Levels of Procedure Codes

The fourth edition of the CPT, first published in 1977, became the standard for insurance billing in the early 1980s, when it was used as the basis for a Medicare procedure coding system, the Healthcare Common Procedure Coding System (HCPCS), pronounced “hick-picks.” Medicare, the government insurance program for the elderly and disabled, is administered by the Centers for Medicare and Medicaid Services (CMS). It will be discussed in detail in Chapter 46.

Sections of the CPT Manual

The CPT manual is used for most procedure coding. Its main part is divided into six sections, each of which defines the procedures and services provided for specific types of medical services. The six sections, and the range of codes for each, are as follows:

In each annual update of the CPT, new codes may be added for new procedures, old codes may be dropped for procedures no longer in use, and modifications may be made to current procedures. A darkened circle in front of a code indicates that the code is new. A darkened triangle in front of the code indicates that the description for the code has been changed or modified (Figure 45-1). The medical assistant must familiarize himself or herself with the important revisions each year when the new codes are published. In addition, codes must be updated in the office computer system and on office forms such as charge slips to be sure that insurance is billed correctly.

The main body of the CPT manual is organized by section, then subsection, subheading, and finally category, each providing a finer level of detail. The back of the manual contains an alphabetic index of procedures. The most common procedures performed in a given office are usually found on the charge slip and in the computer billing program. In the office itself, the provider usually checks off the codes for common procedures done during a patient visit and writes in the name of procedures not found on the charge slip. However, the patient may be billed from the medical office for services provided in another setting—for example, when a physician visits a patient in the hospital during morning rounds, when he or she examines a patient in the emergency room or a nursing home, and when he or she performs surgery in the hospital or an outpatient surgery setting. In most locations the office bills only for office services. If the office bills for labwork done by an outside reference lab, this must be indicated on the insurance form (see Chapter 46).

Looking up CPT Codes in the Index

There are several steps in choosing a correct procedure code for a specific patient service. The first step in coding a procedure is to look up the procedure in the alphabetic index at the back of the CPT manual, but the code should not be recorded at this point. The medical assistant should never code directly from the index because it does not contain descriptions of the code and may result in use of an incorrect code.

It may be necessary to look up the procedure in several ways to locate the correct code. In the index, procedures may be located by looking under the name of the procedure, the anatomic location, and sometimes the diagnosis. The terms are arranged alphabetically with the main term in boldface type and modifying terms arranged below the main term. Each level of modifying term is indented further than the level above it. For example, the main term may be an anatomic location, such as the foot. The first modifying term would identify either a condition, an anatomic location, or a procedure (such as Lesion, Nerve, or Repair). When a procedure is listed in the index (as the main term or any level of modifying term), it is followed by a code or range of codes (e.g., Foot, Nerve, Excision …… 28055). Both main terms and modifying terms may point to a cross-reference using the word See. (See Figure 45-2.)

Several pieces of information may be significant when choosing the correct code for a procedure:

Selecting a Specific CPT Code

After identifying a code or code range from the index, the medical assistant should read all relevant codes carefully in the main text. It may also be necessary to review the guidelines at the beginning of the appropriate section of the CPT manual to obtain additional information that can be helpful in choosing a code. The medical assistant should select the code that is the best match for the medical documentation and determine if it is necessary to use a modifier or an add-on code.

There are two types of CPT codes: stand-alone codes and indented codes. The stand-alone code contains a semicolon (e.g., 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). The indented code, which follows a stand-alone code or another indented code, provides only text to replace the words after the semicolon in the stand-alone code (e.g., 93005 [indent] tracing only, without interpretation and report). In the example given, the code 93000 would be used if the ECG tracing is made and the physician interprets the tracing in the same medical office. The code 93005 would be used if the ECG tracing is made in one office, but insurance should not be billed for the interpretation because it will be done by another physician and billed from another office (Procedure 45-1).

Procedure 45-1   Performing CPT Coding

Outcome

Perform CPT coding for procedures.

Equipment/Supplies

• Patient’s medical record

• Charge slip

• CPT manual

1. Procedural Step. Find the name of the procedure to look up and information about the procedure (if necessary) using the patient’s charge slip and/or medical record.

    Principle. The charge slip usually identifies the procedure(s) performed, but the medical record may be necessary to identify the appropriate level of service.

2. Procedural Step. For E/M services, identify if the patient is a new patient or an established patient.

    Principle. Different codes are used for new patients and established patients.

3. Procedural Step. For E/M services, identify if the patient was seen in the medical office or at another location, such as the hospital, emergency department, or nursing home.

    Principle. Different E/M codes are used depending on the location where the patient was seen. The coding and billing for visits provided by a physician to a hospitalized patient, nursing home resident, or patient in the emergency department are often done by staff at the physician’s medical office.

4. Procedural Step. Using the index at the back of the manual, locate the section in which the category of codes will be found. You may need to look for the name of the procedure, the diagnosis, the type of patient, the location of service, or the location of the lesion.

    Examples:

A To locate an initial office visit for a new patient, look in the index under New Patient, Initial Office Visit (99201-99205) or under Evaluation and Management, Office and Other Outpatient (99201-99215).

B To locate the code for a rapid strep test, look under Streptococcus, Group A, Direct Optical Observation (87880).

5. Procedural Step. Look in the manual at the code or range of codes to read the description and determine the correct code. Do not code from the index.

    Principle. You cannot be sure that you have identified the correct code without reading the description of the code. You may also find additional information in the section to help you code properly.

