Robyn Korn, MBA, RHIA, CPHQ

CPT – Current Procedural Terminology Published 1966 by AMA (American Medical

Association) Until 1983 – only private insurers

recognized CPT Codes HCPCS (Healthcare Common Procedure

Coding System) developed using CPT

Level I – CPT◦ Category I – Main sections of CPT◦ Category II – not mandatory; tracking codes◦ Category III – collect statistical data; temporary

codes Level II - National Codes

◦ Used to bill for services not in Level I and supplies and equipment

Updated annually Notifications sent in early fall Effective January 1 Coding changes

◦ Additions◦ Deletions◦ Changes or revisions

Introduction – text, symbols, history and use of the book

Main body – 6 sections

Appendices - 14 (A-N)

Index

Evaluation and Management - 99201-99499 Anesthesia - 00100-01999, 99100, 99150 Surgery – 10021-69990 Radiology – 70010-79999 Pathology and Laboratory – 80047- 89356 Medicine – 90281-99199, 99500-99602

EXAMPLE: Referencing the Surgery section of your book, you will see the following arrangement:

(Section) Surgery (Subsection) Integumentary System (Subcategory) Skin, Subcutaneous and

Accessory Structures (Heading) Incision and Drainage (Procedure) 10080 Incision and

drainage of pilonidal cyst; simple

. Code includes moderate sedation

New code

Revised code

New or revised text

+ Add-on code

Beginning of each main section

Define items necessary to interpret and report procedures in the section

Guidelines are strictly followed

Can also appear at the beginning of a subsection

Located at the back of the CPT Manual Organized by Main terms

◦ Procedure or service◦ Organ or other anatomic site◦ Condition◦ Synonyms, Eponyms or abbreviations

• Subterms modify the main term

A – Modifiers B – additions, deletions, revised codes C – Clinical Examples D – Add-on codes E - Exempt from -51 F – Exempt from -63 G - Moderate Sedation

H – Alpha index of performance measures I – Genetic testing code modifiers J – Electrodiagnostic Medicine Listing of

sensory, motor and mixed nerves K – Products pending FDA Approval L – Vascular families M – Cross walk deleted codes N – Summary of resequenced codes

Codes are not deleted and renumbered to keep in numerical order

Aids in data maintenance and integrity

Limit number of additions and deletions

# indicates code is out of order or has been resequenced

A CPT modifier is a two-digit code that is appended to the CPT code to indicate that a service or procedure has been altered for some reason, but it does not change the main definition of the code.◦ Further describes the service performed

Level II HCPCS Modifier – two digit alphanumeric code

Reference: Understanding Procedural Coding: A Worktext, 2nd edition , Bowie, Mary Jo

• A service or procedure has both a technical and professional component.

• A service or procedure was performed by more than one physician.

• A service or procedure was performed in more than one location.

• A service or procedure has taken more time to complete than routinely would occur.

• A service or procedure was reduced or increased.

• Only part of a procedure was completed.

• A bilateral procedure was performed.

• A service or procedure was completed multiple times.

• An unusual event occurred during the procedure.

• An accompanying or adjunctive procedure was performed.

Third party payers use different instructions for reporting modifiers – review the instructions when billing

Modifiers that affect fee are listed first

Important to learn pricing modifiers

Only some modifiers are approved for Ambulatory Surgery Center

See Appendix A for current list

Definition of each modifier is in Appendix A

Quick list is found on inside cover of CPT code book

Currently there are 31 modifiers

- 22 Unusual Procedural Services

- 24 Unrelated Evaluation and Management Service, Same Physician, During Postoperative Period

- 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

-26 Professional Component

-50 Bilateral Procedure

-51 Multiple Procedures

-52 Reduced Services

-54 Surgical Care Only

-55 Postoperative Management Only

- 56 Preoperative Management Only

- 57 Decision for Surgery

-58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

-59 Distinct Procedural Service

-78 Return to the Operating Room for a Related Procedure during the Postoperative Period Level II (HCPCS/National) Modifiers

