Understanding Health Insurance (CPT coding) chapter 7

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Michelle A. Green, Understanding Health Insurance: A Guide to Billing and Reimbursement, 2022, Seventeenth Edition, © 2023 Cengage. All
Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 1
Chapter 7
CPT Coding
Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

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Chapter Objectives
By the end of this chapter, you should be able to:
7.1 Define key terms related to CPT coding.
7.2 Describe the organization of CPT.
7.3 Locate main terms, subterms, and cross-references in the CPT index.
7.4 Select appropriate modifiers to add to CPT codes.
7.5 Assign CPT codes from the evaluation and management section.
7.6 Assign CPT codes from the anesthesia section.
7.7 Assign CPT codes from the surgery section.
7.8 Assign CPT codes from the radiology section.
7.9 Assign CPT codes from the pathology and laboratory section.
7.10 Assign CPT codes from Category II and Category III.

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Chapter Outline
• Organization of CPT
• CPT Index
• CPT Modifiers
• Evaluation and Management Section
• Anesthesia Section
• Surgery Section
• Radiology Section
• Pathology and Laboratory Section
• Medicine Section
• CPT Category II and Category III Codes

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Introduction
• Current Procedural Terminology (CPT):
• Service and procedure codes reported on insurance claims
• Published by the American Medical Association
• Includes codes for procedures and services provided to patients
• Level I of the Healthcare Common Procedure Coding System (HCPCS)

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Knowledge Check Activity 7.1
What health care settings do you think require reporting of CPT codes?

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Knowledge Check Activity 7.1: Answer
• What health care settings do you think require reporting of CPT codes?
• Providers in offices, clinics, and private homes
• Providers who care for patients in hospitals, nursing facilities, and hospices
• Providers employed by health care facilities
• Hospital outpatient departments

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Organization of CPT
• Listing of descriptive terms and identifying codes for reporting services and
procedures provided in an outpatient setting
• Professional billing: CPT codes are assigned to inpatient hospital professional
services and procedures provided by physicians and other qualified health care
professionals
• NOTE: For institutional billing, ICD-10-PCS codes are assigned to inpatient
hospital services and procedures provided by the hospital.
• Medical necessity: procedures and services submitted on a claim are linked to
ICD-10-CM codes that justify the need for treatment and results in payer
reimbursement consideration

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Relative Value Units
• Assigned by CMS to each CPT and HCPCS Level II code
• Represent cost of providing a service, and include the following payment
components
• Physician work (physician’s time and intensity in providing the service)
• Practice expense (overhead costs involved in providing a service)
• Malpractice expense (malpractice expenses).
• Medicare physician fee schedule payments are based on payment components
multiplied by conversion factors and geographical adjustments.

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CPT Categories
• Category I codes
• Five-character CPT codes and procedure/service descriptor nomenclature
• Traditionally associated with CPT, and are organized within six sections
• Each section contains subsections, headings (categories), and subheadings
(subcategories)
• Category II codes: “evidence-based performance measurements” tracking
codes, and their use is optional
• Category III codes: “emerging technology” temporary codes assigned for data
collection purposes, and they are archived after five years unless accepted for
placement within Category I sections of CPT

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CPT Sections
• Evaluation and Management (E/M)
• Anesthesia
• Surgery
• Radiology
• Pathology and Laboratory
• Medicine

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CPT Code Number Format
• Five-character code and narrative description for each procedure and service
• Stand-alone code: includes complete description of procedure or service
• Indented code: appears below stand-alone code and requires coder to refer
back to common portion of code description located before a semicolon

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CPT Appendices
• Appendix A: Modifiers
• Appendix B: Added/deleted/revised codes
• Appendix C: Clinical examples
• Appendix D: Add-on codes
• Appendix E: Codes exempt from modifier-51
• Appendix F: Codes exempt from modifier-63
• Appendix G: Removed from CPT
• Appendix H: Removed from CPT
• Appendix I: Removed from CPT
• Appendix J: Electrodiagnostic medicine
listing of sensory, motor, and mixed nerves
• Appendix K: Products pending FDA approval
• Appendix L: List of vascular families
• Appendix M: Crosswalk of deleted and
renumbered codes
• Appendix N: List of resequenced codes
• Appendix O: Administrative codes for
multianalyte assays with algorithmic analyses
• Appendix P: List of synchronous telemedicine
codes to which modifier-95 is added
• Appendix Q: SARS-CoV-2 (COVID-19)
vaccine codes
• Appendix R: Digital Medicine-Services
Taxonomy