6. Procedural Step. If the service is unusual or does not seem to fit the description of the code completely, check the list of modifiers for the section of the manual to see if a modifier is necessary.

    Example:

    A patient has an abscess of the left upper arm, which required incision and drainage again today.

1: In the index, you look up Abscess, Arm, Upper, Incision and Drainage. It refers you to codes 23930-23035.

    Index*:

2: When you look at those codes, you see that these codes refer to deep abscesses.

    Codes*:

3: You review the medical record and determine that the physician called the lesion a subcutaneous abscess.

4: For superficial abscesses, you are referred to codes 10040-10160. The code 10060 (incision and drainage of abscess: simple or single) appears to describe the procedure most accurately. Because the patient came for an office visit specifically for treatment of the abscess and no other E/M services were provided, you do not charge for a separate office visit.

    Codes*:

7. Procedural Step. Enter the correct code(s) on the charge slip, on the encounter form, and if applicable in the patient’s record in the computer so that it can be used for insurance billing.

    Principle. Reimbursement is made by insurance companies based on the codes submitted. They must be accurate and reflect the service or procedure performed. In the example given earlier, the insurance company might refuse to pay for the service (as already provided) without the modifier, which indicates that it is in fact a repeat service of a procedure performed by another physician.

---

^*Copyright © CPT (Current Procedural Terminology), 2011, Standard Edition, American Medical Association. All rights reserved.

Evaluation and Management

The Evaluation and Management (E/M) section contains codes for office visits provided by primary care practitioners and specialists. E/M codes cover the service-oriented, rather than the procedure-oriented, parts of medical care. It is important to determine where the service was provided when selecting the correct E/M code.

Although procedures are fairly easy to define—for instance, incision and drainage of a cyst—the amount of service provided by a physician during an office visit is more difficult to describe. One physician may consider 20 minutes an appropriate amount of time for a visit, whereas another may consider 30 minutes the minimum amount of time to spend with a patient. One physician may focus strictly on the patient’s presenting problem, whereas another may want to examine the patient more completely, especially if he or she has not been seen for several months.

The codes in the E/M section attempt to link reimbursement to the completeness of the examination and the amount of skill required to manage the patient’s problems. Unfortunately, this may push the physician to limit the time spent with patients. If the patient does not have well defined, complex medical problems, the visit is reimbursed as uncomplicated, no matter how much time the visit took. For example, if a patient is in the office for a recheck of an ear infection, the visit would not usually take a significant amount of time. If the patient has several questions about methods other than antibiotics that could be used to treat ear infections, it will take more time for the physician to complete the examination, even though there is no additional medical problem or complication.

When determining the proper code for E/M services, the medical assistant must consider a number of factors.

1. For coding purposes, the patient is either an established patient (one who has been seen in the previous 3 years) or a new patient (one who has not had services performed by any provider in the medical office in the previous 3 years). There are separate groups of codes for each type of patient. New patients are expected to take longer to examine and are reimbursed at a higher rate. The patient is also either an outpatient (one who has not been admitted to a health care facility) or an inpatient (a patient who has been formally admitted to a health care facility). Although most services for patients who are inpatients are billed by the health care facility itself, physicians who are not employees of that facility bill for visits to the patient during a hospital admission, for inpatient consultations, for providing reports for some diagnostic tests performed at the hospital (such as cardiac stress tests), for critical care and intensive care services, as well as care for visits to patients in nursing homes.

2. There are separate groups of codes, depending on where the service is provided and whether the physician is the patient’s primary care provider or a consultant. A medical service could have been provided in the office, in a nursing home, in a hospital to a patient who has been admitted, or in a hospital emergency department. The E/M section of the CPT manual is divided into several subsections, and it is important to select a code from the correct subsection, depending on the service that the physician provided and the location where the service was provided.

3. The level of service depends primarily on three key factors:

• The extent of the medical history (number of body systems discussed)

• The extent of the physical examination (number of body systems examined)

• The complexity of medical decision making

Medical History

History taking consists of four levels: (1) problem focused, (2) expanded problem focused, (3) detailed, and (4) comprehensive.

• A problem-focused history is one that addresses the chief complaint, with a brief history of the illness or problem.

• An expanded problem-focused history addresses the chief complaint, a brief history of the present illness or problem, and a review of systems that have to do with the chief complaint.

• A detailed history addresses the chief complaint, an extended history of the present illness, and a review of body systems, including other systems beyond those related to the chief complaint. Family history is also reviewed as it relates to the present problem.

• A comprehensive history includes a chief complaint; an extended history of the present illness; a review of all body systems, especially those directly related to the present problem; and a complete family history.

Physical Examination

• A problem-focused examination is limited to the affected body system or organ.

• An expanded problem-focused examination is related to the affected body system, as well as other organs or systems that might be symptomatic. For example, the patient may be followed for angina (recurrent chest pain) and have a new complaint of calf pain when walking.

• A detailed examination includes the affected body systems or organs and other related systems or organs.

• A comprehensive examination is a multisystem examination, or a complete examination of one system.

Medical Decision Making

Medical decision making can be straightforward or have a low, moderate, or high level of complexity. If a patient has one problem, medical decision making is usually straightforward. When a patient has multiple problems, especially if they are causing severe or life-threatening symptoms, the decision-making process is more complex. For example, if a new patient has poorly controlled diabetes mellitus type 1, fever, and an increased white blood count, the decision-making process for the physician would be highly complex (Figure 45-3).

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