CPT, a publication of the American Medical Association, contains the most widely used system of codes for physicians’ medical, diagnostic, and procedural services. CPT codes are required for reporting physician practice services on insurance claims and encounter forms. The codes have five digits and a description. Updated versions are released annually. Medical practices must use the current codes for proper billing and reimbursement.
Each year’s CPT codes must be purchased from the American Medical Association, which also publishes changes online.
CPT contains six sections of Category I codes, Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine, followed by the Category II and Category III codes, nine appendixes, and an index. The index is used first in the process of selecting a code; it contains alphabetic descriptive main terms and subterms for the procedures and services contained in the main text. The codes themselves are listed in the main text and are generally grouped by body system or site or by type of procedure.
Each coding section begins with section guidelines, which discuss definitions and rules for the use of codes, such as for unlisted codes, special reports, and notes for specific subsections. When a main entry has more than one code, a semicolon follows the common part of a descriptor in the main entry, and the unique descriptors that are related to the common description are indented below it. Seven symbols are used in the main text: (a) <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/dot.jpg','popWin', 'width=65,height=85,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (0.0K)</a> (a bullet or black circle) indicates a new procedure code; (b) <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/triangle.jpg','popWin', 'width=65,height=85,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (0.0K)</a> (a triangle) indicates that the code’s descriptor has changed; (c) <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/triangles.jpg','popWin', 'width=74,height=82,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (1.0K)</a> (facing triangles) enclose new or revised text other than the code’s descriptor; (d) <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/plus.jpg','popWin', 'width=65,height=85,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (0.0K)</a> (a plus sign) before a code indicates an add-on code that is used only along with other codes for primary procedures; (e) the symbol <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/target.jpg','popWin', 'width=65,height=85,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (1.0K)</a> next to a code means that conscious sedation is a part of the procedure that the surgeon performs; (f) a <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/no.jpg','popWin', 'width=65,height=85,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (1.0K)</a> indicates that the code cannot be modified with a –51 modifier; and (g) a <a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073521914/450710/lightning.jpg','popWin', 'width=65,height=91,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (1.0K)</a> is used for codes for vaccines that are pending FDA approval.
A CPT modifier is a two-digit number that may be attached to most five-digit procedure codes to indicate that the procedure is different from the listed descriptor, but not in a way that changes the definition or requires a different code. Two or more modifiers may be used with one code to give the most accurate description possible.
The first step in selecting a procedure code is to determine the procedures and services to report by reviewing the documentation of the patient’s visit. Next, after checking the coding system to use, CPT codes are located by finding the procedure in the index and verifying the code in the main text. The reporting order for the procedure codes places the code with the highest rate of reimbursement first. The final step is to determine whether modifiers are needed.
A summary of the six sections of Category I codes appears in Table 5.1 on page 14
The key components for selecting Evaluation and Management codes are the extent of the history documented, the extent of the examination documented, and the complexity of the medical decision making. The steps for selecting correct E/M codes are to (a) determine the category and subcategory of service, (b) determine the extent of the history, (c) determine the extent of the examination, (d) determine the complexity of medical decision making, (e) analyze the requirements to report the service level, (f) verify the service level based on the nature of the presenting problem, time, counseling, and care coordination, (g) verify that the documentation is complete, and (h) assign the code.