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CPT Symbols
● New code
▲ Revised code description
 Revised guidelines and notes
; Used to save space in code descriptions
 Add-on code
 Exempt from modifier -51
 FDA approval pending
# Resequenced codes
 Refer to CPT Changes: An Insider’s View for guidance
 Refer to CPT Assistant for guidance.
 Refer to Clinical Examples in Radiology for guidance
 Synchronous telemedicine service code indicating modifier -95 is required
 PLA symbol
Category I PLA symbol

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CPT Sections, Subsections, Categories,
and Subcategories

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CPT Guidelines and Notes
• Guidelines
• Located at beginning of each CPT section
• Carefully reviewed before assigning codes
• Define and explain assignment of codes, procedures, and services in a
particular CPT section
• Notes
• Instructional notes appear throughout CPT to clarify assignment of codes
• Blocked un-indented note: located below subsection title and contains instructions that
apply to all codes in that subsection
• Indented parenthetical note: located below subsection title, code description, or a code
description that contains an example

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Sample CPT Notes

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CPT Unlisted Procedures/Services
• Assigned for procedure or service for which there is no CPT code
• Special report: attached to claim (e.g., copy of procedure report)
• Nature
• Extent
• Need for procedure or service
• Time, effort, and equipment necessary

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CPT Descriptive Qualifiers
• Terms that clarify assignment of CPT code
• Can occur in middle of main clause or after a semicolon
• May or may not be enclosed in parentheses

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Which category of CPT contains five-character codes and descriptions, which are
organized into six sections?
a. Category I
b. Category II
c. Category III

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Which category of CPT contains five-character codes and descriptions, which are
organized into six sections?
a. Category I
Category I codes: five-character CPT codes and procedure/ service descriptor
nomenclature; these are codes traditionally associated with CPT and organized
within six sections; each section contains subsections and anatomic, procedural,
condition, or descriptor subheadings; and codes are presented in numerical order
except for the Evaluation and Management section, which appears as the first
section.

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CPT Index
• Organized by alphabetical main terms and indented subterms
• Main terms represent:
• Procedures or services
• Organs or anatomic sites
• Conditions
• Synonyms, eponyms, and abbreviations
• Modifying terms, called subterms, indented below main terms
• Main terms and subterms are followed by a single code, a range of codes, or a series
of codes separated by commas
• Conventions include boldface type (main terms), use of italicized cross reference terms
(see and see also), and inferred words.

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Coding Procedures and Services
1. Read introduction in CPT coding manual
2. Review guidelines at beginning of each section
3. Review procedure or service listed in source document
4. Use CPT index to locate main term for procedure/service
5. Locate subterms and follow cross-reference terms
6. Review code description, and compare to select correct code
7. Assign code, applicable add-on code
8. Review CPT Appendix B to assign appropriate modifier(s)

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Upon review of the CPT index, which would be reviewed in the coding manual to
select a code for “nail biopsy?”
a. 11730–11732
b. 11755
c. 11720, 11721
d. 10060, 10061
e. 11740

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Upon review of the CPT index, which would be reviewed in the coding manual to
select a code for “nail biopsy?”
b. 11755
Go to CPT index main term Nails and
subterm Biopsy to select code 11755.
(Verify the code to ensure accuracy of
code assignment.)

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CPT Modifiers
• Clarify services and procedures performed by providers
• CPT code and description remain unchanged
• Indicate that description of service or procedure performed has been altered in
some way (e.g., bilateral procedure)
Example: Patient undergoes
bilateral arthrodesis, knees.
Report CPT code 27580 with
bilateral modifier-50, so that
code 27580 50 is reported on
the CMS-1500 claim.

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For a routine preventive annual examination of a 72-year-old new patient, CPT
code 99387 is reported. During examination, the physician palpated an enlarged
spleen, which required office or other outpatient evaluation and management
(E/M) services to determine a treatment regimen. Code 99214 was reported for
the level 4 E/M services. Which modifier is assigned to code 99214?
a. −22 (increased procedural services)
b. −24 (unrelated E/M service by same physician during postop period)
c. −25 (significantly, separately identifiable E/M service by same physician on
same day of procedure or other service)
d. −33 (preventive services)

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For a routine preventive annual examination of a 72-year-old new patient, CPT code
99387 is reported. During examination, the physician palpated an enlarged spleen, which
required office or other outpatient evaluation and management (E/M) services to
determine a treatment regimen. Code 99214 was reported for the level 4 E/M services.
Which modifier is assigned to code 99214?
c. −25 (significantly, separately identifiable E/M service by same physician on same day
of procedure or other service)
The patient receive preventive medicine services from the physician during the same
encounter that the enlarged spleen was palpated. The physician then provided level 4
office or other outpatient E/M services for treatment of the enlarged spleen. When
reporting a preventive medicine code and an office or other outpatient E/M during the
same encounter, a modifier must be added to the office or other outpatient E/M code.

