Chapter 6 - Introduction To CPT, Surgery Guidelines, HCPCs, And Modifiers Flashcards
Category I CPT codes
5 numeric digits for each code. These codes are commonly used for medical services, procedures and professional services.
Category II CPT codes
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
Category III CPT codes
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
; semicolon and indented procedure
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
+ Add On Code
Never reported alone and always accompany a primary code. Never reported with modifier 51.
🚫 Forbidden symbol means
Code is exempt from the use of modifier 51
⚡️ lightning bolt symbol identifies
Vaccines pending FDA approval.
pound sign identifies
Codes that have been resequenced and are out of numerical order.
Each -
Each separate instance. Added to a primary code for each separate instance of a procedure.
Each additional -
Each instance, above and beyond the first code, up to the amount given is reported with this code. No modifier 51 used
Included when performed -
Indicates a procedure, when performed, is not reported separately because it is considered included in the base procedure
Part thereof -
Typically seen in add on codes. Part of or up to the number or percentage listed. If over that number another code is used
Separate procedure -
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.
Single or multiple -
Indicates the code is only reported once
Units -
Number of times a single CPT code is reported
Separate procedure
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.
Unilateral or bilateral
Modifier for bilateral not necessary as the procedure can be used for unilateral or bilateral
Resource based relative value scale (RBRVS)
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
Relative Value Unit
Assigned to each CPT code. Considers three things. Physician work, practice expense, and professional liability / malpractice insurance
Steps for coding multiple procedures
- Select all procedure codes
- 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
- Check RVU’s for remaining codes and sequence by RVU, highest to lowest
Place Of Service codes
Two digit codes placed on all claims to denote the setting where the service was provided. Found in the front of the CPT book
CPT category 1 publish and effective dates
Published late summer / early fall and effective Jan 1 of the next year
CPT category II publish and effective dates
Released three times yearly then effective three months after being released
CPT category III codes publish and effective dates
Published Jan 1 and July 1. Effective 6 months after they are published
Global package
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
Major surgery days
1 day pre op and 90 days post op
Minor surgery days
Day of procedure for pre op and 0 or 10 days depending on procedure performed
000 status indicator
Endoscopies and minor surgeries with pre op and post op relative values on the day of procedure are reimbursable.
010 status indicator
Minor procedures with relative values on the day of the procedure and 10 days post op are reimbursable
090 status indicator
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.
MMM status code
Maternity codes. Usual global period concept does not apply to these codes
XXX status indicator
Global concept does not apply to this code
YYY status indicator
Unlisted code subject to individual pricing
ZZZ status indicator
Add on codes. Related to another service and always included in the global period of the primary service
Services included in the global package
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
Modifier 24
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
Modifier 25
Significant, separately identifiable E/M on the same day as a procedure
Modifier 57
Decision for surgery. E/M provided day before or day of surgery when the decision to have surgery was made.
Modifier 58
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
Modifier 78
Unplanned return to operating room following initial procedure for a related procedure during the post op period.
Modifier 79
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
Permanent hcpc codes
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
Miscellaneous hcpc codes
Used when no existing national code describes the item or service being billed. Manually reviewed with items needing clear descriptions, costs, and medical need
Temporary National hcpc codes
Allow insurers to establish codes before Jan 1 updates. Updated quarterly
Level I hcpc modifiers
Added to procedure or service codes to specify specific special circumstances
Level II hcpc modifiers
Codes for services related to anatomy, transportation, anesthesia, coronary arteries, ophthalmology, professional services, end stage renal disease and dental care
Ambulance origin and destination codes
Two alpha characters combined. First is origin and second is destination. Added to ambulance service codes
A codes
Transportation services, medical and surgical supplies, administrative, misc, and investigational supplies, procedures and services
B codes
Supplies and equipment specific to parenteral and enteral therapies
C codes
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
E codes
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
G codes
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
H codes
Used by Medicaid agencies that are mandated by state law to establish separate codes to report alcohol and drug treatment therapies
J codes
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.
K codes
Temporary DME codes
L codes
Orthotic devices, prosthetics.
M codes
Procedures and services not normally covered by Medicare
P codes
Lab services and travel allowances specific to homebound and nursing homebound patients.
A codes
Temporary codes for supplies, procedures, and services until a Level I CPT code is assigned.
R codes
Transportation of equipment from a facility to a home or nursing home for a diagnostic procedure
S codes
Temporary codes for services not covered by Medicare. Can be paid by commercial insurance. Also used for tracking purposes.
T codes
Added in 2002 for state Medicaid agency reporting
V codes
Vision and hearing services. Speech pathology is included. Hearing services are not covered by Medicare except for specific CPT codes
