Chapter

5
CPT® Concepts

The American Medical Association (AMA) maintains the In general, CPT® codes are divided as follows:
Current Procedural Terminology (CPT®) code set to describe Evaluation and Management 99201–99499
services generally provided by healthcare professionals to
individual patients. CPT® codes are intended to describe Anesthesia 00100–01999
accurately those services, and to provide a convenient method
of communicating this information between providers, payers, Surgery 10021–69990
administrators, and regulators. The codes are shorthand
Radiology 70010–79999
notations that, when used properly, provide essential data to all
those providing care, paying for that care, and overseeing the Pathology and Laboratory 80047–89398
quality of care in the healthcare system. CPT® codes are part of
the Healthcare Common Procedure Coding System (HCPCS) Medicine 90281–99607
code set.
Each of the sections may be further divided. For example, the
The medical biller must be familiar with the CPT® coding surgery codes are generally divided as follows:
system and the information readily available in the CPT®
codebook. The CPT® codebook includes three categories of Integumentary System 10021–19499
codes. Category I codes are those codes that describe services Musculoskeletal System 20005–29999
generally acceptable in the current healthcare system and are
performed by many providers in multiple clinical locations. Respiratory System 30000–32999
These procedures are generally considered to be within
standard medical practice, but the existence of a code does not Cardiovascular System 33010–37799
indicate the conditions under which the use of the particular
procedure would be considered the standard of care. Category Hemic and Lymphatic Systems 38100–38999
I codes are five-digit numerical codes (eg, 12345). Mediastinum and Diaphragm 39000–39599
Category II codes are used primarily as performance measures. Digestive System 40490–49999
Medicare and other payers utilize these codes to document
the quality of services provided to individual patients, Urinary and Genital Systems 50010–53899
and to the patient population under the care of individual
providers. Widespread use of these codes and changes to data Male Genital System 54000-55899
systems may reduce the manual efforts currently necessary to
document provider performance through chart reviews. CPT® Female Genital System 56405-58999
Category II codes are four-digit numeric codes, followed by the Maternity Care and Delivery 59000–59899
letter F (eg, 1234F).
Endocrine System 60000–60699
Category III codes are a set of temporary codes used to
designate emerging technologies, services, and procedures. Nervous System 61000–64999
These codes may be used to document that many providers
perform this service or procedure across the country, which is Eye and Ocular Adnexa 65091–68899
required for eventual inclusion as a Category I code. Category
III codes are four-digit numeric codes, followed by the letter T Auditory System 69000–69979
(eg, 1234T).
The CPT® code that most accurately describes the service
CPT® is organized by code sections, each of which designates provided should be used to designate that service. If a specific
a specific grouping of codes. Placement of a procedure within code accurately describes the actual services provided, it
one code section does not reflect which providers may perform is improper to utilize a more general code or an “unlisted
the service. Providers may perform services within the scope procedure” code.
of their licenses regardless of the CPT® code that describes the
particular service.

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 71
CPT® Concepts Chapter 5

An established set of conventions and symbols are used  Designates code descriptors that have been altered.
throughout the CPT® codebook. They are designed to Appendix B shows what has been altered in the
communicate information clearly and in an easily recognizable description of the CPT® code.
manner.

; Semicolon and Indented Procedure—The use of the Example

semicolon was developed so that CPT® did not have to list
74250 R adiologic examination, small intestine, includes
full descriptions for every code in the publication. A CPT®
multiple serial images
procedure or service code that contains a semicolon is
divided into two parts; the description before the semicolon In Appendix B, the following appears:
and the description after the semicolon.
74250 R adiologic examination, small intestine, includes
(a) Th
 e words before the semi-colon are considered the multiple serial films images.
“common procedure” in the code descriptor.

(b) The indented descriptor is dependent on the preceding Indicates new and revised text, such as parenthetical
 
“common procedure” code descriptor. notes and guidelines. Revised text is in green.
(c) It is not necessary to report the main code (eg, 20100)
when reporting the indented codes (eg, 20101, 20102 or Example
20103).
+ 66990 Use of ophthalmic endoscope (List separately in addition
to code for primary procedure)
Example
(66990 may be used only with codes 65820, 65875, 65920,
20100 E xploration of penetrating wound (separate procedure); 66985, 66986, 67036, 67039, 67040, 67041, 67042, 67042, 67113)
neck
20101 chest
+ Designates add-on codes, which are also listed in
20102 abdomen/flank/back Appendix D. Modifier 51 is never appended to an
20103 extremity add-on code. An add-on code is never reported alone
and is always reported with a parent code.
The full descriptor for CPT® code 20101, 20102 and 20103 includes
the portion before the semicolon in 20100 to make the full
description of the codes: Example:
20101 Exploration of penetrating wound (separate procedure); 16035 Escharotomy; initial incision
chest
+16036 each additional incision (List separately in addition to
20102 E xploration of penetrating wound (separate procedure); code for primary procedure)
abdomen/flank/back
(Use 16036 in conjunction with 16035)
20103 E xploration of penetrating wound (separate procedure);
In this example, the add-on code, 16036, should always be
extremity
reported with its parent code 16035. Two parenthetical instruc-
tions guide the coding. First, in the description of 16036, it
states to list separately in addition to the code for the primary
One or more symbols may be attached to specific CPT® codes procedure. This indicates another procedure code should also
to designate information relevant to that particular code. These be reported. The second parenthetical note states to use 16036
symbols include the following: in conjunction with 16035. This parenthetical instruction gives us
  New procedure or service: this symbol appears for only the primary code to report with the add-on code.
one year after a code is added to the CPT® code set.

Example  Designates codes that are exempt from the use of

modifier 51, but are not add-on codes. Add-on codes
54437 Repair of traumatic corporeal tear(s) are inherently exempt from modifier 51. Modifier 51
indicates multiple procedures. Codes that are exempt
from modifier 51 are procedures that are typically

72 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

performed with other procedures, but not always. than deleting and renumbering, resequencing allows
These are also listed in Appendix E. existing codes to be relocated to an appropriate
location for the code concept, regardless of the
numeric sequence. The pound sign appears next to the
Example:
out-of-sequence code, and that code is reproduced in
17004 Destruction (eg, laser surgery, electrosurgery, cryosur- correct sequence in the codebook with a notation of
gery, chemosurgery, surgical curettement), premalignant where to find the code with its description.
lesions (eg, actinic keratoses), 15 or more lesions.
When procedure code 17004 is reported with another procedure, Example:
modifier 51 is not appended to 17004.
When you look for CPT® code 24071 you see:
# 24071 Code is out of numerical sequence. See 24065-24155
 Designates codes that include moderate sedation This directs us to look at code range 24065-24155 to locate 24071.
as an inherent part of the procedure. When a code Code 24071 is found under code 24075:
has this symbol, it is not appropriate to report the
moderate sedation codes 99143-99145 in addition to 24075 Excision, tumor, soft tissue of upper arm or elbow area,
the procedure as it is included in the payment for the subcutaneous; less than 3 cm
procedure. These are also listed in Appendix G. # 24071 3 cm or greater

Example:
The medical biller should be familiar with these symbols and
10030 I mage-guided fluid collection drainage by catheter how they affect coding and payment for services. For example,
(eg, abscess, hematoma, seroma, lymphocele, cyst), if an add-on code is included on a claim, the parent code must
soft tissue (eg, extremity, abdominal wall, neck), also be included. It is incorrect to submit an add-on code
percutaneous without the parent code. The symbols also designate proper
payment guidelines. For example, codes designated as modi-
In this example, CPT® codes 99143-99145 would not be reported
fier 51 exempt are not subject to the usual multiple surgical
in addition to 10030 when moderate sedation is performed
reductions that are taken when more than one procedure is
because it is included in the procedure.
performed during the same setting.

