Presentation 29581 2013 CPC Study Guide Cy

User Manual: 29581

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CPC®
Certification Review

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CPT®
CPT® copyright 2011 American Medical Association. All rights
reserved.
Fee schedules, relative value units, conversion factors and/or related
components are not assigned by the AMA, are not part of CPT®, and
the AMA is not recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical services. The AMA
assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
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The Business of Medicine

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Payers
• Self-pay
• Insurance
– Private (commercial) insurance
•
•
•
•

BCBS
Aetna
Cigna
Etc

– Government insurance
• Medicare
• Medicaid
• TriCare
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Medicare
•
•
•
•

Part A – Inpatient hospital care
Part B – Outpatient medical care
Part C – Medicare Advantage
Part D – Prescription drug coverage

RBRVS
– Non-Facility Pricing Amount
[(Work RVU * Work GPCI) +
(Transitioned Non-Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor (CF)

– Facility Pricing Amount
[(Work RVU * Work GPCI) +
(Transitioned Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * CF
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Medical Necessity
Services or supplies that:
• are proper and needed for the diagnosis or treatment of your
medical condition,
• are provided for the diagnosis, direct care, and treatment of
your medical condition,
• meet the standards of good medical practice in the local
area, and
• aren’t mainly for the convenience of you or your doctor.
www.cms.gov/apps/glossary
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National Coverage Determinations
• National Coverage Determinations (NCD) help to spell out
CMS policies on when Medicare will pay for items or
services
– Each Medicare Administrative Carrier (MAC) is then responsible
for interpreting national policies into regional policies
– LCD’s only have jurisdiction within their regional area

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Advance Beneficiary Notice
• Providers are responsible for obtaining an ABN prior to
providing the service or item to a beneficiary.
– The form must be filled out in its entirety as well as the cost to the
patient and the reason why Medicare may deny the service
– Only the approved Form CMS-R-131 is valid and the forms may not
be altered

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HIPAA
• National standards for electronic health care transactions
and code sets;
• National unique identifiers for providers, health plans, and
employers;
• Privacy and Security of health data.

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HITECH
• The Health Information Technology for Economic and Clinical
Health Act
– Promote the adoption and meaningful use of health information
technology
– Strengthened HIPAA
– Patient audit trail

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OIG Compliance Plan
1.
2.
3.
4.
5.
6.
7.

Conduct internal monitoring and auditing.
Implement compliance and practice standards.
Designate a compliance officer or contact.
Conduct appropriate training and education.
Respond appropriately to detected offenses and develop corrective
action.
Develop open lines of communication with employees.
Enforce disciplinary standards through well-publicized guidelines.
http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp

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ICD-9-CM Coding

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NEC vs. NOS
• NEC

Not elsewhere classifiable

―We know what’s wrong, but there isn’t a specific code for it.‖
• NOS

Not otherwise specified
―We aren’t sure what’s wrong.‖

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Punctuation
[ ] Brackets: in tabular enclose synonyms or alternate
wording
Example:
008.0 Escherichia coli [E. coli]

[ ] Slanted brackets: in index identifies manifestations and
indicates sequence.
Example:
Diabetes, diabetic 250.0x
cataract 250.5x [366.41]
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Punctuation
( ) Parentheses: enclose supplementary words that may be
present in the description

Example:
Cyst (mucus)(retention)(serous)(simple)

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Additional Terms
599.0 Urinary tract infection, site not specified
Excludes

candidiasis of urinary tract (112.2)
urinary tract infection of newborn (771.82)

280 Iron deficiency anemias
Includes
anemia
asiderotic
hypochromic-microcytic
sideropenic
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Use Additional Code
282.42 Sickle-cell thalassemia with crisis
Sickle-cell thalassemia with vaso-occlusive pain
Thalassemia Hb-S disease with crisis
Use additional code for the type of crisis, such as:
acute chest sydrome (517.3)
splenic sequestration (289.52)

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Use Additional Code, if Applicable
416.2 Chronic pulmonary embolism
Use additional code, if applicable, for associated long-term
(current) use of anticoagulants (V58.61)

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Combination Codes
Single codes:
787.02 Nausea alone
787.03 Vomiting alone
Combination code:
787.01 Nausea with vomiting

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Steps to Look Up
a Diagnosis Code
1. Find the documented diagnosis
2. Determine the main term
3. Look up the main term in the Index to Diseases (Volume
2)
4. Find the code in the Tabular List (Volume 1)
5. Read all notes associated with the code

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•

ICD-9-CM Official Guidelines for Coding and
Reporting
Section 1
– A: Coding conventions
– B: Coding guidelines
– C: Chapter-specific guidelines

• Sections 2 & 3
– Inpatient Only

• Section 4
– UHDDS guidelines for first listed conditions for outpatient and
office visits www.cdc.gov/nchs/data/icd9/icdguide10.pdf
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ICD-9-CM Guidelines
Hierarchy of Rules
1. Always follow instructions within ICD-9-CM that are
specific to the code.
2. Follow chapter or section instructions when they do not
conflict with the individual code instructions.
3. Follow guidelines when they do not conflict with the
chapter, section, or individual code instructions.
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General Coding Guidelines:
Section I. B.
1.
2.
3.
4.
5.

Use of Both Alphabetic Index and Tabular List
Locate each term in the Alphabetic Index and Tabular List
Level of Detail in Coding
Code or codes from 001.0 through V91.99
Selection of codes 001.0 through 999.9

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General Coding Guidelines:
Section I. B.
6. Signs and symptoms
7. Conditions that are an integral part of the disease
process
8. Conditions that are not an integral part of the disease
process
9. Multiple coding for a single condition
10. Acute and Chronic conditions

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General Coding Guidelines:
Section I. B.
11.
12.
13.
14.
15.
16.

Combination code
Late Effects
Impending or threatened conditions
Reporting same diagnosis more than once
Admissions/encounters for rehabilitation
Documentation of BMI (Body Mass Index) and pressure
ulcer stages
17. Syndromes
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Section IV: Diagnostic Coding and Reporting
Guidelines for Outpatient Services
A. Selection of first-listed condition
1. Outpatient surgery
2. Observation stay
B. Codes from 001.0 through V91.99
C. Accurate reporting of ICD-9-CM diagnosis codes
D. Selection of codes 001.0 through 999.9
E. Codes that describe symptoms and signs

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Section IV: Diagnostic Coding and Reporting
Guidelines for Outpatient Services
F. Encounters for circumstances other than a disease or
injury
G. Level of detail in coding
4th

5th

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Section IV: Diagnostic Coding and Reporting Guidelines for
Outpatient Services
H. ICD-9-CM code for the diagnosis, condition, problem, or
other reason for encounter/visit
I. Uncertain diagnosis
J. Chronic diseases
K. Code all documented conditions that co-exist

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Section IV: Diagnostic Coding and Reporting Guidelines for
Outpatient Services
L.
M.
N.
O.
P.