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Evaluation and Management Section
• First CPT section because codes describe evaluation and management (E/M) services,
which are most frequently provided by all health care providers
• Accurate assignment is essential because most revenue is generated by E/M services
• E/M are cognitive services, which means provider must acquire information from
patients, use reasoning skills to process information, interact with patients to provide
feedback, and respond by creating appropriate plans of care
• Significant procedural services (e.g., diagnostic tests or surgical procedures) are coded
separately
• However, some services provided are included, such cleansing traumatic lesions,
closing lacerations with adhesive strips or surgical glue, applying dressings, and
providing counseling and educational services

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Overview of Evaluation and Management
Section
• Level of E/M service reflects amount of work involved in providing health care to patients
• Between three and five levels of service are included in E/M categories
• Documentation in patient’s record must support the level of service reported.
• E/M codes are often referred to as level numbers, with the level number corresponding to
the last digit of the CPT code
• Accurate assignment of E/M codes depends on
• Identifying place of service, type services, or whether miscellaneous service was provided
• Determining whether patient is new or established, if applicable
• Applying CMS documentation guidelines for E/M services (not applicable to Office or Other
Outpatient Service codes)
• Determining whether E/M guidelines or heading/subheading notes apply

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Evaluation and Management Services
Guidelines
• E/M guidelines overview and classification of E/M services
• Definitions of commonly used terms
• Guidelines common to all E/M services (e.g., level of E/M services)
• Guidelines and instructions for hospital observation; hospital inpatient;
consultations; emergency department; nursing facility, domiciliary, rest home,
or custodial care; and home services
• Instructions for selecting a level of office or other outpatient service
• Unlisted service and special report
• Clinical examples

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A 54-year-old established patient was seen in the office as follow-up for a
diagnosis of high blood pressure. She lost 50 pounds during the past year, but
upon examination her blood pressure continues to be 145/98. The decision was
made to place the patient on Hyzaar as treatment for hypertension. The patient is
scheduled to return in three months for recheck. Today’s visit was 40 minutes in
length. Which CPT E/M code is reported for this office or other outpatient service?
a. 99203
b. 99204
c. 99214
d. 99215

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A 54-year-old established patient was seen in the office as follow-up for a
diagnosis of high blood pressure. She lost 50 pounds during the past year, but
upon examination her blood pressure continues to be 145/98. The decision was
made to place the patient on Hyzaar as treatment for hypertension. The patient is
scheduled to return in three months for recheck. Today’s visit was 40 minutes in
length. Which CPT E/M code is reported for this office or other outpatient service?
d. 99215
The type of service is “office or other outpatient service,” and the place of service
is “office.” The case scenario documents a 40-minute encounter for an
established patient. Thus, CPT code 99215 is reported.

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Anesthesia Section
• Codes are assigned for administration of analgesia/anesthesia
• Local, regional, epidural, general anesthesia, and monitored anesthesia care
• Anxiolytics and amnesia-inducing medications
• Anesthesia is administered by anesthesiologists or certified registered nurse
anesthetists (CRNA)
• Anesthesia care for patients
• Preanesthesia evaluation
• Postanesthesia recovery and evaluation

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Assigning Anesthesia Codes
• Codes are assigned for anesthesia administered during surgical, radiology, burn
excisions/debridement, obstetric, and other procedures
• Separate or multiple procedures: report the anesthesia code that represents the
most complex procedure performed, and total the time for anesthesia
administered during all procedures
• Qualifying circumstances for anesthesia: anesthesia services provided during
situations/circumstances that make administration more difficult
• Anesthesia modifiers: provider-type and physical status
• Anesthesia time reporting: time units are based on total anesthesia time

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The provision of local or regional anesthetic services with certain
conscious-altering drugs when provided by a physician, anesthesiologist,
or medically directed CRNA is called
a. Anxiolytics and amnesia-inducing medications
b. Epidural, general, or regional anesthesia
c. Local or peripheral block anesthesia with sedation
d. Monitored anesthesia care

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The provision of local or regional anesthetic services with certain conscious-
altering drugs when provided by a physician, anesthesiologist, or medically
directed CRNA is called
d. Monitored anesthesia care
Monitored anesthesia care (MAC) requires sufficiently monitoring the patient to
anticipate the potential need for the administration of general anesthesia, and it
requires continuous evaluation of vital physiologic functions as well as recognition
and treatment of adverse changes.