The CPT® contains significant information beyond the codes

 Designates vaccine codes pending approval from the and their descriptors. Being familiar with this additional infor-
Food and Drug Administration (FDA). Some vaccine mation is critical to utilizing the CPT® to its fullest potential.
products are assigned a CPT® Category I code in Each section of the CPT® has an introduction that provides
anticipation of future approval from the FDA. When general guidelines to the use of those codes.
the vaccine has been approved by the FDA, a revision
notation will be provided on the AMA CPT® “Cate-
Example
gory I Vaccine Codes” website: www.ama-assn.org/
ama/pub/category/10902.html (see Appendix K for A claim is billed with procedure codes 14020 and 11402. In the
Products Pending FDA Approval).These are also listed CPT® codebook, the following guidelines are found for an adja-
in Appendix K. cent tissue transfer:
Adjacent Tissue Transfer or Rearrangement
Example:
Codes 14000-14302 are used for excision (including lesion)
90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, and/or repair by adjacent tissue transfer or rearrangement
for intramuscular use. (eg, Z-plasty, W-plasty, V-Y plasty, rotation flap, random island
flap, advancement flap). When applied in repairing lacerations,
the procedures listed must be performed by the surgeon to
# A pound sign indicates that the code has been accomplish the repair. They do not apply to direct closure or
sequenced out of order. The AMA began organizing rearrangement of traumatic wounds incidentally resulting in
codes out of order in 2010 to combat CPT®’s lack of these configurations. Undermining alone of adjacent tissues to
flexibility and capacity for new code creation. Rather achieve closure, without additional incisions, does not constitute
adjacent tissue transfer, see complex repair codes (13100–13160).

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 73
CPT® Concepts Chapter 5

The excision of a benign lesion (11400–11446) or a malignant 2) The name of the procedure or medical service
lesion (11600–11646) is not separately reportable with codes documented: eg, Removal, Suture, Fasciotomy
14000–14302.
3) The name of the anatomic site or organ: eg, Neck, Skin,
In this example, subsection guidelines for Adjacent Tissue Transfer Femur
or Rearrangement indicates that a benign lesion removal is not
reportable with the adjacent tissue transfer. Code 11402 should 4) Synonyms, eponyms and abbreviations: eg, Toe/Inter-
not be reported on the same claim as 14020, so this would be phalangeal Joint, Watson-Jones Procedure, EEG
an error on the claim. The more inclusive code (14020) should be
reported alone. Information in the alphabetic index expands by subterms
listed alphabetically below each main term. The subterms
further clarify the main term by noting condition, procedure,
The medical biller should be familiar with the use of or anatomic site. With each subterm is a listing of the CPT®
parenthetical notes as directions that apply to specific codes or code or code ranges located in the numeric section of the
groups of codes. These notes direct the use of specific codes for CPT® codebook.
services or prohibit the use of certain code combinations.
To clarify and ensure selection of the correct CPT® code, the
code or code range from the alphabetic index is located in the
Example CPT® numeric section.
A claim is billed with procedure codes 15757, 69990. You can find
the following parenthetical instructions under code 15757 in the Example
CPT® codebook:
Let’s look for the CPT® code for a flexible diagnostic colonoscopy.
15757 Free skin flap with microvascular anastomosis. Look in the CPT® alphabetic index for Colonoscopy/Flexible/
(Do not report code 69990 in addition to code 15757) Diagnostic.

In this example, there is a parenthetic instruction to give Colonoscopy

guidance on reporting of the add-on code 69990. The Flexible
parenthetic instruction states not to report add-on code 69990 in
addition to code 15757. Diagnostic. . . . . . . . . . . . . 45378

69990 is not reported on the same claim as 15757 and this would When CPT® code 45378 is referenced in the numeric section,
be an error on the claim. additional information for correct code assignment is defined.
The defining information written in the numeric section for the
CPT® code 45378 is:
It is also important to understand how to use the index
effectively as a cross-reference to locate specific procedure
codes based on anatomic locations, general procedural Section: Surgery
designations, acronyms, abbreviations, and other criteria that Subsection: Digestive System (40490–49999)
may assist the medical biller in identifying which code should
be used to describe a particular procedure. Subheading: Colon and Rectum (45000–45999)
To assign appropriate CPT® codes, the documentation is Category: Endoscopy (45300–45399)
thoroughly reviewed and the procedure or service is selected
to accurately describe the care provided. The CPT® alphabetic 45378 Colonoscopy, flexible; diagnostic, including collection
index is referenced for a CPT® code or code range. After of specimen(s) by brushing or washing, when performed
locating the approximate CPT® code in the alphabetic index, (separate procedure)
the numeric section is used for code specifications. A code is
not to be selected using only the alphabetic index.  CPT® Changes: An Insider’s View 2015

The CPT® Index is alphabetized with main terms organized by  CPT® Assistant Spring 94:9; Aug 99:3, Jan 02:12, Jan
condition, procedure, anatomic site, synonyms, eponyms, and 04:4, May 05:3, Dec 10:3, Apr 11:12, Jan 13:11, Nov 14.3,
abbreviations. For example: Dec 14.3

1) A condition: eg, Cerumen, Cyst, Angle Deformity (Do not report 45378 in conjunction with 45379-45393,
45398)

74 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

(For colonoscopy with decompression [pathologic 3. Parenthetic instructions—below code 45378, there are
distention], use 45393) two parenthetic instructions. The first indicates not
to report 45378 in conjunction with 45379-45393, and
CPT® conventions, symbols, and references are taken under 45398. The second indicates that code 45393 should be
consideration to report the correct use of the code (as seen in reported for a colonoscopy with decompression.
the 45378 example). Important considerations found in the
example’s descriptor include: All information from the CPT® numeric section should
1. Separate Procedure—When the service or procedure be analyzed before assigning a CPT® code. Some health
is designated as a “separate procedure” it is performed plans have specific billing instructions and coverage
alone, or is considered unrelated to another procedure/ issue clarifications posted on their websites for review
service provided during the same patient encounter. prior to code assignment. CMS publishes Internet Only
Manuals (IOMs) and a Medicare Coverage Center
Modifier 59 may be appended to a “separate procedure” that can help medical billers with billing and coverage
designated CPT® code if guidelines are met within the instructions on their website. Online documents are
medical documentation. Modifier 59 guidelines and its not updated with every new Transmittal, Program
uses will be discussed later. Memorandum, or Medlearn Matters article, so pay
particular attention to when these documents were last
2. This example cites two references: updated. Each Medicaid agency maintains its website
and program requirements.
 CPT® Assistant—the Spring 1994 issue, page 9; the
August 1999 issue, page 3; the January 2002 issue, page Internet-Only Manuals (IOMs): www.cms.gov/
12; the January 2004 issue, page 4; the May 2005 issue, Regulations-and-Guidance/Guidance/Manuals/
page 3; the December 2010 issue, page 3; the April 2011 Internet-Only-Manuals-IOMs.html. Some of the main
issue, page 12; the January 2013 issue, page 11; the internet only manuals to review for information include:
November 2014 issue, page 3; and the December 2014
issue, page 3.

CPT® Changes: An Insider’s View 2015. This indicates

a change was made to the procedure description in the
year 2015.

Publication # Title
100-01 Medicare General Information, Eligibility and Entitlement Manual
100-02 Medicare Benefit Policy Manual
100-03 Medicare National Coverage Determinations (NCD) Manual
100-04 Medicare Claims Processing Manual

Medicare Coverage Center: www.cms.gov/Medicare/Coverage/CoverageGenInfo/index.html

Section Review 5.1

1. What does the icon indicate for procedure code 44370?

A. Procedure code 69990 cannot be reported in addition to 44370.

B. Procedure codes 99143-99145 cannot be reported in addition to 44370.
C. Procedure code 44370 should always be reported with 69990.
D. A procedure code from range 99143-99145 should be reported in addition to 44370.

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 75
CPT® Concepts Chapter 5

2. Which option shows the correct way to report procedure code 22515?

A. 22515
B. 22514, 22515
C. 22514, 22515, 99144
D. 22515, 99144

3. What is the full descriptor for CPT® code 35632?

A. Ilio-celiac
B. Aortioceliac, aortomesenteric, aortorenal, ilio-celiac
C. Bypass graft, with other than vein; ilio-celiac
D. Bypass graft, with other than vein; common carotid-ipsilateral internal carotid, ilio-celiac

4. What is the CPT® code for removal of a pancreatic calculus?

A. 48020
B. 43264
C. 43264, 48020
D. 43265

5. What CPT® code(s) is/are reported for removal of two skin tags?

A. 11200
B. 11200 x 2
C. 11200, 11201
D. 11201 x 2

The appendices also provide information that is both useful Appendix B

and necessary for successful coding as a payer or provider. The Summary of Additions, Deletions, and Revisions—Appendix
medical biller should have a general familiarity with these and B contains the actual changes and additions to the CPT® codes
will likely find the following appendices the most useful: from the previous year to the current publication.
Appendices A through O are located in the CPT® codebook Appendix C
after the Category III CPT® codes. The Appendix section
Clinical Examples—Limited to E/M services, the AMA has
references topics important for coding specificity and provides
provided clinical examples for different specialties. These
examples for the reader.
clinical examples do not encompass the entire scope of medical
Appendix A practice, and guides medical billers to follow E/M patient
encounter rules for level of service.
Modifiers—This appendix lists modifiers categorized as:
Appendix D
1. CPT® Level I Modifiers—lists all of the modifiers appli-
cable to CPT® codes Summary of CPT® Add-on Codes—Lists codes not reported
as a single or stand-alone code. The codes listed are identified
2. Anesthesia Physical Status Modifiers throughout CPT® with the + symbol.
3. CPT® Level I Modifiers approved for Ambulatory
Surgery Center (ASC) Hospital Outpatient Use
4. Level II (HCPCS/National) Modifiers