-79 Unrelated Procedure or Service by the Same Physician during the Postoperative Period

Used with HCPCS Level II codes

Two digit alphanumeric

Use the website of insurance carriers and CMS for the use of these modifiers

Comprehensive list is in Appendix 2 of HCPCS code manual

Ambulance origin and destination modifiers

Marty went to the doctor’s office with a sore throat and an upset stomach. The doctor performed an exam and evaluation of Marty. In the course of the evaluation, Marty mentioned he was having some back pain. The doctor also evaluated this issue and performed an osteopathic manipulation on one body region. The doctor reported a 99213 with a __________modifier and a 98925 for the OMT.

Case 1—Modifier 25 Rationale: An Evaluation and Management

Code (99213) and a procedure (OMT-98925) for the same day require a modifier to identify that two separate and distinct services were performed. Modifier 25 is reported with the E/M code.

Dr. Albert is performing a complicated pyeloplasty on Kelly. Kelly was tolerating the procedure fairly well until her blood pressure began to drop dangerously low. After having trouble stabilizing her, Dr. Albert discontinued the procedure because he felt it would be too dangerous to continue. The doctor reported the part of the service he performed with a 50400 and a______modifier.

Case 2—Modifier 53 Rationale: Because of the extenuating

circumstances of the drop in blood pressure, the doctor felt it was in the patient’s best interest to stop the procedure.

Jamie South was out of town playing football two weeks ago, and he sustained a broken ankle. He was taken to the local hospital, and Dr. Books performed a closed treatment of trimalleolar ankle fracture with manipulation. Today he is being seen by Dr. Thompson for the postoperative care for the fracture treatment. Dr. Thompson should report code 27818 with modifier _______.

Case 3—Modifier 55 Rationale: Modifer 55 is appended to the

code to report that the provider is completing postoperative management only.

Mary Beth is a 19-day-old neonate, who weighs 3.2 kg and who is undergoing an arthrotomy with biopsy of the interphalangeal joint. The surgeon reports code 28054 with modifier ______.

Case 4—Modifier 63 Rationale: When a procedure is completed

and the patient is a newborn and less than 4 kg, modifier 63 is appended to the procedure code.

Dr. Cook is performing a pulmonary valve replacement. Dr. Samson is the assistant surgeon for the case. Dr. Cook reports code 33475, whereas Dr. Samson should report _________.

Case 5—33475-80 Rationale: Modifier 80 is appended to the

procedure code to report that the provider is the assistant surgeon for the case.

Sam is a 10-year-old child who has had chronic ear infections for the last year. Today Dr. Abbes has decided that Sam needs to have tubes inserted into his ears. This is scheduled to occur in 3 weeks. Today’s visit was coded with 99214 appended with modifier ________.

Case 6—Modifier 57 Rationale: Modifier 57 denotes that the

decision for surgery was made.

James Tree is a patient at an intermediate care facility. Today he is being seen by Dr. Rip because of a state mandate for the resident to be seen every 6 months. Code 99315 was reported with modifier ______ to report the mandated service.

Case 7—Modifier 32 Rationale: When a service occurs because

the service is mandated, modifier 32 is appended to the basic procedure code.

Dr. Whoo interprets a MRI of the temporomandibular joint. This is reported with code 70336, appended with modifier ________.

Case 8—Modifier 26 Rationale: Modifier 26 is appended to the

code to report that the provider completed the professional component of the procedure.

Drs. Jones and Smith work as a surgical team to perform a double lung transplant with cardiopulmonary bypass. Dr Jones would report code 32854, and Dr. Smith would report code 32854-66. Is this correct?

Case 9—No, both should report 32854-66.

Rationale: Since the providers worked as a team, modifier 66 would be reported by both providers.

Dr. Jackson performed a therapeutic

pneumothorax on Sally Small and reported code 32960. Later that same day, the procedure was repeated. How should the second procedure be reported?

Case 10—32960-76 Rationale: Modifier 76 would be appended

to the procedure code to denote that the procedure was repeated.