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Surgery Section
• Organized by body system
• Include subsections, headings, and subheadings
• To code surgeries properly, ask the following questions:
1. What body system was involved?
2. What anatomic site was involved?
3. What type of procedure was performed?
• Carefully read the procedure outlined in the operative report. Sometimes the
discriminating factor between one code and another will be the surgical
approach or type of procedure documented.

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Surgical Package (Global Surgery)
Global period: number of days associated with surgical package and designated
by the payer as 0, 10, or 90 days or as a three-character code, such as MMM
(global period policy does not apply)

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Separate Procedure
• Parenthetical note that follows a code description, such as 38100 Splenectomy;
total (separate procedure)
• Identifies procedures that are an integral part of another procedure or service
• However, the separate procedure code is reported if the procedure is:
• Performed independently of a comprehensive procedure or service
• Unrelated to or distinct from another procedure or service performed at the
same time

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Multiple Surgical Procedures
• Two or more surgeries performed during the same operative session
• Major surgical procedure code is reported on line 1 of Block 24A on the
CMS-1500 claim.
• Lesser surgical procedure codes are reported on subsequent lines of Block
24A on the CMS-1500 claim, in descending order of cost.
• Modifier-51 is added to lesser surgical procedure codes if symbols  or 
do not appear in front of the codes.
• Ranking of major and minor procedure codes is due to payers reducing fees
associated with second and subsequent procedures

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A patient undergoes a cystourethroscopy, with ureteral catheterization, irrigation,
instillation, and ureteropyelography, including brush biopsy of urethra and renal
pelvis. Which CPT code is assigned?
a. 52000 Cystourethroscopy (separate procedure)
b. 52001 Cystourethroscopy, with irrigation and evacuation of multiple
obstructing clots
c. 52005 Cystourethroscopy, with ureteral catheterization, with or without
irrigation, instillation, or ureter pyelography, exclusive of radiologic service;
d. 52007 with brush biopsy of ureter and/or renal pelvis
e. 52010 Cystourethroscopy, with ejaculatory duct catheterization, with or without
irrigation, instillation, or duct radiography, exclusive of radiologic service

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A patient undergoes a cystourethroscopy, with ureteral catheterization, irrigation,
instillation, and ureteropyelography, including brush biopsy of urethra and renal
pelvis. Which CPT code is assigned?
c. 52005 Cystourethroscopy, with ureteral catheterization, with or without
irrigation, instillation, or ureter pyelography, exclusive of radiologic
service;
d. 52007 with brush biopsy of ureter and/or renal pelvis
Assign CPT code 52007 because it includes the description of code 52005 before
the semicolon, plus the description of code 52007. Do not report both codes!

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Radiology Section
• Includes subsections for:
• Diagnostic radiology (imaging)
• Diagnostic ultrasound
• Radiation oncology
• Nuclear medicine
• Subsections are subdivided into anatomic headings.
• Radiologic views: studies taken from different angles
• Determines code selection for many diagnostic radiologic procedures
• Complete: a reference to the number of views required for a full study of a
designated body part

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A patient underwent 2-view posterolateral chest X-ray for probable pneumonia on
the left side. Which code is assigned?
a. 71045 Radiologic examination, chest; single view
b. 71046 2 views
c. 71047 3 views
d. 71048 4 or more views

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A patient underwent 2-view posterolateral chest X-ray for probable pneumonia on
the left side. Which code is assigned?
b. 71046 2 views
A posterolateral chest X-ray is a 2-view chest X-ray, and is assigned code 71046.

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Pathology and Laboratory Section
• Organized according to type of pathology or laboratory procedure
• Within each subsection, procedures are listed alphabetically
• Example: Report code 80061 when the physician orders a lipid panel. The
following tests are performed on the blood sample: cholesterol, serum, total
(82465); lipoprotein, direct measurement, high-density cholesterol (HDL
cholesterol) (83718); and triglycerides (84478).

