so it doesn’t have to be listed each time. Everything before the ; is common to the procedure. Indented portion is specific to each code. No need to report main common portion when using an indented code

Question 5

+ Add On Code

Answer 5

Never reported alone and always accompany a primary code. Never reported with modifier 51.

Question 6

🚫 Forbidden symbol means

Answer 6

Code is exempt from the use of modifier 51

Question 7

⚡️ lightning bolt symbol identifies

Answer 7

Vaccines pending FDA approval.

Question 8

pound sign identifies

Answer 8

Codes that have been resequenced and are out of numerical order.

Question 9

Each -

Answer 9

Each separate instance. Added to a primary code for each separate instance of a procedure.

Question 10

Each additional -

Answer 10

Each instance, above and beyond the first code, up to the amount given is reported with this code. No modifier 51 used

Question 11

Included when performed -

Answer 11

Indicates a procedure, when performed, is not reported separately because it is considered included in the base procedure

Question 12

Part thereof -

Answer 12

Typically seen in add on codes. Part of or up to the number or percentage listed. If over that number another code is used

Question 13

Separate procedure -

Answer 13

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

Question 14

Single or multiple -

Answer 14

Indicates the code is only reported once

Question 15

Units -

Answer 15

Number of times a single CPT code is reported

Question 16

Separate procedure

Answer 16

When a service or procedure is designated as separate procedure it is performed alone, or is considered unrelated to another procedure provided during the same visit.

Question 17

Unilateral or bilateral

Answer 17

Modifier for bilateral not necessary as the procedure can be used for unilateral or bilateral

Question 18

Resource based relative value scale (RBRVS)

Answer 18

System to reimburse physicians based on the CPT code submitted. Each CPT code has a Relative Value Unit assigned when multiplied by the conversion factor and geographic region adjustment creates the reimbursement rate

Question 19

Relative Value Unit

Answer 19

Assigned to each CPT code. Considers three things. Physician work, practice expense, and professional liability / malpractice insurance

Question 20

Steps for coding multiple procedures

Answer 20

1. Select all procedure codes
2. Check codes against NCCI and the mutually exclusive table for bundling and eliminate and bundled codes. If documentation supports a modifier to report a bundled code append modifier to the column 2 code
3. Check RVU’s for remaining codes and sequence by RVU, highest to lowest

Question 21

Place Of Service codes

Answer 21

Two digit codes placed on all claims to denote the setting where the service was provided. Found in the front of the CPT book

Question 22

CPT category 1 publish and effective dates

Answer 22

Published late summer / early fall and effective Jan 1 of the next year

Question 23

CPT category II publish and effective dates

Answer 23

Released three times yearly then effective three months after being released

Question 24

CPT category III codes publish and effective dates

Answer 24

Published Jan 1 and July 1. Effective 6 months after they are published

Question 25

Global package

Answer 25

Payment for surgical procedures includes standard pre op, intra op, and post op services. Can be furnished in any service location. Commercial plans may vary in number of post op days included

Question 26

Major surgery days

Answer 26

1 day pre op and 90 days post op

Question 27

Minor surgery days

Answer 27

Day of procedure for pre op and 0 or 10 days depending on procedure performed

Question 28

000 status indicator

Answer 28

Endoscopies and minor surgeries with pre op and post op relative values on the day of procedure are reimbursable.

Question 29

010 status indicator

Answer 29

Minor procedures with relative values on the day of the procedure and 10 days post op are reimbursable

Question 30

090 status indicator

Answer 30

Major procedures with 1 day pre op and 90 days post op are considered to be a component of the global package of the major surgery.