76 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

Appendix E illustrates vascular “families” that emerge from the aorta using
Summary of CPT® Codes Exempt from Modifier 51—This brackets to identify the order of vessels: First, Second, Third,
listing is a summary of CPT® codes that are exempt from the and Beyond Third Order of vascular branches. The largest
use of modifier 51. The codes are identified in the CPT® code- First Order Branch emerges from the aorta. The Second Order
book with the  symbol. Branch emerges from the First Order Branch, and so on to
include the vessel’s Third Order Branch and Beyond Third
Appendix F Order Branches. If the starting point of the catheterization is
Summary of CPT® Codes Exempt from Modifier 63—This other than the aorta, the orders might change.
listing is a summary of CPT® codes that are exempt from the
Appendix M
use of modifier 63. The listed codes will also be identified by
the CPT® convention of parenthetical instruction “(Do not Crosswalk to Deleted CPT® Codes—This listing is a summary
report modifier 63 in conjunction with…).” of the crosswalks noting the deleted CPT® codes and
descriptors from the previous years to the current year. This is
Appendix G an essential tool when updating charge masters, charge capture
Summary of CPT® Codes That Include Moderate (Conscious) documents, and any system or process using CPT® codes.
Sedation—CPT® codes identified by the  symbol, indicates
Appendix N
the reported procedure includes conscious sedation and it is
not appropriate to report sedation codes 99143–99145. Summary of Resequenced CPT® Codes—This listing is a
summary of CPT® codes not appearing in numeric sequence.
Appendix H This allows existing codes to be relocated to an appropriate
Alphabetic Clinical Topics Listing (AKA—Alphabetic location.
Listing)—This has been removed from the CPT® codebook,
Appendix O
because CPT® Category II codes, clinical conditions, and
measure abstracts rapidly change and expand. This listing is Multianalyte Assays with Algorithmic Analyses—This is a
now solely accessed on the AMA website www.ama-assn.org/ listing of administrative codes for Multianalyte Assays with
go/cpt. Algorithmic Analyses (MAAA) procedures. These are typically
unique to a single clinical laboratory or manufacturer.
Appendix I
Genetic Testing Code Modifiers—This appendix was removed
with the deletion of the molecular pathology stacking codes
Evaluation and Management Codes
(83890-83914). The genetic testing code modifiers were Entire books have been written regarding proper use of the
reported with the codes that were deleted. New codes for Evaluation and Management (E/M) codes. Most E/M codes
molecular pathology were created eliminating the need for the are based on the three key components of history, examina-
modifiers included in Appendix I. tion, and medical decision making along with contributing
factors of counseling, coordination of care, the nature of the
Appendix J presenting problem, and time. Some E/M codes are based
Electrodiagnostic Medicine Listing of Sensory, Motor, solely on time or age. In general, the following criteria must be
and Mixed Nerves—This appendix provides a summary considered when deciding which E/M code best describes the
that assigns each sensory, motor, and mixed nerve with its services provided:
appropriate nerve conduction study code to enhance accurate
Location of the service (eg, office, hospital, critical care unit,
reporting of codes.
nursing home, etc.). Each location typically has guidelines for
Appendix K the use of those codes.
Product Pending FDA Approval—Some vaccine products
listed as CPT® Category I codes are still pending approval from Example
the FDA and can be found in this appendix. The lightning bolt
symbol identifies the pending codes throughout the CPT® code Office or Other Outpatient Services
set. For updated vaccine approvals by the FDA, visit the AMA The following codes are used to report evaluation and manage-
CPT® Category I Vaccine Code information on website www. ment services provided in the office or in an outpatient or other
ama-assn.org/go/cpt-vaccine. ambulatory facility. A patient is considered an outpatient until
inpatient admission to a healthcare facility occurs.
Appendix L
Vascular Families—Based on the assumption that a vascular To report services provided to a patient who is admitted to a
catheterization has a starting point of the aorta, Appendix L hospital or nursing facility in the course of an encounter in the

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 77
CPT® Concepts Chapter 5

office or other ambulatory facility, see the notes for initial hospital Example
inpatient care (page 15) or initial nursing facility care (page 25).
99214 Office or other outpatient visit for the evaluation and
For services provided in the emergency department, see management of an established patient, which requires at least 2
99281-99285. of these 3 key components:
For observation care, see 99217-99226. llA detailed history;
For observation or inpatient care services (including admission ll A detailed examination;
and discharge services), see 99234-99236. ll Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians,

other qualified healthcare professionals, or agencies are provided
New vs. established patient (a “new” patient is one who has consistent with the nature of the problem(s) and the patient’s
not received face-to-face services from the same physician or and/or family’s needs.
another physician of the exact same specialty and subspecialty
within the same group practice within the previous three Usually, the presenting problem(s) are of moderate to high
years: See “Decision Tree for New vs. Established Patients” severity. Typically, 25 minutes are spent face-to-face with the
preceding the E/M Service Guidelines in the CPT® codebook). patient and/or family.
If the patient has seen another provider, in the same group, of In this example, only 2 of the three components are required.
the same specialty and subspecialty, within the three years, the If documentation shows a problem focused history, a detailed
patient is established. In addition, when a provider is acting as examination, and moderate medical decision making, 99214 is
on call, the visit is classified based on the provider who is not still applicable because the level of examination and medical
available. decision making are met. If the code requires 3 of 3 key compo-
nents to be met, all three key components would have to meet
The extent and complexity of the following key components:
the level specified.
Patient history—the history is used for the provider to
troubleshoot the chief complaint based on an interview with
the patient. History is divided into the history of present
illness (HPI), review of systems (ROS), and past, family, and Billing Tip
social history (PFSH).
When referring to a level of E/M visit, it is sometimes stated as
Some categories of service only require an interval history, Office Visit—Level 3 or Office Consultation—Level 2. The level
such as subsequent hospital care, follow-up inpatient consulta- refers to the last digit in the code section. For example, an Office
tions and subsequent nursing facility care. An interval history Visit—Level 3 for an established patient is reported with CPT®
is the history during the time period since the physician last code 99213; an Office Consultation—Level 2 is reported with
performed an assessment of the patient. As such, the PFSH is CPT® code 99242.
not required for an interval history.

Physical examination—The physician’s physical examina-

tion of the patient. To qualify as a consultation, three requirements must be
met: 1) the services must be requested by another provider;
Medical decision-making (MDM)—the nature of the 2) the consulting provider must render an opinion or
presenting problem and medical necessity of the encounter recommendation or make a decision to accept responsibility
are the best MDM indicators. The overall MDM level based for ongoing care; and 3) the consulting provider must respond
on three factors; the number of diagnoses or manage- to the requesting provider with a written report. Medicare and
ment options, the amount and/or complexity of data to be some commercial payers do not reimburse for consultations.
reviewed and the risk of complications and morbidity or CMS recommends reporting new and established office/
mortality. outpatient E/M codes or initial and subsequent hospital care
codes. Check with individual payers for specific benefits.
Each E/M description identifies the level of key components
required for that visit. In addition, the description identifies Preventive medicine services are based on the age of the
whether two or three key components are required. patient and whether it is a new vs. established patient.

For purposes of the CPB® exam, the extent and complexity of

the key components will be given. The examinee will not be
expected to determine those levels but should recognize which
E/M code is associated with those given levels.

