The CPT book divided into 7 major sections:Evaluation and ManagementAnesthesiaSurgeryRadiologyPathology and LaboratoryMedicineAppendixes Use this story as an easy way to remember the order of the sections the book:The patient has gone to the doctor and the doctor said "operation". (evaluation and management). The patient is taken to the operating room and placed under sedation (anesthesia). The doctor comes into the OR and operates (surgery). The doctor may need the help of diagnostic equipment during the operation. (radiology). The doctor may also send a biopsy to the lab. (pathology and laboratory). After the surgery, the patient goes home with prescriptions for medications, or orders for physical therapy. (medicine)
Use the index to look up procedure in various ways:1. by procedure, or2. by body organ or anatomic site involved, or3. by condition for which the patient is being treatedIf you are unable to locate a procedure or code in one of the ways mentioned above, try looking up the procedure, organ, or condition in your dictionary to find a synonym for it. (Example: cancer = carcinoma) You may also try to check under eponyms (proper names of inventors or founders, i.e., Colles Fracture). Another way to find a procedure is by looking up its abbreviation ( CPK = creatininephosphokinase test). After you locate the procedure in the index, check the code in the corresponding section to verify the correct code for that procedure and check to see if any exemptions delete use of that code.
Editorial Notations:The bullet precedes the code and means that the code and its description are new to the book for that year.The triangle precedes the code and means that the description of the code has changed since last year.
The Evaluation and Management Section Most of the coding for procedures that are done in the medical office will be office visits. These visits are coded under the Evaluation and Management section. Depending on the type of practice, and the extent to which the physicians perform other procedures in the office will take into account codes listed throughout the CPT book. Remember, all codes in the Evaluation and Management Section begin with the number 9.Services found in the Evaluation and Management Section include histories, examinations and decisions that must be made regarding the patient's diagnosis and treatment.A new patient is one who has not received any professional services from a physician or services from another doctor of the same specialty within the same group practice in the past three years.An established patient is one who has received professional services from a given physician of the same specialty and within the same group practice in the past three years.There are 4 different kinds of histories, 4 different kinds of examinations and a variety of decisions that can be made before you try to use the Evaluation and Management codes.The four different histories are: Problem-Focused History (obtains chief complaint and takes a brief history of the present illness or problem)Expanded Problem-Focused History (obtains chief complaint, takes a brief history of the present illness or problem and conducts a problem-pertinent "system" review)Detailed History (obtains chief complaint, takes an extended history of the present illness or problem, completes a problem-pertinent system review which include a review of a limited number of additional systems, and acquires a pertinent past, family and or social history directly related to the patient's problems.)Comprehensive History (obtains the chief complaint, takes and extended history on the present illness or problems, reviews the systems directly related to the problem or problems as well as all additional body systems and acquires a complete past family and social history)The four different examinations are:Problem-Focused Examination (limited to affected body area or organ system)Expanded Problem-Focused Examination (examines the affected body organ or system and checks other symptomatic or related organ systems)Detailed Examination (performs an extended examination of the affected body area and other symptomatic or related organsComprehensive Examination (performs a complete single system specialty examination or a complete multisystem examination)4 kinds of medical decision making:Straightforward (minimal number of diagnoses, amount of date to check and risk of more serious illness or death)Low Complexity(limited number of diagnoses, amount of date to check and risk of more serious illness or death)Moderate Complexity(multiple, or moderate number of diagnoses, amount of date to check and risk of more serious illness or death)High Complexity(extensive or high number of diagnoses, amount of date to check and risk of more serious illness or death) To qualify for a particular Evaluation and Management code, most new patient visits require that all three key components be met or exceeded and most established patient visits require that only two of three key components be met or exceeded.
Look it up!<br />Use the index to look up procedures:by procedureby body organby condition<br />
Symbols and Conventions<br />* The asterisk, or star follows a code. Stars can be found only in the Surgery Section. It means that the surgical package concept does not apply (the pre-op and post op services are NOT included with the procedure as listed.<br />◄ The inverted triangles show the reader that some text other than the actual descriptions of the code has been added or changed.<br />+ Codes that have the plus sign are known as "add-on" codes. You will find that some serve in CPT take into account "more parts" of another service.<br />ø The exempt symbol specifically relates the fact that codes found with this notation do not require the use of the multiple procedure modifier-51.<br />
Modifiers<br />Find complete list of CPT modifiers inside front cover of coding manual<br />Clarify services and procedures (there has been an alteration of the service or procedure)<br />CMS 1500 allows up to 4 modifiers per CPT code<br />Special E & M cases<br />Greater, reduced or discontinued services<br />Global surgery<br />Special surgical and procedural events<br />Bilateral & multiple procedures<br />Repeat services<br />Multiple surgeons<br />Professional & technical components<br />Unusual anesthesia<br />Laboratory services<br />
E & M Codes (evaluation and management)<br />New patient/Established patient<br />Key components:1. Extent of history2. Extent of examination3. Medical Decision-making complexity<br />Other components include:1. counseling2. coordination of care3. nature of presenting problem4. time<br />Complexity of patient symptoms<br />Description/need for service<br />Diagnostic & therapeutic procedures<br />Pt. diagnosis & concurrent problems<br />Pertinent physical findings<br />Time, effort, equipment required<br />