Patients receiving diagnostic services only
Patients receiving therapeutic services only
Patients receiving preoperative evaluations only
Ambulatory Surgery
Routine outpatient prenatal visits

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CPT®, Surgery Guidelines, HCPCS
Level II, and Modifiers

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Introduction to CPT®
• The CPT® code set includes three categories of medical
nomenclature with descriptors.

–

Category I
– Category II
– Category III

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Introduction to CPT®
• Instructions for use of the CPT ® code book
–
–
–
–

Unlisted procedure
CPT® use by any qualified health care professional
Parenthetical notes
Accuracy and quality of coding
• Related guidelines
• Parenthetical instructions
• Other coding resources

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CPT® Guidelines
• Referenced in the introduction of each section and
subsection of the CPT® manual
• Applicable to the section being referenced
• Define the information necessary for choosing the correct
code

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CPT® Conventions and Iconography
Used throughout the CPT ® manual and include:
– Indentations
– Code symbols - iconology
– Parenthetical instructions

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CPT® Conventions and Iconography
;

The semicolon and the conventional use of indentions

The use of the semicolon divides the description of a code into
two parts:
• The ―stand-alone‖ code or the ―common portion of the
procedure‖ code descriptor
• The indented descriptor is dependent on the preceding
―stand-alone‖ code
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CPT® Conventions and Iconography
+

The ―add-on‖ code symbol - Add-on codes
are never reported alone

Example:
+11201 each additional ten lesions, or part thereof
(Use 11201 in conjunction with 11200)

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CPT® Conventions and Iconography
l The red bullet - new procedure code
Example:
l 31660 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,
when performed; with bronchial thermoplasty, 1 lobe

p The (blue) triangle - code revision
Example:
p 32551 Tube thoracostomy, includes connection to drainage system, (eg,
water seal), when performed, open (separate procedure)
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CPT® Conventions and Iconography
ut

Opposing triangles - indicate new and
revised text other than the procedure
descriptors

29581 Application of multi-layer compression system; leg (below knee), including
ankle and foot
u
(Do not report 29581 in conjunction with 29540, 29580, 29582, 36475,
36478) t

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CPT® Conventions and Iconography
 The circle with a line through it - exempt from the use of
modifier 51
Example:  20974 Electrical stimulation to aid bone healing; noninvasive
(nonoperative)

8 The bulls eye - includes moderate sedation
Example: 8 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without
collection of specimen(s) by brushing or washing (separate procedure)

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CPT® Conventions and Iconography
The lightening bolt symbol - codes for vaccines that are
pending FDA approval.
Example: 90661 Influenza virus vaccine, derived from cell cultures, subunit,
preservative and antibiotic free, for intramuscular use
AMA CPT® ―Category I Vaccine Codes‖ website: www.ama-assn.org

# The number symbol - Resequenced
numerical order

and

are out of

Example: 46947 Code is out of numerical sequence. See 46700-46947.
# 46947 Hemorrhoidopexy (for prolapsing internal hemorrhoids) by stapling
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Category I CPT® Codes
The CPT® coding manual divides Category I CPT ® codes
into six main section titles:
–
–
–
–
–
–

Evaluation and Management
Anesthesiology
Surgery
Radiology
Pathology and Laboratory
Medicine
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Category I CPT® Codes
•

Section titles have subsections divided by anatomic location,
procedure, condition, or descriptor subheadings.

•

The subheadings, structured by CPT® conventions, may list alternate
coding suggestions in parenthetical instructions.

•

Example:
•
•
•
•

Section: Surgery (10021-69990)
Subsection: Integumentary System
Subheading: Skin, Subcutaneous and Accessory Structures
Category: Debridement

Alternate coding
suggestions

»
»
»
»

(For dermabrasions, see 15780 – 15783)
(For nail debridement, see 11720-11721)
(For burn(s), see 16000-16035)
(For pressure ulcers, see 15920-15999)

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The CPT® Coding Manual
•
•
•
•
•
•
•
•

CPT®

Sections
Section Guidelines
Section Table of Contents
Notes
Category II codes (0001F – 7025F)
Category III codes (0019T – 0318T)
Appendices A-O
Alphabetic Index

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CPT® Code Basics
•
•

Review medical documentation thoroughly and gather
additional reports
Reference the alphabetical index for a CPT ® numerical
code and/or code range.
–
–
–
–

•
•

Condition
Procedure or service
Anatomic site
Synonyms, eponyms and abbreviations

Review the numerical code and/or code range for
specific descriptions
Follow CPT® Guidelines, Conventions and Iconology
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National Correct Coding Initiative (CCI)
• Implemented by CMS
• Promotes correct coding methodologies
• Controls the improper assignment of codes that results in
inappropriate reimbursement
Medicare publishes CCI:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/

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Sequencing
• Based on RBRVS
– Physician Work
– Practice Expense
– Professional Liability/Malpractice Insurance

• Highest RBRVS listed first
www.cms.hhs.gov/PhysicianFee-Sched/

CPT® Assistant
•
•
•
•
•
•

Articles answering everyday coding questions
CCI bundling information
E/M billing guidance
Current code use and interpretation
Case studies demonstrating practical application of codes
Anatomical illustration charts and graphs for quick
reference
• Information for appealing insurance denials
• Information to validate code usage when audited
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Category II CPT® Codes
• Alphanumeric format, with the letter ―F‖ in the last position,
eg, 0001F
• Optional ―performance measurement‖ tracking codes
• Physician Quality Reporting Initiative (PQRI)

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Category III CPT® codes
• Temporary codes
• Alphanumeric structure, with a ―T‖ in the last position, eg,
0019T
• Can be reported alone, without an additional Category I
code

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CPT® Appendices
Appendix A - Modifiers categorized:
–
–
–
–

Modifiers applicable to CPT® codes
Anesthesia Physical Status Modifiers
CPT® Level I Modifiers approved for Ambulatory Surgery
Center (ASC) Hospital Outpatient Use
Level II (HCPCS/National) Modifiers

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CPT® Appendices
• Appendix B - changes and additions to the CPT ® codes
from the previous year
• Appendix C - clinical E/M examples for different specialties
• Appendix D – Add-on Codes

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CPT® Appendices
• Appendix E – Exempt from the use of modifier 51 (multiple
procedures)
• Appendix F – Exempt from the use of Modifier 63
(procedures performed on infants less than 4kg)
• Appendix G – Include Moderate (Conscious) Sedation
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CPT® Appendices
• Appendix H – Alphabetic Index of Performance Measures
by Clinical Condition or Topic
– Available only on the AMA website
– www.ama-assn.org.