78 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

Example Counseling and coordination of care could include discussion

with the patient (or his or her family) about one or more of the
A patient visits her family provider with sinus congestion and a following, according to CPT® guidelines:
cough. The provider performs an expanded problem focused ll Diagnostic results
history, an expanded problem focused exam, and medical
ll Impressions and/or recommended diagnostic studies
decision making of moderate complexity. For this scenario, the
correct E/M level is 99213. ll Prognosis

ll Risks and benefits of treatment options

99213 Office or other outpatient visit for the evaluation and
management of an established patient which requires at least 2 of ll Instructions for treatment and/or follow-up

these 3 key components: ll Importance of compliance with chosen treatment options

ll An expanded problem focused history ll Risk-factor reduction

ll An expanded problem focused examination ll Patient/family education

ll Medical decision making of low complexity

The provider’s documentation should support the content and
Although we have a medical decision making of moderate
extent of the patient counseling. For example, Mary presents
complexity, we need at least two of the three key components
with a wrist injury. After history and exam are performed, she
to qualify for the level of E/M. In this example, the requirements
is counseled on care to prevent further damage of the weak
for the examination and the medical decision making are met for
wrist, including: no lifting of heavy objects and no gymnastic
E/M code 99213.
activities involving direct pressure on the wrist (such as hand
springs, head stands, etc.). The provider spent 30 minutes
with the patient and over 50 percent of that time was spent on
counseling. In this case, time is the dominant factor of the E/M
Billing Tip
visit; not the E/M visit leveling of history, exam, and MDM.
In the Evaluation and Management Services section of your CPT®
It is important to note that a level of visit in one category does
codebook, highlight or underline the number of key components
not directly correlate to another category. For example, the
necessary for a code. In the example above, highlight or
requirements to meet for a 99213 are not the same as what is
underline “requires at least 2 of these 3 components.”
required for 99203. See the chart below:

Code 99203 - New Patient 99213 - Established

Time may be considered the controlling factor to qualify Requires 3 of 3 Key Patient Requires 2 of
for a particular E/M service level, “When counseling and/or Components 3 Key Components
coordination of care dominates (more than 50 percent) the
encounter,” according to CPT® guidelines. The E/M category History Detailed Expanded Problem
selected must include a time reference. As an example, the Focused
descriptor for level V established patient outpatient service Examination Detailed Expanded Problem
99215 specifies, “Typically, 40 minutes are spent face-to-face Focused
with the patient and/or family.”
Medical Low Low
Time includes face-to-face time in the office or other outpatient Decision
setting, or floor/unit time in the hospital or nursing facility, Making
and includes time spent with parties who have assumed Time 30 minutes 15 minutes
responsibility for the care of the patient or decision making (typical face-
whether they are family members. to-face time)

The time the physician or other qualified healthcare profes-

sional spends taking the patient’s history or performing an Example
examination does not count as counseling time. The provider
A patient is seen by the provider with pain in her knee. The
must look at the entire patient encounter and decide if he or
provider performs an expanded problem focused history, an
she spent the majority of time in counseling and/or coordi-
expanded problem focused exam, with low medical decision
nating care or if the key components of history, exam, and
making. For an established patient, this is reported as 99213.
MDM should be the deciding factor when choosing an E/M
However, for a new patient where all three key components must
level.
be met, this is reported as 99202.

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 79
CPT® Concepts Chapter 5

Billing Tip The most important part of coding by time is complete

and adequate documentation of the visit—including
When a provider selects a level of visit for a new patient and it is documentation of the total visit time and the total time the
discovered the patient is established, do not select the same level provider spends counseling.
of established patient visit. Query the provider for the correct
level of visit.

Section Review 5.2

1. A patient is seen in the ED after having an auto accident. The patient is new to this provider. What subcategory of E/M is
reported?

A. Office or Other Outpatient Services; New Patient

B. Initial Observation Care; New or Established Patient
C. Initial Hospital Care; New or Established Patient
D. Emergency Department Services; New or Established Patient

2. A patient is seen by their family provider at the provider’s office. The patient last saw the provider four years prior. Which
range of codes would a code be selected from?

A. 99201–99215
B. 99201–99205
C. 99211–99215
D. 99221–99233

3. A patient is admitted to the hospital for observation on date of service 01/02/XX and discharged from observation on
date of service 01/03/xx. Which range of codes would the code(s) be selected from for the admit and discharge from
observation?

A. Admit 99221–99223; Discharge 99238–99239

B. Admit and Discharge 99234–99236
C. Admit 99218–99220; Discharge 99217
D. Admit 99218–99220; Discharge 99224–99226

4. A patient is seen for a follow-up visit in the hospital. A problem focused interval history, an expanded problem focused
exam, and MDM of low complexity. What E/M code is reported?

A. 99213
B. 99224
C. 99231
D. 99241

5. A 43-year-old established patient is seen for their annual preventive exam by the family physician. A comprehensive
history, comprehensive exam, and medical decision making of low complexity is performed. What E/M code is reported?

A. 99215
B. 99396
C. 99386
D. 99402

80 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

Anesthesia Example
The CPT® codes describing anesthesia services (00100–01999) To look up the anesthesia code for a percutaneous liver biopsy,
are used to describe the administration of anesthesia for you can look in the Index or in the tabular section of the CPT®
the associated surgical procedure. To determine the proper codebook.
anesthesia code, it is necessary to consider what surgical
procedure is performed during anesthesia care services. The 1. In the Index
anesthesia CPT® codes are organized by anatomic regions. – Anesthesia
There are three different types of anesthesia: General, Regional, Biopsy
and Monitored Anesthesia Care (MAC): Ear 00120
General Anesthesia—A drug-induced loss of consciousness Liver 00702
Regional Anesthesia—A loss of sensation in a region of the Salivary Glands 00100
body, such as: Refer to the code (00702) in the tabular section to verify it is
ll Spinal Anesthesia—An anesthetic agent is injected in the correct.
subarachnoid space into the cerebral spinal fluid (CSF) in 2. In the tabular section Anesthesia table of contents, look for
the patient’s spinal canal for surgeries performed below Lower Abdomen which directs you to code range 00700–
the upper abdomen. 00797. 00702 is anesthesia for a percutaneous liver biopsy.
ll Epidural Anesthesia—An anesthetic agent is injected in
00702 Anesthesia for procedures on upper anterior abdominal
the epidural space. A small catheter may be placed for a wall; percutaneous liver biopsy
continuous epidural. An epidural can also remain in place
after surgery to assist with postoperative pain.
ll Nerve Block—An anesthetic agent is injected directly into
Until the medical biller becomes familiar with anatomical
the area around a nerve to block sensation for the region codes, it is best to use the index found in the back of the
the surgery is being performed. Commonly used for book, and look for the term Anesthesia, to begin learning.
procedures on the arms or legs. Keep in mind codes are not always found under the surgical
Monitored Anesthesia Care (MAC)—Anesthesia service description and the biller may need to default backward to find
where the patient is under light sedation or no sedation the most accurate description.
while undergoing surgery with local anesthesia provided
by the surgeon. The patient can respond to purposeful There are several modifiers that are specific to anesthesia
stimulation and can maintain his airway. The service is codes. P1–P6 are physical status modifiers that designate the
monitored by an anesthesia provider who is prepared at all general health status of the patient. Some payers recognize
times to convert MAC to general anesthesia if necessary. these modifiers for payment purposes. There are also four
add-on codes that are used to identify specific qualifying
Anesthesia services are typically reported using both the circumstances, including extreme age (99100), the use of total
appropriate CPT® code and the time that the anesthesia body hypothermia (99116), the use of controlled hypotension
services were provided. Time is reported in actual minutes. (99135), and emergency conditions (99140). If the qualifying
Payment for anesthesia services is calculated using the number circumstance is part of the CPT® code description, the
of base anesthesia units associated with each anesthesia code, qualifying circumstance is not reported. There is typically
the time those services were provided (most payers calculate a parenthetic instruction stating not to use the qualifying
time units as 15 minutes for one unit), and modifying units circumstance code.
(physical status and qualifying circumstances). The units are
then multiplied by a conversion factor or dollar amount.
Example:
Selecting an anesthesia code follows the same basic steps as
00834 Anesthesia for hernia repairs in the lower abdomen not
assigning procedure codes for other specialties. Billers either
otherwise specified, infants younger than 1 year of age.
will use the CPT® Index under Anesthesia, in the back of the
CPT® codebook to locate the correct anatomic area, or turn to (Do not report 00834 in conjunction with 99100).
the blue edged “Anesthesia 00100” pages with an index page
99100 reports anesthesia for a patient who is younger than one
at the beginning of the section and look under the appropriate
or older than 70. The descriptor for 00834 indicates in the
anatomic heading.
procedure description that it is for a patient younger than
one. Therefore, the qualifying circumstance code - 99100 -
is not reported.