Question 31

MMM status code

Answer 31

Maternity codes. Usual global period concept does not apply to these codes

Question 32

XXX status indicator

Answer 32

Global concept does not apply to this code

Question 33

YYY status indicator

Answer 33

Unlisted code subject to individual pricing

Question 34

ZZZ status indicator

Answer 34

Add on codes. Related to another service and always included in the global period of the primary service

Question 35

Services included in the global package

Answer 35

Pre op visits per procedure period, Intra op services, complications following surgery, post op visits per procedure period, post surgical pain management by the surgeon, miscellaneous services

Question 36

Modifier 24

Answer 36

Unrelated E/M service by the same physician or other qualified healthcare professional during a post op period. Must be sufficiently documented to support use

Question 37

Modifier 25

Answer 37

Significant, separately identifiable E/M on the same day as a procedure

Question 38

Modifier 57

Answer 38

Decision for surgery. E/M provided day before or day of surgery when the decision to have surgery was made.

Question 39

Modifier 58

Answer 39

Staged or related procedure during post op period. Maybe necessary to indicate that a procedure was planned before the procedure, more extensive than the procedure, or for therapy following a diagnostic procedure

Question 40

Modifier 78

Answer 40

Unplanned return to operating room following initial procedure for a related procedure during the post op period.

Question 41

Modifier 79

Answer 41

Unrelated procedure or service during the post op period. May be necessary to indicate another procedure or service unrelated to the procedure was needed during the post op phases

Question 42

Permanent hcpc codes

Answer 42

Updated once a year on January 1, but codes can be deleted or added throughout the year. National coding system managed by multiple agencies working together

Question 43

Miscellaneous hcpc codes

Answer 43

Used when no existing national code describes the item or service being billed. Manually reviewed with items needing clear descriptions, costs, and medical need

Question 44

Temporary National hcpc codes

Answer 44

Allow insurers to establish codes before Jan 1 updates. Updated quarterly

Question 45

Level I hcpc modifiers

Answer 45

Added to procedure or service codes to specify specific special circumstances

Question 46

Level II hcpc modifiers

Answer 46

Codes for services related to anatomy, transportation, anesthesia, coronary arteries, ophthalmology, professional services, end stage renal disease and dental care

Question 47

Ambulance origin and destination codes

Answer 47

Two alpha characters combined. First is origin and second is destination. Added to ambulance service codes

Question 48

A codes

Answer 48

Transportation services, medical and surgical supplies, administrative, misc, and investigational supplies, procedures and services

Question 49

B codes

Answer 49

Supplies and equipment specific to parenteral and enteral therapies

Question 50

C codes

Answer 50

Introduced to report surgical supplies and drugs specific to procedures performed under the Outpatient Prospective Payment System (OPPS). Report use of goods that Medicare will pay in addition to the Ambulatory Payment Classification (APC). Only facilities using APC can use C codes

Question 51

E codes

Answer 51

Durable medical equipment. Must be able to be used repeatedly, serve a medical purpose, not generally useful to a person in absence of illness or injury, appropriate for home use

Question 52

G codes

Answer 52

Temporary codes. Reviewed for possible inclusion in CPT. Until replaced by a CPT code G codes are used to report specific procedures and services that do not have a Level I or II code

Question 53

H codes

Answer 53

Used by Medicaid agencies that are mandated by state law to establish separate codes to report alcohol and drug treatment therapies

Question 54

J codes

Answer 54

Codes and descriptions specific to drugs and biologicals, injectable chemo drugs. Usually injected. Sub category for contraceptive devices. Must meet medical diagnosis criteria for reimbursement.

Question 55

K codes

Answer 55

Temporary DME codes

Question 56

L codes

Answer 56

Orthotic devices, prosthetics.

Question 57

M codes

Answer 57

Procedures and services not normally covered by Medicare

Question 58

P codes

Answer 58

Lab services and travel allowances specific to homebound and nursing homebound patients.

Question 59

A codes

Answer 59

Temporary codes for supplies, procedures, and services until a Level I CPT code is assigned.

Question 60

R codes

Answer 60

Transportation of equipment from a facility to a home or nursing home for a diagnostic procedure

Question 61

S codes

Answer 61

Temporary codes for services not covered by Medicare. Can be paid by commercial insurance. Also used for tracking purposes.

Question 62

T codes

Answer 62

Added in 2002 for state Medicaid agency reporting

Question 63

V codes

Answer 63

Vision and hearing services. Speech pathology is included. Hearing services are not covered by Medicare except for specific CPT codes