• Appendix I – Genetic Testing Code Modifiers
– Removed from the 2013 code set

• Appendix J - Electrodiagnostic Medicine Listing of
Sensory, Motor, and Mixed Nerves
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CPT® Appendices

• Appendix K - Product Pending FDA Approval
• Appendix L - Vascular Families
– Based on the assumption that a vascular catheterization has a
starting point of the aorta

• Appendix M - Crosswalk to Deleted CPT ® Codes
• Appendix N - Summary of Resequenced CPT® Codes
• Appendix O – Multianalyte Assays
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CPT® Global Surgical Package
• Includes a standard package of preoperative,
intraoperative, and postoperative services
• Payer policies may vary
• May be furnished in any service location
– For example, a hospital, an ambulatory surgical center (ASC), or
physician office

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CPT® Global Surgical Package

Inclusive

Included in the surgery package and not separately billable:
– Local infiltration, metacarpal/metatarsal/digital block or topical
anesthesia
– Subsequent to the decision for surgery, one related E/M encounter
on the date immediately prior to or on the date of procedure
(including history and physical)
– Immediate postoperative care, including dictating operative notes,
talking with the family and other physicians
– Evaluating the patient in the postanesthesia recovery area
– Writing orders
– Typical postoperative follow-up care
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CMS Global Surgical Package
• Major Surgery: Has a preoperative period of 1 day with 90
days for the postoperative period.
• Minor Surgery: The preoperative period is the day of the
procedure with a postoperative period of either 0 or 10
days depending on the procedure.

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HCPCS Level II
• Types of Level II Codes
– Permanent National Codes maintained by the CMS HCPCS
Workgroup
• Responsible for additions, deletions, revisions
• Updated annually

– Temporary National Codes maintained by the CMS HCPCS
Workgroup
• Responsible for additions, deletions, revisions
• Updated quarterly
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HCPCS Level II
Types of Temporary Codes
• G codes
– Professional health care procedures/services with no CPT ®
codes
– Example:
• G0412 – G0415 – unilateral or bilateral
• 27215 – 27218 – unilateral only, use modifier 50 for bilateral

• H codes
– Used by State Medicaid Agencies for mental health services
such as alcohol and drug treatment services
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HCPCS Level II
Appendices:
– Level II modifiers
• May be used with some CPT® codes, i.e., LT/RT

– Table of Drugs
• Names of Drugs, dosage, delivery method, J code

– Medicare References
– Jurisdiction List
– Deleted Code Crosswalk
(each publisher may have different appendices)
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Modifiers
• 22 – Increased Procedural Service
– Service provided is greater than that usually required for the
listed procedure

• 24 - Unrelated E/M by the same physician during a
postoperative period

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Global Package Modifiers
• 25 - Significant, separately identifiable evaluation and
management service by the same physician on the same
day of the procedure or other service
• 57 - Decision for surgery

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Global Package Modifiers
• 58 - Staged or related procedure or service by the same
physician during the postoperative period
• 78 - Unplanned return to the operating/ procedure room
by the same physician following initial procedure for a
related procedure during the postoperative period
• 79 - Unrelated procedure or service by the same
physician during the postoperative period
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Surgical Modifiers
• 50 - Bilateral Procedure
• 51 - Multiple Procedures
• 52 - Reduced Services
• 53 - Discontinued Procedure
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Modifier 59 - Distinct
Procedural Service
•
•
•
•
•
•

Procedures not normally reported together
Different Session or Patient Encounter
Different Procedure or Surgery
Different Site or Organ System
Separate Incision/Excision
Separate Lesion

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Modifiers
• Modifier 63 - Procedures Performed
on Infants Less than 4kg Increased work intensity
• Modifier 76 - Repeat Procedure or Service by Same
Physician
• Modifier 77 - Repeat Procedure or Service by Another
Physician
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Multiple Surgeon Modifiers
•

62 – Two Surgeons
–
–
–
–

•

Work together as primary surgeons
Perform distinct parts of a procedure
Dictate op report of their distinct part
Each will submit the same code and append modifier 62

66 – Surgical Team
– Highly complex procedures
– Require differently specialties
– Modifier 66 appended to procedures coded by the surgical team

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Assistant Surgeon Modifiers
•

80 – Assistant Surgeon
– Assistant surgeon present for entire or substantial portion of the operation
– Reports the same surgical procedure with modifier 80 appended

•

81 – Minimum Assistant Surgeon
– Circumstances present that require the services of an asst surgeon for a short
time. Minimal assistance.
– Reports the same surgical procedure with modifier 81 appended

•

82 – Assistant Surgeon (when qualified resident surgeon not
available)
– Used in a teaching hospital that employs residents
– No residents available and another surgeon is used
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Ancillary Modifiers
• Global – a procedure containing both a technical and a
professional component
• Modifier 26 – Professional Component
• Modifier TC – Technical Component

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Laboratory Modifiers
• 90 – Reference (Outside) Laboratory
– Used to bill for lab services purchased from an outside lab

• 91 – Repeat Clinical Diagnostic Lab Test
– Not used to confirm results
– Not used to repeat a test due to equipment malfunction

• 92 – Alternative Lab Platform Testing
– Single use
– HIV testing

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Anesthesia Modifiers
• 23 - Unusual Anesthesia
• 47 – Anesthesia by Surgeon
• Physical Status Modifiers

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Integumentary System

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Anatomy of the Skin
• Epidermis
– Top layer
• Made up of 4-5 layers; function is protection

• Dermis
– Mid layer
• Blood vessels, connective tissue, nerves, etc.

• Subcutaneous Tissue
– Connective tissue and adipose tissue

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ICD-9-CM: Integumentary
• Chapter 2 – Neoplasms
• Chapter 12 – Diseases of the Skin and Subcutaneous Tissue
• Chapter 17 – Injury and Poisoning

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ICD-9-CM: Integumentary
Chapter 12: Diseases of the Skin and Subcutaneous Tissue
– Skin infections (bacterial and fungal)
– Inflammatory conditions of the skin
– Other disorders of the skin
•
•
•
•

Corns and calluses
Keloid scars
Keratosis
etc.

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Inflammatory Conditions of the Skin
• Erythema multiforme:
–
–
–
–

Code for erythema multiforme
Code associated manifestation
Code percent of skin exfoliation (695.50-695.59)
An additional E code if drug induced

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Pressure Ulcers
• Decubitus ulcers/bed sores
• Coding
– Identify the location of the ulcer
– Identify the stage of the ulcer

26

Injury and Poisoning
• Open Wounds (870-897)
• Superficial Injury (910-919)
• Contusion with Intact Skin Surface (920-924)
• Burns (940-949)

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Burns
• Location
• Severity (degree) of burn
• Total Body Surface Area (TBSA)

Disorders of the Breast
• Category 610 - Mammary dysplasia
• Category 611 - Disorders of the breast
• Category 612 – Deformity and disproportion of reconstructed
breast

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Skin, Subcutaneous,
and Accessory Structures
• Incision and Drainage
– Simple
– Complicated*
* Complicated = placement of a drain, presence of infection,
hemorrhaging that requires ligation, extensive time

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Debridement
• Debridement
– Method for removing dead tissue, dirt, or debris from infected
skin, burn or wound
– Based on percent of body surface area

• Debridement of necrotizing soft tissue
– Based on area of body being debrided

• Medicine codes
– 97597-97602

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Biopsy
• 11100 single lesion
• 11101 each separate/additional lesion
• Three lesions
– 11100 and 11101 x 2