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 81
CPT® Concepts Chapter 5

HCPCS Level II modifiers are applied to report the circum- ll QZ—CRNA service: without medical direction by a
stances surrounding the various methods of anesthesia physician
delivery: These modifiers report if the anesthesiologist person-
ally performed the anesthesia, provided medical supervision of Note: State scope of practice may prohibit an Anesthesiologist
the anesthesia, or provided medical direction of the anes- Assistant from reporting claims with a non-medical direction
thesia. To apply the provider modifiers correctly, the types of modifier. If a provider moves from QK—Medical direction of
providers must be understood. 2, 3, or 4 concurrent anesthesia procedures involving qualified
individuals to AD—Medical supervision by a physician: more
The anesthesiologist is a physician licensed to practice medi- than four concurrent anesthesia procedures, the CRNA still
cine and has completed an accredited anesthesiology program. reports QX as the CRNA would not necessarily know the
These physicians may personally perform, medically direct, or number of cases the anesthesiologist is overseeing.
medically supervise members of an anesthesia care team.
Medical Direction modifiers are associated with specific
A certified registered nurse anesthetist (CRNA) is a registered providers and are reported in the first position after the
nurse who has completed an accredited nurse anesthesia- anesthesia CPT® code because payment often is related to the
training program. The CRNA may be either medically directed modifier reported.
by an anesthesiologist or non-medically directed.
Additional anesthesia-related modifiers usually are reported
An anesthesiologist assistant (AA) is a health professional who in the second position after any related medical direction
has completed an accredited Anesthesia Assistant training modifiers, as they are considered informational or statistical.
program. The AA may only be medically directed by an Modifiers affecting payment always should be reported in the
anesthesiologist. Anesthesiologist Assistant should be spelled position before information/statistical modifiers.
out because the abbreviation (AA) must not be confused with
the HCPCS Level II modifier containing the same letters. If more than one surgical procedure is performed during
a single anesthetic, the anesthesia code that describes the
An anesthesia resident is a physician who has completed his most complex procedure (highest unit value) is reported. The
medical degree and is in a residency program specifically for remaining procedures are reflected in the increased time that
anesthesiology training. the anesthesia services were provided.
A student registered nurse anesthetist (SRNA) is a registered
nurse who is training in an accredited nurse anesthesia Example
program.
A patient has two surgical procedures at one time:
These modifiers are reported only with anesthesia CPT® codes:
01220 Anesthesia for all closed procedures involving upper
ll AA—Anesthesia services performed personally by
two-thirds of femur
anesthesiologist
01380 Anesthesia for all closed procedures on knee joint
ll AD—Medical supervision by a physician: more than four
concurrent anesthesia procedures The closed procedure involving the upper two-thirds of the
femur has 4 base units and the closed procedure on the knee
Note: “Concurrency” refers to all current ongoing anesthesia joint has 3 base units. Only the code for the femur (01220) is
cases during the same time under the direction or supervision reported because it is more complex and has a higher base value
of an anesthesiologist. than the closed procedure on the knee.

ll QK—Medical direction of 2, 3, or 4 concurrent anesthesia

procedures involving qualified individuals
ll QY—Medical direction of one certified registered nurse Surgery
anesthetist (CRNA) by an anesthesiologist
CPT® codes describing surgical procedures describe a package
ll GC—This service has been performed in part by a resident of services that may include:
under the direction of a teaching physician
ll Local anesthesia (including digital nerve blocks)

ll One E/M encounter on the day of, or immediately

The following medical supervision/direction modifiers are
preceding the date of, surgery (unless the decision for
reported with CRNA or anesthesiologist assistant services:
surgery was actually made at that visit, in which case it
ll QX—CRNA service: with medical direction by a physician
may be claimed separately)

82 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

ll Immediate post-operative care in the recovery area, day postoperative period are not reimbursable. (eg, CPT®
including writing orders and dictating operative notes 17261, 40800, 64612).
ll Talking with the family and other physicians
090 M
 ajor procedures with one day preoperative period
ll Typical postoperative follow-up care and 90-days postoperative period are considered to be
a component of global package of the major procedure.
Follow-up services provided during the post-operative global Evaluation and management services on the day prior to
period are typically included in the fee; however, there is no the procedure, the day of the procedure, and during the
single definition of “global period” for all payers. Medicare 90-day postoperative period are not reimbursable. (eg,
designates either a 0-day, 10-day (minor surgery) or 90-day CPT® 21048, 32664, 49582).
(major surgery) global period for each surgical code. Many
payers adopt the Medicare global period, and these will be MMM Maternity codes; the usual global period concept does
used for purposes on the CPB® exam. not apply. (eg, CPT® 59400, 59612).

XXX Th
 e global concept does not apply to this code. (eg,
Billing Tip Evaluation and Management services, Anesthesia,
Laboratory and Radiology procedures) CPT® 10021,
Mark the global days in the surgical section of your CPT®
36593, 38220, 44720.
codebook:
10-day—minor surgery YYY Th
 ese are unlisted codes, and subject to individual
pricing. (eg, CPT® 19499, 20999, 44979).
90-day—major surgery
ZZZ These represent add-on codes. They are related to
another service and are always included in the global
To determine the global period, the Medicare Physician Fee period of the primary service. (eg, CPT® 27358, 44955,
Schedule can be referenced: 67335).

GLOB Follow-up care for diagnostic procedures includes care

HCPCS MOD DESCRIPTION DAYS related to recovery from the procedure. Care related to the
underlying condition for which the diagnostic procedure was
11740 Drain blood from under nail 000
performed is not included. Any such care performed during
11750 Removal of nail bed 010 the recovery period may be separately reported. Follow-up
11752 Remove nail bed/tip 010 care for therapeutic procedures includes those services that
are typically included as part of the surgical procedure. Care
11755 Biopsy nail unit 000 required due to complications, exacerbations, recurrences,
11760 Repair of nail bed 010 or other diseases may be separately reported. Medicare will
11762 Reconstruction of nail bed 010 only reimburse separately for postoperative complications
that result in a return to the operating room. Postoperative
11765 Excision of nail fold toe 010 complications treated during an office visit during the
11770 Remove pilonidal cyst simple 010 postoperative period are included with the global payment and
should not be listed separately.
11771 Remove pilonidal cyst exten 090
When multiple procedures are performed during a single
surgical episode, the major (or most complex) procedure is
Global Days Status Indicators reported with the appropriate CPT® code. The additional
000 E
 ndoscopies or minor procedures with preoperative and procedures are reported with modifier 51 attached to the CPT®
postoperative relative values on the day of the procedure codes that describe those additional procedures. The use of
only are reimbursable. Evaluation and management modifiers is discussed more fully in the section on Modifiers.
services on the same day of the procedure are generally
not payable. (eg, CPT® 43255, 53020, 67346).

010 Minor procedures with preoperative relative values

on the day of the procedure and postoperative relative
values during a 10 day postoperative period are
reimbursable services. Evaluation and management
services on the day of the procedure and during the 10

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 83
CPT® Concepts Chapter 5

Billing Tip Surgical procedures are often found in the CPT® Index
under the anatomic location or under the procedure being
Some payers request modifier 51 not be appended as the payers performed.
processing system is programmed to automatically append
modifier 51 to subsequent procedures. It is necessary for a
medical biller to know the policies of their payers.
Example
The code for a liver biopsy can be found in the CPT® Index under
Biopsy/Liver which directs you to 47000-47001, 47100, 47700 or
Some codes are designated with the plus sign symbol as add-on under Liver/Biopsy which directs you to more options.
codes. These codes usually designate additional lesions, levels,
Biopsy
locations, or procedures performed in addition to the primary
procedure. Add-on codes should never be reported without a Liver 47000-47001, 47100, 47700
parent code with which it is associated. Because these codes are Looking under Liver/Biopsy gives more options and narrows
already designated as add-on codes and can only be reported down the code selection:
with a parent code, it is not necessary to attach modifier 51 to
these codes. Liver
Biopsy 47700
Example Needle 47000, 47001
15260 Full thickness graft, free, including direct closure of Wedge 47100
donor site, nose, ears, eyelids, and/or lips; 20 sq cm or with Staging Laparotomy 49220
less
+15261 each additional 20 sq cm, or part thereof (List
separately in addition to code for primary procedure) It is very important to read the section guidelines and
parenthetical instructions in the surgical section as they give
The proper reporting for a full thickness graft of the nose that is
guidance on correct coding for procedures. Some guidance
30 sq cm is 15260, 15261. Modifier 51 is not appended to 15261
that can be found in the surgical section guidelines and
because it is an add-on code.
parenthetical instructions includes:

1. Each lesion excision is reported separately while the

Numerous codes include the term “separate procedure” in length of multiple repairs performed within the same
the code descriptor. This is often misunderstood to mean that anatomic section and complexity are added together to
these codes may be billed separately no matter what other report the correct code.
procedures are performed during the same setting. That is an
incorrect interpretation. These codes are used when the proce- Example
dure described by the code is performed alone as a “separate
procedure.” If the procedure is performed as part of another A 7.5 cm intermediate repair is performed on a wound on the
procedure that typically includes the “separate procedure,” right leg and a 2.5 cm intermediate repair is performed on a
then separate reporting of the “separate procedure” code is wound on the right arm. Because both wounds are classified
incorrect. to the extremities and are both intermediate repairs, the length
of the repairs are added together (7.5 cm + 2.5 cm = 10 cm) to
Example report 12034.
12034 R epair, intermediate, wounds of scalp, axillae, trunk and/or
CPT® codes 45330 Sigmoidoscopy, flexible; diagnostic, including
extremities (excluding hands and feet); 7.6 cm to 12.5 cm
collection of specimen(s) by brushing or washing when
performed (separate procedure) and 45331 Sigmoidoscopy,
flexible; with biopsy, single or multiple cannot be reported
together. Even though CPT® code 45330 is designated as a 2. A diagnostic endoscopy or arthroscopy is always
separate procedure, that procedure is inherent within the included when performed with a surgical endoscopy or
description of CPT® code 45331. If only the procedure described arthroscopy respectively.
by CPT® code 45330 is performed, then that code may be
reported separately.