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A pathologist spent 60 minutes on a clinical consultation for a patient with a highly complex clinical
problem that required a comprehensive review of the patient’s history and medical records and
high level of medical decision making. An additional 30 minutes was spent on this clinical
consultation. Which codes are reported? (Select more than one answer.)
a. 80503 Pathology clinical consultation; for a clinical problem, with limited review of
patient's history and medical records and straightforward medical decision making
(5-20 minutes of time spent on the date of consultation)
b. 80504 for a moderately complex clinical problem, with review of patient’s
history and medical records and moderate level of medical decision making
c. 80505 for a highly complex clinical problem, with comprehensive review of patient’s
history and medical records and high level of medical decision making
d. 80506 prolonged service, each additional 30 minutes (list separately in addition to
code for primary procedure)

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A pathologist spent 60 minutes on a clinical consultation for a patient with a highly complex clinical
problem that required a comprehensive review of the patient’s history and medical records and
high level of medical decision making. An additional 30 minutes was spent on this clinical
consultation. Which codes are reported? (Select more than one answer.)
c. 80505 for a highly complex clinical problem, with comprehensive review of patient’s
history and medical records and high level of medical decision making
d. 80506 prolonged service, each additional 30 minutes (list separately in addition to code for
primary procedure)
Codes 80505 and 80506 are both assigned for this case because the pathologist met the criteria
for code 80505 (and 60 minutes of time), plus an additional 30 minutes of time on the clinical
consultation.

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Medicine Section
• Classifies noninvasive or minimally invasive diagnostic and therapeutic
procedures and services
• Noninvasive procedures require no surgical incision or excision, and they
are not open procedures.
• Minimally invasive procedures include percutaneous access.
• Subsections
• Classify procedures and procedure-oriented services (e.g., immunizations)
• Apply to various medical specialties (e.g., gastroenterology, ophthalmology,
otorhinolaryngology, and psychiatry)
• Apply to different types of health care providers (e.g., physical therapists and
occupational therapists)

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A patient was treated in the ambulance received cardiopulmonary resuscitation.
Which code is reported?
a. 92950 Cardiopulmonary resuscitation
b. 92960 Cardioversion, elective, electrical conversation of arrhythmia;
external
c. 92961 internal (separate procedure)
d. 99203 Level 3 E/M office or other outpatient service

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A patient was treated in the ambulance received cardiopulmonary resuscitation.
Which code is reported?
a. 92950 Cardiopulmonary resuscitation

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CPT Category II and Category III Codes
• CPT Category II Codes
• Supplemental tracking codes used for performance measurement
• Assigned for certain services or test results, which support nationally established performance
measures that have proven to contribute to quality patient care
• Facilitate collection of information about quality of services provided to patients
• Use of Category II is expected to decrease time required for patient record abstracting and
review, minimizing administrative burden
• CPT Category III Codes
• Temporary codes that allow for utilization tracking of emerging technology, procedures, and
services
• May or may not eventually be assigned a CPT Category I code and description
• Archived five years from the date of initial publication unless a modification to the date is made

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A patient underwent community-acquired bacterial pneumonia assessment.
Which code is assigned?
a. 0012F Community-acquired bacterial pneumonia assessment
(includes all of the following components)
b. 1026F Comorbid conditions assessed
c. 2010F Vital signs recorded
d. 2014F Mental status assessed
e. 2018F Hydration status assessed

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A patient underwent community-acquired bacterial pneumonia assessment.
Which code is assigned?
a. 0012F Community-acquired bacterial pneumonia assessment
(includes all of the following components)
Assign code 0012F only because that code includes codes 1026F, 2010F, 2014F,
and 2018F as per the parenthetical note in the code 0012F description.

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Self-Assessment
• Were you able to apply the information from the chapter to the assignment of
CPT codes during exercises and reviews?
• What areas of CPT coding will you need to restudy?
• What are your plans to update your CPT coding skills on an annual basis?

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Summary
Now that the lesson has ended, you should have learned how to:
• Define key terms related to CPT coding.
• Describe the organization of CPT.
• Locate main terms, subterms, and cross-references in the CPT index.
• Select appropriate modifiers to add to CPT codes.
• Assign CPT codes from the evaluation and management section.
• Assign CPT codes from the anesthesia section.
• Assign CPT codes from the surgery section.
• Assign CPT codes from the radiology section.
• Assign CPT codes from the pathology and laboratory section.
• Assign CPT codes from Category II and Category III.

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