• Obtaining of tissue during another procedure is not
considered a separate biopsy

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Skin, Subcutaneous,
and Accessory Structures
• Removal of Skin Tags
– 11200 up to and including 15 lesions
– 11201 add-on code for each additional 10 lesions

• Shaving of Epidermal Lesions 11300-11313
– Include local anesthesia & chemical/electocauterization of
wound
– Select codes on size and anatomic location
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Skin, Subcutaneous,
and Accessory Structures
• Excision of Lesions
– Measurement
• Lesion diameter plus narrowest margins

• Code Selection
– Benign or Malignant
– Size in centimeters
– Anatomical location
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Nails
• Fingernails and/or toenails
• Trimming or Debridement

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Integumentary System
• Pilonidal Cyst
– Coded according to complexity of excision

• Introduction
–
–
–
–
–
–

Intralesional Injections
Tattooing
Tissue Expansion
Contraceptive Capsule insertion/removal
Hormone implantation
Drug Delivery Implants
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Repair
• Three factors
– Length of wound in centimeters
– Complexity of repair
– Site of wound

• Wound closure includes sutures, staples tissue adhesive
• Wound repair using only adhesive strips report with E/M
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Repair
• Adjacent Tissue Transfer or Rearrangement
–
–
–
–
–

Z-plasty
W-plasty
V-Y plasty
Rotation Flaps
Advancement Flaps

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Repair
• Skin Replacement Surgery & Skin Substitutes
– 15002-15005 based on size of repair and site
– 15040-15261 reported for autografts and tissue cultured
autografts
– 15271-15278 reported for skin substitute grafts
– 15050 is pinch graft measured in centimeters
– All other skin graft codes are determined by the size of the
defect in square centimeters
– Square centimeters calculation
length in cm x width in cm
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Repair
• Other Procedures
–
–
–
–
–
–
–

Dermabrasion
Chemical Peels
Cervicoplasty
Blepharoplasty
Rhytidectomy
Abdominoplasty
Lipo-suction

Destruction
• Ablation by any method other than excision
–
–
–
–

Electrosurgery
Cryosurgery
Laser treatment
Chemical treatment

• Benign/premalignant based on number of lesions
• Malignant lesion according to location and size in
centimeters
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Destruction
• Mohs Micrographic Surgery
–
–
–
–

Removal of complex or ill-defined skin cancer
Physician acts as surgeon and pathologist
Removes tumor tissues and performs histopathologic exam
Repair of site may be reported separately

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Breast
• Incision
• Excision
• Introduction
– Preop needle localization wire

• Repair
• Reconstruction
• Biopsy
– Percutaneous
– Incisional

Breast
• Mastectomy
– Muscles and lymph nodes involved will determine code selection

• Repair Reconstruction
– Reconstruction after mastectomy

• Mastopexy (breast lift)
• Reduction mammoplasty (breast reduction)

CPC® Certification Review

96

32

Musculoskeletal System

CPC® Certification Review

97

Anatomy
– Skeleton
• Axial
• Appendicular

– Muscles
• Assist with heat production
• Posture

– Ligaments – attach bones to other bones
– Tendons – attach muscles to bones
– Cartilage – Acts as a cushion between bones in a joint
CPC® Certification Review

98

ICD-9-CM Coding
Fifth Digit Specification
0—Site unspecified
1— Shoulder region (Acromioclavicular joint, Clavicle, Glenohumeral joint(s), Scapula,
Sternoclavicular joint(s))
2— Upper arm (Elbow joint, Humerus)
3—Forearm (Radius, Ulna, Wrist joint)
4— Hand (Carpals, Metacarpals, Phalanges (fingers))
5— Pelvic region and thigh (Buttock, Femur, Hip joint)
6— Lower leg (Fibula, Knee joint, Patella, Tibia)
7— Ankle and foot (Ankle joint, Digits (toes), Metatarsals, Phalanges, foot, Tarsals, Other
joints in foot)
8— Other specified sites (Head, Neck, Ribs, Skull, Trunk, Vertebral column)
9—Multiple sites
CPC® Certification Review

99

33

Diseases of the Musculoskeletal System and
Connective Tissue
• Arthropathy – pathology or abnormality of a joint
• Dorsopathies – disorders affecting the spinal column
• Rheumatism – non-specific term for any painful disorder of
the joints, muscles, or connective tissue
• Enthesopathies – disorders of ligaments
• Bursitis – inflammation of the bursa

CPC® Certification Review

100

Injury and Poisoning
• Sprains and Strains
• Fractures
–
–
–
–
–
–
–

Comminuted
Impacted
Simple
Greenstick
Pathologic
Compression
Torus or Incomplete
CPC® Certification Review

101

CPT® : Musculoskeletal System
Formatted by anatomic site:
– General
– Head, Neck (soft tissues)
and Thorax
– Back and Flank
– Spine (vertebral column)
– Abdomen
– Shoulder, Humerus and
Elbow

–
–
–
–
–
–

Forearm and Wrist
Hand and Fingers
Pelvis and Hip Joint
Femur and Ankle Joint
Foot and Toes
Application of Casts and
Strapping
– Endoscopy/ Arthroscopy

CPC® Certification Review

102

34

Musculoskeletal System
• ―General‖ subheading
– Many different anatomic sites

• Other subheadings
– Divided by anatomic site, procedure type, condition and
description
• Incision, excision, introduction or Removal, Repair, Revision and/or
Reconstruction, Fracture and/or dislocation, Arthrodesis, Amputation

CPC® Certification Review

103

Guidelines
Types of Fracture Treatment
• Closed - the fracture site not surgically exposed.
• Open – used when fractured bone is surgically exposed
• Percutaneous skeletal fixation

CPC® Certification Review

104

General
• Not specific to anatomic site
• Incision of soft tissue abscess
– Associated with deep tissue

• Wound Exploration
– Traumatic wounds
– Include surgical exploration/enlargement, debridement, removal of
foreign bodies, ligation/coagulation minor blood vessels
CPC® Certification Review

105

35

General
• Excision & Biopsy
– Muscle or Bone
– Depth of wound or tissue excised

• Introduction or Removal
– Injections
– Foreign body removal

CPC® Certification Review

106

Anatomical Subheadings
• Based on anatomic site
• Divided based on procedure
– Incision
– Excision
– Fracture

• Read notes carefully
CPC® Certification Review

107

CPC® Certification Review

108

Spine
• Anatomy
– Cervical C1-C7

• C1 Atlas
• C2 Axis
– Thoracic T1-T12
– Lumbar L1-L5

• Spinal Instrumentation
– Segmental
– Non-segmental

36

Endoscopy/Arthroscopy
• Divided by body area
– Elbow
– Shoulder
– Knee

• Surgical endoscopy/arthroscopy includes a diagnostic
endoscopy/arthroscopy
• Multiple surgical procedures performed through scope
may be reported
• ―Separate procedure‖ – included in more extensive
procedure
CPC® Certification Review