84 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

Example Endoscopy

29800 Arthroscopy, temporomandibular joint, diagnostic, with When performing a diagnostic or screening endoscopic proce-
or without synovial biopsy (separate procedure) dure on a patient who is scheduled and prepared for a total
colonoscopy, if the physician is unable to advance the colono-
29804 Arthroscopy, temporomandibular joint, surgical scope to the cecum or colon-small intestine anastomosis due to
CPT® code 29800 is inclusive to CPT® code 29804 and is not unforeseen circumstances, report 45378 (colonoscopy) or 44388
reported separately. (colonoscopy through stoma) with modifier 53 and provide
appropriate documentation.

3. Some interventional codes have supervision and

interpretation codes reported in addition to the 5. Coding guidance may also be found in parenthetic
procedure code. There are often instructions for this instructions.
in both the section guidelines and in parenthetical
instructions. Example
58672 Laparoscopy, surgical; with fimbrioplasty
Example
58673 Laparoscopy, surgical; with salpingostomy
Transluminal Angioplasty (salpingoneostomy)
Percutaneous (Codes 58672 and 58673 are used to report unilateral procedures.
Codes for catheter placement and the radiologic supervision and For bilateral procedure, use modifier 50)
interpretation should also be reported, in addition to the code(s)
for the therapeutic aspect of the procedure.
35476 Transluminal balloon angioplasty, percutaneous; venous Example
(For radiological supervision and interpretation, use 75978) 63620 Stereotactic radiosurgery (particle beam, gamma ray, or
linear accelerator); 1 spinal lesion

4. Sometimes, the use of modifiers in certain circum- (Do not report 63620 more than once per course of treatment)
stances is included in the section guidelines.

Example
Digestive System
Colon and Rectum

Section Review 5.3

1. What is the CPT® code for anesthesia performed for surgical arthroscopy on the ankle?

A. 29891
B. 01464
C. 00400
D. 01522

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 85
CPT® Concepts Chapter 5

2. Anesthesia procedures 00830 (4 base units) and 00832 (6 base units) are both performed. How are these reported on the
claim form?

A. 00830, 00832 with the time units per procedure

B. 00830, 00832-51 with the time units per procedure
C. 00830 with the time units for both procedures
D. 00832 with the time units for both procedures

3. What CPT® code is reported for a diagnostic proctosigmoidoscopy?

A. 45300
B. 45305
C. 45317
D. 45320

4. What guidance is found under CPT® code 64492?

A. Report modifier 50 when the procedure is performed bilaterally

B. Do not report 64492 in conjunction with 64490
C. Do not report 64492 in conjunction with 64491
D. Do not report 64492 more than once per day

5. Which reporting option below is correct for CPT® code 69424?

A. 69424-50
B. 69424-50, 69420
C. 69433, 69424
D. 69801, 69424

Radiology Example
CPT® codes in the 70000 range describe radiological You can see how the payment is distributed based on the
services. Often these services are performed as part of an modifier by looking at the Physician Fee Schedule for 71020:
interventional procedure and are designated as “radiological
supervision and interpretation.” In those cases where a single HCPCS SHORT NON-FACILITY
provider performs both the interventional procedure and the CODE MODIFIER DESCRIPTION PRICE
radiological services, that provider may submit both codes to 71020 Chest X-ray 2vw $28.03
describe the total services provided. frontal&latl
Most radiology codes can be divided into technical and 71020 26 Chest X-ray 2vw $11.14
professional components, designated with the TC modifier for frontal&latl
the technical component and the 26 modifier for the profes- 71020 TC Chest X-ray 2vw $16.89
sional component. The entity that owns the equipment used frontal&latl
to perform the service usually files a claim for the technical
component, while the professional interpreting the image If the provider owns the equipment and provides the
claims the professional component. If the same provider owns interpretation and report, 71020 is reported.
the equipment and provides the interpretation, the global If the X-ray is taken at the hospital and the provider only provides
service is reported without a modifier. the interpretation and report, 71020-26 is reported by the provider.

86 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

In the CPT® Index, some imaging can be found under the in addition to the codes for the laboratory tests. Sometimes,
location being imaged. Other entries in the index where the insurance carrier will consider the collection of the
imaging may be found include X-Ray, CT Scan for computed specimen inclusive to an office visit and is considered a write
tomography, Magnetic Resonance Imaging (MRI), etc. off by the provider.

Example Example
Chest 99213 Office or other outpatient visit
Diagnostic Imaging 36415 Collection of venous blood by venipuncture
Angiography 71275 Some insurance carriers will pay for the office visit and deny the
collection of blood as inclusive to the office visit.
CT Angiography 71275
CT Scan 71250, 71260, 71270
Magnetic Resonance Angiography 71555 The CPT® contains approximately 10 panels that contain
specific combinations of tests. These codes are not used unless
Magnetic Resonance Imaging (MRI) 71550-71552 every test in the panel is performed. When a combination of
PET Imaging 78811, 78814 tests is performed that does not exactly match one of the stan-
dard panels, the code for the panel that contains the greatest
Ultrasound 76604 number of tests actually performed is listed and the additional
X-Ray tests are reported individually.
See X-Ray, Chest
Example
A physician performs a battery of tests that includes sodium,
When coding radiology services, it is important to know which potassium, chloride, carbon dioxide, urea nitrogen, creatinine, and
views and how many views are taken. Many codes in this glucose. This almost matches the basic metabolic panel (80047),
section are based on the views taken. but the basic metabolic panel also includes ionized calcium.
The physician cannot claim 80047. She can, however, use 80051
Example (electrolyte panel) to describe the sodium, potassium, chloride
and carbon dioxide measurements and separately claim the urea
71020 Radiologic examination, chest, 2 views, frontal and lateral nitrogen (84520), creatinine (82565), and glucose (82947) tests.

It is also important to note when contrast is used for Codes describing anatomic, cytological, and surgical
imaging. Code selection for some radiologic procedures will pathology services may be divided into technical and profes-
have code options for with contrast, without contrast, and sional components. Similar to radiological procedures, the
without contrast followed by with contrast. According to the entity that owns the laboratory equipment claims the technical
CPT® guidelines, the term “with contrast” is used when the component, while the provider interpreting the results of the
contrast is administered intravascularly, intra-articularly, or test claims the professional component.
intrathecally. An intravascular injection is one that is given
within the vessel (artery or vein). An intra-articular injection Codes for this section can be found in the CPT® Index under
is given into the joint. An intrathecal injection is given into the Pathology and Laboratory.
subarachnoid space of the spinal cord. Oral and rectal contrast
do not qualify as a study “with contrast.”
Medicine
The Medicine section includes codes describing numerous
Laboratory diverse medical services, including but not limited to
CPT® codes in the 80000 range are for reporting specific immunization services, psychiatric services, dialysis,
laboratory tests or specific groups of tests, commonly known cardiovascular services (including catheterization,
as panels. These codes do not include the collection of the angioplasties, stent placement, and various implantable cardiac
specimen on which the tests are performed. The appropriate devices), allergy treatments, neurological testing, intravenous
codes describing various specimen collections may be claimed infusions, and physical medicine and rehabilitation services.