109

CPC® Certification Review

110

HCPCS Level II
• Orthotic and Prosthetic
• Basic Orthopedic Supplies
–
–
–
–
–
–

Crutches
Canes
Walkers
Traction Devices
Wheelchairs
Other orthopedic supplies

Respiratory,
Hemic, Lymphatic, Mediastinum and
Diaphragm

CPC® Certification Review

111

37

Respiratory System
•
•
•
•
•
•
•

Nose
Larynx
Pharynx
Trachea
Bronchi
Bronchioles
Lungs

• Alveoli
– Located at the ends of the
bronchioles
– Function is gas exchange
(CO2 and O2)

• Pleura

CPC® Certification Review

112

Mediastinum and Diaphragm
• Mediastinum-thoracic cavity between the lungs that contains
the heart, aorta, esophagus, trachea, thymus gland
• Diaphragm-muscle that divides the thoracic cavity from the
abdominal cavity

CPC® Certification Review

113

Hemic and Lymphatic Systems
• Network of channels
• Structures dedicated to circulation and production of
lymphocytes
• Three interrelated functions
– Removal for interstitial fluid from tissues
– Absorbs and transports fatty acids to circulatory system
– Transport antigen presenting cells to lymph nodes

CPC® Certification Review

114

38

Hemic and Lymphatic Systems
• Spleen
– Located left side of stomach
– Reservoir for blood cells
– Produces lymphocytes involved in fighting infection

CPC® Certification Review

115

ICD-9-CM: Respiratory
•
•
•
•

Acute Respiratory Infections (460-466)
Other Disease of the Upper Respiratory System (470-478)
Pneumonia and Influenza (480-488)
COPD and Allied Conditions (490-496)

CPC® Certification Review

116

CPC® Certification Review

117

ICD-9-CM
• Mediastinum and Diaphragm
– Diaphragm Herniation
– Diaphragmatic Paralysis
– Thymic hyperplasia

• Hemic and Lymphatic Systems
–
–
–
–
–

Lymphoma
Lymphadenitis
Hypersplenism
Splenic Rupture
Leukemia

39

Rules/Guidelines
• Respiratory procedures
– Progress downward from the head to the thorax

• Parenthetical statements
– Directions on how to use specific codes
– Apply to codes above parenthetical note; not below

• Most codes are unilateral
• Use modifier 50 if bilateral procedure performed
– Unless code descriptor states bilateral

CPC® Certification Review

118

CPC® Certification Review

119

CPC® Certification Review

120

Nose
• Rhinotomy
• Excision
– Biopsy code
– Removal of lesions, cysts, and/or polyps
– Turbinates

• Rhinectomy

Nose
• Introduction
– Therapeutic turbinate injection
– Prosthesis for deviated nasal septum
• Plug placed by physician

• Removal of foreign body
– Office setting
– Facility setting
• General anesthesia

40

Nose
• Repair
– Rhinoplasty
– Septoplasty, Atresia. Fistulas, Dermatoplasty

• Destruction
– Turbinate mucosa

• Other procedures
– Control of epitaxis (nose bleed)
– Fracturing of turbinates

CPC® Certification Review

121

Accessory Sinuses
• Four pairs of sinuses
• Procedures
– Obliterative
– Non-obliterative

• Endoscopies
– Diagnostic/Surgical
– All surgical endoscopies always include a diagnostic endoscopy

CPC® Certification Review

122

CPC® Certification Review

123

The Larynx
•
•
•
•
•

Laryngotomy
Laryngectomy
Pharyngolarungectomy
Arytenoidectomy
Incision
– Emergency endotracheal intubation
– Change of tracheotomy tube

41

The Larynx
• Endoscopy
– Use of operating microscope or telescope
• Parenthetical statement instructs not to code the operating microscope

– Direct visualization
• View anatomical structures via bronchoscope inserted into laryngoscope

– Indirect visualization
• Structures viewed in a laryngoscopic mirrored reflection

CPC® Certification Review

124

Trachea and Bronchi
• Endoscopy
– Many bronchoscopy codes
• Use common portion of main or parent code (up to the semicolon) as the first
part of each indented code descriptor under the parent code
• Bulls eye icon – code includes moderate sedation and is not reported
separately when performed

– Bronchoscopy codes
•
•
•
•
•

Bronchial lung biopsies
Foreign body removals
Stent or catheter placements
Flexible or rigid scopes
Many parenthetical statements
CPC® Certification Review

125

Trachea and Bronchi
• Excision and Repair
– Carinal reconstruction
• Needed after removal of cancer at this site

– Tracheal tumor excision
• Thoracic and intrathoracic

– Stenosis and anastamosis excision
– Injury suturing
– Tracheostomy scar revision

CPC® Certification Review

126

42

Lungs and Pleura
• Incision codes
–
–
–
–
–

Thoracostomy
Thoracotomy
Pneumonostomy
Pleural scarification
Decortication

CPC® Certification Review

127

CPC® Certification Review

128

CPC® Certification Review

129

Lungs and Pleura
• Excision
– Biopsies
• Read parenthetical statement directions

– Pleurectomy

• Removal
–
–
–
–
–

Pneumocentesis
Thoracentesis
Total pneumonectomy
Lobectomy
Resections

Lungs and Pleura
• Introduction and Removal
– Thoracostomy (chest tube)

• Endoscopy
– Diagnostic vs. surgical
– VATS

43

Lungs and Pleura
• Lung Transplantation
– Three steps
• Harvesting
• Backbench
• Insertion

– Live donors
• Rare
• Only one lobe donated

– Cadaver donors
• Most commonly used

CPC® Certification Review

130

CPC® Certification Review

131

CPC® Certification Review

132

Lungs and Pleura
• Surgical collapse therapy/thoracoplasty
– Resection
– Thoracoplasty

• Other procedures
– Lung lavage
– Tumor ablation
– Unlisted - 32999

Pulmonary
• Ventilator Management
• Other Procedures
–
–
–
–
–
–
–

Spirometry
Pulmonary capacity studies
Respiratory flow studies
Pulmonary stress testing
Inhalation treatment
Oxygen uptake
Pulse oximetry

44

Mediastinum & Diaphragm
• Mediastinum
– Mediastinotomy – based on approach
– Excision (cyst, tumor)
– Endoscopy

• Diaphragm
– Hernia repair
– Resections

CPC® Certification Review

133

Hemic and Lymphatic Systems
• Spleen
– Splenectomy
• Code selection based on type

– Splenorrhaphy
• Reported when a ruptured spleen is repaired

• General
– Bone Marrow or Stem Cell Services

CPC® Certification Review

134

Hemic and Lymphatic Systems
• Lymph Nodes & Lymphatic Channels
– Drainage of lymph node abscess
– Biopsy or Excision
• Code selection based on method and location

– Lymphadenectomy
• Limited – removes only lymph nodes
• Radical – removal of lymph nodes, glands and surrounding tissue

– Injection Procedures
– Lymphangiography

CPC® Certification Review

135

45

Cardiovascular System

CPC® Certification Review

136

Heart
• 4 Chambers

• Valves

– Two atria
– Two ventricles

• Three layers
– Myocardium
– Epicardium
– Pericardium

– Atrioventricular valves
• Tricuspid
• Bicuspid

– Semilunar valves
• Pulmonary
• Aortic

CPC® Certification Review

137

Oxygenation Process
RA > tricuspid valve > RV
RV > pulmonary valve > pulmonary artery
LUNGS (gas exchange)
LA > mitral valve > LV
LV > aortic valve > BODY via arteries
BODY > via veins > RA

CPC® Certification Review

138

46

Electrical Conduction in the Heart
– Conduction begins in sinoatrial node of right atrium
• Nature’s pacemaker
• Firing causes contraction of muscle

– Moves to atrioventricular node
• Then to Bundle of His along septum
• Then to Purkinje fibers along the surface of ventricles

CPC® Certification Review

139

Coronary Arteries &
Blood Vessels
• Arteries
– Carry oxygenated blood
– Take blood away from heart to the body

• Veins
– Carry deoxygenated blood
– Bring blood back to the heart from the capillary beds

• Capillaries
– Connect arteries and veins

CPC® Certification Review

140

Circulations
• Pulmonary Circulation
– Pushes deoxygenated blood into the lungs
– Carbon dioxide removed and oxygen added
– Blood flows to the left atrium

• Systemic Circulation
– Blood flows from left atrium into the left ventricle
– Pumped to the body to deliver oxygen and remove carbon
dioxide

CPC® Certification Review

141

47

ICD-9-CM Coding
Chapter 01 – Infectious and parasitic diseases
Chapter 02 – Neoplasms
Chapter 07 – Diseases of the Circulatory System
Chapter 14 – Congenital Anomalies
Chapter 16 – Signs, Symptoms and Ill-Defined Conditions

CPC® Certification Review

142

ICD-9-CM: Hypertension
• Hypertensive Disease
–
–
–
–

401 Essential hypertension
402 Hypertensive heart disease
403 Hypertensive chronic kidney disease
404 Hypertensive heart and chronic kidney disease

CPC® Certification Review

143

ICD-9-CM: Arteriosclerosis
• CAD of native coronary artery (414.01)
– The patient is not a heart transplant
– The patient has CAD with no history of CABG
– The patient had a prior PTCA of native coronary artery and the
patient is admitted with re-occlusion of this lesion

CPC® Certification Review

144

48

ICD-9-CM Coding
•
•
•
•
•
•

Endocarditis
Heart Failure
Pericarditis
Peripheral Arterial Disease (PAD)
Valve Disorders
Myocardial Infarction (MI)
– Acute MI
– Chronic MI and Old MI
CPC® Certification Review

145

CPC® Certification Review

146

CPT® Coding
• Surgical Section
• Radiology Section
–
–
–
–
–

Heart
Vascular
Diagnostic Ultrasound (various CPT ® s)
Radiologic Guidance
Nuclear Medicine

• Medicine Section
– Cardiovascular
– Noninvasive Vascular Diagnostic Studies

Pacemakers/Defibrillators
• Pacemaker System
• Pacing cardioverter-defibrillator system
• Codes
– Insertion or replacement
– Implanted pacemakers
– Biventricular (2 ventricles)

CPC® Certification Review

147

49

Cardiac Valve Procedures
• Aortic Valve
• Mitral Valve
• Tricuspid Valve
• Pulmonary Valve

CPC® Certification Review

148

CABG & Transluminal Angioplasty
• Coronary Artery Bypass Graft
–
–
–
–
–

Venous
Arterial-Venous
Reoperation
Arterial
Arterial Graft

• Transluminal Angioplasty

CPC® Certification Review

149

CPC® Certification Review

150

Bypass Grafts
• Non-coronary vessels
– Vein
– In-situ vein
• Vein is left in native location

– Other than vein

• Code by type/location

50

Central Venous Access Devices (CVAD)
•
•

Placed for frequent access to bloodstream
Tip of catheter must terminate in the:
–
–
–
–

•

Subclavian
Brachiocephalic
Iliac
Inferior or superior vena cava

Code by
–
–
–
–

•

Procedure (insertion, repair, replacement, removal, etc.)
Tunneled or not
With pump or port
Patient age

See CVAP table in CPT®
CPC® Certification Review

151

Interventional Procedures
• Vascular Injection Procedures
– Selective catheterizations should be coded to the highest level
accessed within a vascular family
– The highest level accessed includes all of the lesser order
selective catheterizations used in the approach
– Additional second and/or third order arterial catheterization
within a vascular family of arteries or veins supplied by a single
first order should be coded

CPC® Certification Review

152

CPT®: Cardiovascular
•
•

Hemodialysis (36800-36822)
Portal Decompression (37140-37183)
– Treat hypertension/occlusion of portal vein
– TIPS (37182, 37183) diverts blood from the portal vein to the hepatic
vein

•

Transcatheter Procedures
– Removal of clot
•
•
•
•

Arterial (37184-37186)
Venous (37187-37188)
Other (37191-37216)
Foreign body retrieval, stent placement, etc.
CPC® Certification Review

153

51

Endovascular Revascularization
•
•

Treat occlusive disease in lower extremities
Three territories
– Illiac
– Femoral/Popliteal
– Tibial/Peroneal

•

Codes arranged in a hierarchy for each territory
–
–
–
–

stent placement with atherectomy (highest)
stent placement
atherectomy
angioplasty (lowest)
CPC® Certification Review

154

Bundled into Endovascular Revascularization
•
•
•
•
•

conscious sedation
vascular access
catheter placement
traversing the lesion
imaging related to the intervention (previously billed as the
supervision and interpretation code for the specific
intervention)
• use of an embolic protection device (EPD)
• imaging for closure device placement
• closure of the access site
CPC® Certification Review

155

Interventional Radiology
• Consider
– The number of catheter access sites
– The number of catheter end points
– The number of vessels visualized

• Vascular Family Order
– Review Appendix L

CPC® Certification Review

156

52

Radiology Vascular Procedures
• Diagnostic angiography
– Sometimes separately reportable
– Diagnostic angiography performed at a separate setting from an
interventional procedure is separately reportable
– Diagnostic angiography performed at the time of an
interventional procedure is NOT separately reportable if it is
specifically included in the interventional code descriptor

CPC® Certification Review

157

CPC® Certification Review

158

Radiology
• Heart
– Cardiac MRI & CT

• Cardiovascular System
– Cardiac SPECT
– Blood pool imaging
– PET

Medicine Section
•
•
•
•
•
•
•
•
•
•

Therapeutic services and procedures
Cardiography
Cardiovascular monitoring services
Implantable wearable cardiac device evaluations
Echocardiography
Cardiac Catheterizations
Intracardiac Electrophysiological Procedures/Studies
Peripheral Arterial Disease Rehabilitation
Noninvasive physiologic studies and procedures
Other procedures
CPC® Certification Review