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 87
CPT® Concepts Chapter 5

As with other sections in the CPT codebook, pay close operative report, and there is no other procedure code to describe
attention to the guidance found in the section guidelines and the extensive services.)
in parenthetic instructions.
Appropriate Uses:
ll Excessive blood loss during the particular procedure
Modifiers ll Excessively large surgical specimen
Modifiers are appended to CPT® and HCPCS Level II codes
ll Trauma extensive enough to complicate the particular
to report specific circumstances or alterations to a procedure,
procedure and not billed as additional procedure codes
service, or medical equipment without changing the definition
ll Other pathologies, tumors, malformations (genetic,
of the code. Both CPT® and HCPCS Level II codebooks list
modifiers and their descriptions. traumatic, surgical) that interfere directly with the
procedure but are not billed separately
CPT® modifiers are two digit codes. Appendix A lists CPT®
modifiers, and includes a wide range of modifiers, including Inappropriate Uses:
those used for anesthesia and modifiers reported by ASCs and ll Increased time to perform a procedure due to provider
hospital outpatient facilities. HCPCS Level II modifiers are variation in practice or minor anatomical variation
located in Appendix B of the HCPCS Level II codebook.
ll Another code exists that describes the increased work

When reporting codes with more than one modifier, always

list functional, or pricing modifiers in the first position. Keywords: extended time, took longer than normal, extenuating
Payers consider functional modifiers when determining circumstances, etc
reimbursement. Next, report the informational modifiers;
these modifiers clarify certain aspects of the procedure or
service provided for the payer (eg, procedures performed on
Modifier 24
the left or right side of the patient’s body). Unrelated E/M by the Same Physician or Other Qualified
Healthcare Professional During a Postoperative Period:
Modifiers affecting payment include those that identify the The physician or other qualified healthcare professional may
following: need to indicate an E/M service was performed during a
ll Procedures with both professional and technical
postoperative period for reason(s) unrelated to the original
components, but only one component is included on the procedure. This circumstance may be reported by adding
claim modifier 24 to the appropriate level of E/M service.
ll When more than one provider performed all or part of the Appropriate Uses:
procedures
ll Added to CPT® codes 99201-99499 and 92012-92014
ll Procedures that were increased or decreased from the to indicate the evaluation is unrelated to the surgical
usual procedure definition, but no other procedure code procedure.
correctly identifies the modified procedure
ll Some insurance carriers allow the use of modifier 24 when
ll When multiple different procedures were performed the E/M is due to a complication of the surgical procedure.
during the same session This is carrier specific.
ll When a single procedure was performed more than once Inappropriate Uses:
during the same session
ll Adding modifier 24 for hospital visits during the initial
ll When a single procedure was performed bilaterally post-operative period, unless the physician is providing
one of the following services:
££ Immunosuppressive therapy
Modifier 22
££ Chemotherapy
Increased Procedural Services: When the service(s) provided
is greater than that usually required for the listed procedure, it ££ Critical care services unrelated to the original surgery

may be identified by adding modifier 22 to the usual procedure ll Office visit during the global period when the major
code number. Documentation must support the substantial purpose of the visit is to follow up on the original surgery
additional work and the reason for the additional work.
Modifier 22 is not appended to E/M codes. Keywords: unrelated, outside of, not related to, etc.
(Append modifier 22 to a procedure code when the provider
describes “above and beyond” circumstances within his

88 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

Modifier 25 Appropriate Uses:

ll An imaging study is performed in a hospital and
Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician or Other interpreted by a physician. The physician appends
Qualified Healthcare Professional on the Same Day of modifier 26 to the code and the hospital submits a claim
the Procedure or Other Service: It may be necessary to for the technical component of the test
indicate that on the day a procedure or service identified by ll The physician should only submit a claim for professional
a CPT® code was performed, the patient’s condition required services in those instances where he or she interprets the
a significant, separately identifiable E/M service above and test and prepares a written report of that interpretation for
beyond the other service provided or beyond the usual use by others
preoperative and postoperative care associated with the
procedure performed. It is not required that the E/M service Inappropriate Uses:
have a different diagnosis than the other procedure. ll Using both modifier 26 and modifier TC to report
the professional and technical components by a single
Appropriate Uses:
provider. If the same provider performs both the
ll With E/M codes describing initial hospital visits (99221- professional and technical components, it is considered
99223), initial hospital consult (99251-99255), or hospital global and no modifier is appended
discharge (99238 or 99239) on the same day as a separate
ll Using the modifier when re-reading a study original
inpatient hospital service, such as dialysis, that would not
interpreted by another provider. Many insurance
typically require such E/M services
carriers, including Medicare, will only pay for a single
ll When a significant, separately identifiable E/M service interpretation of a study, regardless of how many
is performed on the same day as a preventive care visit. professionals review the study for their own decision
The E/M service must be performed for a non-preventive making purposes
reason and must be clearly documented
Keywords: independent radiologist, performed in a hospital, etc.
Inappropriate Uses
ll Used to indicate the E/M service resulted in the decision
to perform a major surgery (see Modifier 57). Modifier 50
ll On a surgical procedure code (10021-69990). It is added to
Bilateral Procedure: Bilateral procedures performed at the
the E/M code when both are performed together. same operative session code. For most insurance carriers,
bilateral services are reported with a single use of the
ll On an office visit E/M code when the primary purpose of
appropriate code with modifier 50 appended. Some insurance
the visit is to perform a minor surgical procedure. In this carriers require the code be reported twice with modifier 50
instance, only the minor surgical procedure should be added to one of the codes.
billed.
Not all procedures can be reported with modifier 50. Some
Keywords: unrelated, outside of, not related to, etc code definitions include the statement “unilateral or bilateral”
or similar language, indicating that the code is used only once
even if the procedure is performed on both sides.
Billing Tip
Instructions for use of modifier 50 are often found in the CPT®
Modifier 25 is commonly misused. To use modifier 25, work with
guidelines and parenthetic instructions.
your coder to determine if the documentation supports an E/M
visit separate from the surgical procedure performed at the same Appropriate Uses:
time. This modifier is under constant evaluation by payers.
ll When the exact same service is performed bilaterally

ll Medicare indicates which CPT® codes can be reported

with modifier 50 on the Medicare Physician Fee Schedule
Modifier 26 (MPFS). Other insurance carriers also determine when
they will accept the 50 modifier
Professional Component: Certain procedures are a
combination of a professional component and a technical ll Medicare recognizes the 50 modifier appended to

component. When the professional component is reported radiology codes when the same study is performed on
separately, identify it as such by adding modifier 26 to the each side. Not all insurance carriers allow this modifier
usual procedure code. combination

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CPT® Concepts Chapter 5

Inappropriate Uses: ll Appended to time-based services, such as psychotherapy,

ll Bilateral procedures performed on different areas of the anesthesia, or critical care services
right and left sides of the body
ll Appending the 50 modifier to a code identified as a
Keywords: partially, to be reduced, part of procedure not
bilateral procedure in the description of the code completed, etc.
ll Appending the 50 modifier to a code identified as a
unilateral or bilateral procedure in the description of the Modifier 53
code Discontinued Procedure: Under certain circumstances,
the physician or other qualified healthcare professional may
Keywords: bilateral, both sides, left and right, etc. elect to terminate a surgical or diagnostic procedure. Due to
extenuating circumstances, or those that threaten the well-
being of the patient, it may be necessary to indicate that a
Modifier 51 surgical or diagnostic procedure was started but discontinued.
Multiple Procedures: When multiple procedures, other than
E/M services, Physical Medicine and Rehabilitation services, or Appropriate Uses:
provision of supplies are performed at the same session by the ll When a provider begins a procedure but decides to
same provider. discontinue the procedure due to:
Appropriate Uses: ££ Uncontrollable bleeding, hypotension, or physiologic

changes
ll Append modifier 51 to additional procedures (that are not
modifier 51 exempt) performed during the same operative ££ Unexpected findings during surgery making

session continuing surgery unnecessary or ill-advised

ll Multiple instances of the same service if each service is ££ Anesthesia complication

listed on a separate line and does not require modifier 59 ll Modifier 53 may be used to report terminated procedures
in the office
Inappropriate Uses:
ll Separating or unbundling a procedure into its Inappropriate Uses:
components and appending modifier 51 to one or more ll Elective cancellation of a procedure prior to anesthesia
components induction and/or surgical preparation in the surgical suite
ll Appending modifier 51 to add-on codes or to codes listed
as modifier 51 exempt Keywords: procedure stopped before completion, aborted the
ll Appending to an E/M code
procedure, etc.