159

53

Digestive System

CPC® Certification Review

160

Digestive System
• Lips/Mouth
– Teeth
– Gums
– Tongue

• Pharynx
– Conduit for respiration and digestion

• Esophagus
– Conduct food from the pharynx to the stomach
– Peristaltic action moves the food
CPC® Certification Review

161

Digestive System
•

Stomach
–
–
–
–

•

Cardia
Fundus
Pylorus (antrum)
Body

Small Intestine (small bowel)
– Duodenum
– Jejunum
– Ileum

•

Large Intestine (large bowel)
– Cecum (appendix attached)
– Colon
•
•
•
•
•
•

Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus

CPC® Certification Review

162

54

Digestive System
• Pancreas
– Endocrine and exocrine organ
– Secretes insulin into the bloodstream

• Liver (Hepatic)
– Largest organ and largest gland

• Gallbladder/Biliary System

CPC® Certification Review

163

ICD-9-CM: Digestive
Chapter 1 – Infectious and Parasitic Diseases
Chapter 2 – Neoplasms
Chapter 9 – Disease of the Digestive System
Chapter 14 – Congenital Anomalies
Chapter 16 – Signs, Symptoms, and Ill-Defined Conditions

CPC® Certification Review

164

Diseases of the Digestive System
• Esophageal and Swallowing Disorders
–
–
–
–
–
–

Barrett’s Esophagus
Esophagitis
Esophageal varices
Mallory-Weiss Tear
Hiatal Hernia
Swallowing Disorders/Dysphagia

• Gastritis and Peptic Ulcer Disease
• Gastrointestinal Bleeding
• Gastroenteritis
CPC® Certification Review

165

55

Diseases of the Digestive System
•
•
•
•

Inflammatory Bowel Disease (IBD)
Irritable Bowel Syndrome (IBS)
Foreign Bodies
Diverticular Disease
– Diverticulosis
– Diverticulitis

CPC® Certification Review

166

Diseases of the Digestive System
• Anorectal Disorders
–
–
–
–
–

Rectal prolapse
Abscess
Hemorrhoids
Anal fissure
Anal fistula

• Pancreatitis
• Benign and Malignant Neoplasms of the Gastrointestinal
Tract
• Congenital Disorders
CPC® Certification Review

167

CPT®: Digestive
• Organized by anatomic site and procedure
• Endoscopy
– Visualization of a hollow viscus or canal by means of an endoscope
or scope
– Laparoscope is an endoscope

CPC® Certification Review

168

56

CPT®: Digestive
• Lips
– Vermilionectomy
– Cheiloplasty

• Mouth
– Vestibuloplasty
– Glossectomy
– Palatoplasty

CPC® Certification Review

169

CPC® Certification Review

170

CPT®: Digestive
• Pharynx, Adenoids and Tonsils
–
–
–
–
–

Tonsillectomy
Adenoidectomy
Biopsy
Pharyngoplasty
Pharyngostomy

• Esophagus

CPT®: Digestive
• Endoscopy
– Select and report an appropriate code for each anatomic site
examined
– Esophagoscopy
– Upper GI Endoscopy (EGD)
– Endoscopic retrograde cholangiopancreatography (ERCP)

CPC® Certification Review

171

57

CPT®: Digestive
• Stomach
– Gastrectomy
– Bariatric and Gastric Bypass
– Endoscopic procedures

CPC® Certification Review

172

CPT®: Digestive
• Intestines (except rectum)
– Incision
• Enterolysis
• Exploratory procedures

– Endoscopic
• Small intestines
• Beyond the second portion of the duodenum and stomal endoscopy
• Colonoscopies

– Enterostomy

CPC® Certification Review

173

CPC® Certification Review

174

CPT®: Digestive
• Rectum
– Incision – drainage of abcesses
– Excision
• Proctectomy – partial or complete

– Endoscopy
• Proctosigmoidoscopy
• Sigmoidoscopy
• Colonoscopy

• Anus
– Hemorrhoids

58

CPT®: Digestive
• Liver
• Biliary Tract
• Pancreas

CPC® Certification Review

175

CPT®: Digestive
• Abdomen, Peritoneum, and Omentum
–
–
–
–

Exploratory laparotomy
Drainage of abscess – open or percutaneous
Laparoscopy
Hernia codes
• Type of hernia
• Strangulated or incarcerated
• Initial or subsequent repair

CPC® Certification Review

176

CPC® Certification Review

177

HCPCS
• Colorectal cancer screening
– G0104-G0106
– G0120-G0122

59

Urinary System and
Male Genital System

CPC® Certification Review

178

Anatomy: Urinary System
•
•
•
•
•

Two kidneys (filters)
Renal pelvis/one per kidney (funnels urine into ureters)
Two ureters (to bladder)
One bladder (storage)
One urethra (exit)

Nephro = kidney
Renal = related to kidney
Pyelo = renal pelvis

CPC® Certification Review

179

Anatomy: Male Reproductive System
•
•

Testicles (sperm production, contained in scrotum)
Duct system (transport sperm)
– Epididymis
– Vas deferens

•

Accessory glands (contribute to ejaculate)
– Seminal vesicles
– Prostate gland

•

Penis
– shaft
– glans
– prepuce
CPC® Certification Review

180

60

ICD-9-CM: Urinary
Look primarily to 580-629
• Listed anatomically
–
–
–
–

Kidney
Ureters
Bladder
Urethra

CPC® Certification Review

181

ICD-9-CM: Urinary
• Inflammation
– Nephritis (583)
– Glomerulonephritis (580-582)

• Renal failure (584-586)
• CKD (585)
– ESRD
– With hypertension (403-405)

CPC® Certification Review

182

ICD-9-CM: Urinary
• Renovascular disease (588)
– Report underlying condition first
• Central diabetes inspidus (253.5)
• Nephrogenic diabetes insipidus (588.1)

•
•
•
•

Small Kidney (589)
Pyelonephritis (590)
Hydronephrosis (591)
Calculi (592)
CPC® Certification Review

183

61

ICD-9-CM: Urinary
• VUR (593.7x)
– Backflow or urine into ureter

• Cystitis (595)
– Bladder inflammation

• Voiding disorders (596)
– Urinary incontinence (788.3x)

• UTI (599)
– Report organism, when known
CPC® Certification Review

184

ICD-9-CM: Male Genital System
Look primarily to 600-608
• Listed anatomically
– Prostate
– Testes
– Penis

Also…
•
•
•

Congenital Anomolies
Neoplasms
Signs/Symptoms
CPC® Certification Review

185

ICD-9-CM: Male Genital System
•
•
•
•
•

BPH
Hyperplasia
Prostatitis
PSA
Dysplasia
– PIN III
– PIN I or II

CPC® Certification Review

186

62

ICD-9-CM: Male Genital System
• Spermatic cord, Testis, Tunica Vaginalis, Epididymis
– Hydrocele
– Orchitis

• Penis
–
–
–
–
–

Phimosis
Balantitis
Routine circumcision
Male infertility
Peyronie’s disease
CPC® Certification Review

187

ICD-9-CM: Male Genital System
• Congenital Anomalies
– Cryptorchidism
– Hyposadias
– Epispadias

• Neoplasms (by location)
• Injury
• Signs and Symptoms
CPC® Certification Review

188

CPT®: Urinary
• Arranged by location/procedure type
– Incision, excision, repair, etc.