Keywords: a different procedure, separate from, etc. Modifiers 54, 55, and 56
Modifiers 54, 55, and 56 are appended to procedures to
Modifier 52 indicate different providers provided the pre-operative
(modifier 56), intra-operative (modifier 54) and post-operative
Reduced Services: Under certain circumstances a service or
services (modifier 55). These modifiers are only appended
procedure is partially reduced or eliminated at the physician’s
to codes that have a global period. For procedures without
or other qualified healthcare professional’s discretion. Under
a global period (global period of zero days), pre- and post-
these circumstances, the service provided can be identified by
operative services are reported separately without using
its usual procedure code and the addition of modifier 52.
modifiers.
Appropriate Uses:
Insurance carriers usually establish the percentage of the
ll Indicate the provider reduced or eliminated some services global fee attributable to each partial service. For Medicare, the
usually associated with the code to which the modifier is surgeon performing the procedure must see the patient at least
appended once before transferring care to the provider assuming post-
operative management.
Inappropriate Uses:
ll Indicate terminated procedures (refer to modifier 53)
Appropriate Uses:
ll Modifier 54 is appended to indicate the provider
ll Appended to E/M services
performed only the surgical procedure

90 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

ll If a single provider provides surgical and post-operative Modifier 58

care, but not the pre-operative care, modifiers 54 and 55
Staged or Related Procedure or Service by the Same
are appended
Physician or Other Qualified Healthcare Professional
During the Postoperative Period: It may be necessary to
Inappropriate Uses:
indicate the performance of a procedure or service during the
ll Appending modifier 54 to surgical codes without a global postoperative period was:
period
a) planned prospectively at the time of the original
ll Appending modifier 55 to inpatient post-operative visits procedure (staged);
by another provider; those visits should be identified by
hospital visit E/M codes (99231-99233) b) more extensive than the original procedure; or
ll Appending modifier 54, 55, or 56 to an E/M code
c) for therapy following a diagnostic surgical procedure
Modifier 54 Keywords: only performed the surgical procedure, Report the circumstance by adding modifier 58 to the staged
no pre or post-op management, etc. or related procedure.
Modifier 55 Keywords: post-op follow-up only, postoperative Appropriate Uses:
care turned over to, transfer of care, etc. ll When a patient is planned to have the second procedure
(eg, daily debridement of a burn)
Modifier 56 Keywords: pre-op evaluation only, covering for
surgeon, etc. ll When the procedure is more extensive than the original
procedure (eg, a lumpectomy followed by a complete
mastectomy on the same breast)
Modifier 57
Decision for Surgery: When an E/M service provided the Inappropriate Uses:
day before or the day of a surgery results in the decision to ll When a patient is returned to the operating room for a
perform surgery, append modifier 57 to the appropriate level complication
of E/M service. Most insurance carriers, including Medicare,
only recognize this modifier when appended to an E/M
Keywords: return to OR, will proceed with additional services in
service performed on the day of or day before a major surgical
next procedure, etc.
procedure, which is identified as having a 90-day global period.
Some insurance carriers recognize the use of this modifier for
minor procedures. Modifier 59
Distinct Procedural Service: Under certain circumstances,
Appropriate Uses:
it may be necessary to indicate a procedure or service was
ll For a Medicare claim, append modifier 57 to the E/M
distinct or independent from other non-E/M services
service during which the decision was made, if that E/M performed on the same day. Modifier 59 is used to identify
visit occurred the day before or the day of a surgical services not normally reported together, but are appropriate
procedure with a 90 day global period under the reported circumstances. CMS NCCI documentation
ll When the decision for a subsequent surgery occurs during has specific examples for the correct use of modifier 59.
the global period of a previous surgery, append both
modifier 24 and modifier 57 to the E/M code Appropriate Uses:
ll Used with code pairs listed in the NCCI edits when
Inappropriate Uses: supported in the documentation as a different session or
ll Do not use on a Medicare claim for the decision to
patient encounter, different procedure or surgery, different
perform a minor procedure site or organ system, separate incision/excision, separate
lesion, or a separate lesion and allowed by the NCCI edit
ll Do not use on an E/M code on the day of surgery when
ll Modifier 59 is appended to the column 2 code if
the actual decision for surgery was made in advance
circumstances permit both services to be reported
ll Do not append to a surgical procedure
separately
ll Modifier is considered the modifier of last resort and is
Keywords: decision to perform surgery, will need to go to OR, etc.
only used when there is no other appropriate modifier

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 91
CPT® Concepts Chapter 5

Inappropriate Uses: Appropriate Uses:

ll Depending on carrier policy, do not use with codes that ll The second procedure must be unrelated to the original
are not listed in the NCCI edits procedure, must be performed by the same provider, and
ll Do not use with E/M codes must be performed during the global period of the first
procedure
ll For Medicare claims, do not use with a code pair that has
a correct coding modifier (CCM) indicator restricting the
use of a modifier or if one of the X-[ESPU] modifiers is Inappropriate Uses:
more appropriate. The abbreviation represents the separate ll Do not use modifier 79 when the second procedure is
Encounter, Structure, Practitioner, and Unusual service. related to the first
These will be discussed in more detail in Chapter 7.
ll Documentation does not support the services were Keywords: not related to previous care, etc.
separate and distinct
ll If another modifier exists to describe the service Modifier 80
ll Do not append with modifier 51 on the same procedure Assistant Surgeon: Surgical surgeon assistant services may
code be identified by adding modifier 80 to the usual procedure
code(s).
Keywords: separate procedure, needed additional services, etc.
Appropriate Uses:
ll The provider assisted the surgeon during the procedure
Modifier 79
ll An assistant surgeon is appropriate for the procedure. The
Unrelated Procedure or Service by the Same Physician or MPFS Relative Value Files containing this information
Other Qualified Healthcare Professional During the Postop- can be found on the CMS website
erative Period: The physician or other qualified healthcare
professional may need to indicate the performance of a proce-
Inappropriate Uses:
dure or service during the postoperative period was unrelated
to the original procedure. This circumstance may be reported ll Use by a provider not qualified to assist in surgery

by using modifier 79. ll Use with a procedure that is not eligible for an assistant
surgeon

Keywords: assisted, surgeon called in to help, etc.

Section Review 5.4

1. What CPT® code is reported for an MRI of the brain without contrast?

A. 70350
B. 70551
C. 70552
D. 70553

2. A provider orders a lipid panel. According to the practice standards, this includes a complete blood count (85027), total
cholesterol (82465), HDL cholesterol (83718), and triglycerides (84478). What is reported on the claim form?

A. 80061
B. 80061, 85027
C. 80053, 82465, 83718, 84478
D. 85027, 82465, 83718, 84478

92 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 5 CPT® Concepts

3. Which reporting option below is correct for immunization administration for vaccines or toxoids?

A. 90460, 90474
B. 90471, 90473
C. 90461, 90474
D. 90472, 90474

4. Which reporting option below is correct use of the modifier 50?

A. 19318-50
B. 36251-50
C. 36252-50
D. 69801-50

5. Which reporting option below is correct use of a modifier with an E/M code?

A. 99213-22
B. 99213-25
C. 99213-59
D. 99213-54, 55, 56

Glossary Global Surgery Status Indicator—An assigned indicator, which

determines classification for a minor or major surgery, based
Add-on Code—CPT® code used to report a supplemental or on RVU calculations.
additional procedure appended to a primary procedure (stand-
alone) code. Add-on codes are recognized by the CPT® symbol Major Surgery—Surgeries classified as major have a global
+used throughout the CPT® codebook. surgical period that includes the day before the surgery, the day
of surgery, and any related follow-up visits with/by the physi-
Centers for Medicare & Medicaid Services (CMS)—Agency cian 90 days after the procedure.
within the United States Department of Health and Human
Services that administers the Medicare program and works in Minor Surgery—Surgeries classified as minor have a global
partnership with state governments to administer Medicaid surgical period that includes the preoperative service the day
and State Children’s Health Insurance Programs. of surgery, the surgery, and any related follow-up visits with/by
the physician 0–10 days after the surgery.
Current Procedural Terminology (CPT®)—A code set copy-
righted and maintained by the American Medical Association National Correct Coding Initiative (NCCI)—Used by
(AMA). professional billers to determine codes considered by
CMS to be bundled codes for procedures and services
Global Package—The period (0–90 days as determined by deemed necessary to accomplish a major procedure. This
the health plan) and services provided for a surgery inclusive is to promote correct coding methodologies and to control
of preoperative visits, intraoperative services, post-surgical improper assignment of codes that results in inappropriate
complications, postoperative visits, post-surgical pain reimbursement.
management by the surgeon, and several miscellaneous
services as defined by the health plan, regardless of setting,
eg, in a hospital, an ambulatory surgical center (ASC), or
physician office.

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