• Bilateral vs. Unilateral
• Operating Microscope (69990) may be separate
• Surgical endoscopy always includes diagnostic endoscope

CPC® Certification Review

189

63

CPT®: Kidney
• Incision (―otomy‖)
–
–
–
–

Nephrotomy = incision of kidney
Pyelotomy = incision of renal pelvis
Nephrolithotomy
Percutaneous removal of calculi
• Nephrostomy tract

• Excision (―ectomy‖)
– e.g., nephrectomy
– Radical
– Ablation
CPC® Certification Review

190

CPT®: Kidney
• Repair
– Ureteral repair
– Creation of ureteral conduit

• Introduction (aspiration, injection, instillation)
– Ureteral stents
– Catheter changes
– Bladder irrigation and/or instillation

CPC® Certification Review

191

CPT®: Urinary
• Laparoscopy
– Code by procedure

• Endoscopy
– Performed through natural or created opening

• Other Procedures of Kidney
–
–
–
–

Renal Transplantation
Lithotripsy
Percutaneous ablation of renal tumors
Cryotherapy for renal tumors

• Urodynamics
CPC® Certification Review

192

64

CPT®: Male Genital System
Penis
•
•
•

•
•

Incision
Destruction
Excision

Introduction
Repair
– Hypospadia/epispadia
– Prosthesis

– Excision of plaque
– Penectomy
– Circumcision

•

Manipulation

CPC® Certification Review

Female Genital System

CPC® Certification Review

194

Anatomy
External genitalia

Internal Genitalia

•
•
•
•
•
•

•
•
•
•

Mons pubis
Labia (majora and minora)
Hymen
Bartholin’s glands
Clitoris
Urethra

•

Vagina
Uterus
Cervix
Fallopian tubes (―tubes‖ or
oviducts)
Ovaries

CPC® Certification Review

195

65

ICD-9-CM: Female Genital System
Chapter 10: Disease of the Genitourinary System
Chapter 11: Complications of Pregnancy, Childbirth, and the
Puerperium
Chapter 2: Neoplasms
Chapter 18: V Codes

CPC® Certification Review

196

ICD-9-CM: Female Genital System
• Female Genitourinary System
• Complications of Pregnancy, Childbirth, and the
Puerperium
– Have sequencing priority
– Report any condition that affects pregnancy (labor, delivery,
post-partum)
– If pregnancy is incidental to condition treated, report V22.2 as
secondary code

• Must document that condition treated does not affect
pregnancy
– Only for mother, not newborn
CPC® Certification Review

197

ICD-9-CM: Female Genital System
• Routine outpatient prenatal visits w/o complication
–
–
–
–

First pregnancy
Subsequent pregnancy
First-listed Dx
Not to be used with other Chapter 11 Codes

High-risk Pregnancy
•
•
•

Code from category V23
First-listed dx.
May be reported with other Ch. 11 codes
CPC® Certification Review

198

66

CPT®: Female Genital System
Surgery
•

Arranged by anatomy ―outside to inside‖
– Terms used to describe external female genitalia
•
•
•
•

Perineum
Vulva
Pudenda
Introitus

• Consider terminology to determine procedure
– -ectomy = removal
– etc.
CPC® Certification Review

199

CPT®: Female Genital System
• Vulva
• Vagina
– 57022 - Only CPT® code related to obstetrical complications NOT
in labor/delivery section

• Cervix Uteri
– Os = opening of cervix

CPC® Certification Review

200

CPT®: Female Genital System
• Uterus
– Endometrial sampling
– D&C
– Hysterectomy
• Total
– Removal of fundus + cervix (e.g., 58150)
– TAH = removed through abdomen
– TVH = removed through vagina

• Partial

• Oviduct/Ovary
CPC® Certification Review

201

67

Maternity Care/Delivery
Antepartum care
•
•

Initial visit during pregnancy
Ongoing visits during pregnancy
– Average of 13 visits (global OB package)

•

OB package includes…
–
–
–
–

Antenatal care
Delivery
Episiotomy and repair
Postpartum care
CPC® Certification Review

202

Maternity Care/Delivery
Postpartum care includes…
•
•
•

Hospital visits
6-week checkup in the office
Services related to cesarean delivery
– e.g., two week incision check

Unrelated encounters are reported separately

CPC® Certification Review

203

Maternity Care/Delivery
• ―Partial‖ maternity/delivery care
– Patient moves
– Change of coverage, etc.

• Cesarean Delivery

• Twin delivery
• Ultrasound
– NOT included in OB global package
• Some payers may include one U.S. in global package (standard of care)

– More than one U.S. may be performed
CPC® Certification Review

204

68

Abortion
• Spontaneous
– Miscarriage
• Complete
• Missed
– D&C may be required

• Induced
– Therapeutic (medical termination of pregnancy)
• Failed induced abortion
– Hysterotomy

CPC® Certification Review

205

Endocrine and Nervous System

CPC® Certification Review

206

Anatomy: Endocrine
• Comprised of ductless glands that secrete hormones into the
circulatory system

– Thyroid
– Parathyroid
– Thymus
– Adrenal glands
• Medulla
• Cortex
CPC® Certification Review

207

69

Anatomy: Endocrine
• Pancreas
– Endocrine and digestive functions

• Carotid body
– Contains glandular tissue

• Pituitary gland
– Anterior and posterior lobes

• Pineal gland
• Structures classified elsewhere
– eg, kidneys, testes, ovaries
CPC® Certification Review

208

Anatomy: Nervous System
• Comprised of two components
– CNS
• Brain
• Spinal Cord

– PNS
• Nerves running throughout the body

CPC® Certification Review

Nerve Plexi
•

Cervical

•

Brachial

•

Lumbar

•

Sacral

209

Anatomy: Nervous System

– Head, neck, shoulders
– Chest, shoulders, arms, hands
– Back, abdomen, groin, thighs, knees, calves
– Pelvis, buttocks, genitals, thighs, calves, feet

• Solar (Coccygeal)
– Internal organs
CPC® Certification Review

210

70

Anatomy: Nervous System
• Spinal cord functions:
– Motor information to muscles
– Sensory information to brain
– Reflex coordination

• Segment (bone) vs. interspace (space between)
• Segments (Body, Lamina, Process [Spinous, Transverse],
Foramen)
• Facet joints
– One per side, where segments meet
CPC® Certification Review

211

Anatomy: Nervous System
The Brain
– Frontal lobe
• Cerebrum

– Two temporal lobes
– Parietal lobes
• Primary sensory cortex

–
–
–
–

Occipital lobe
Cerebellum
Brainstem
Ventricles
CPC® Certification Review

212

ICD-9-CM: Endocrine
Categories 240-279, by location
– Thyroid
– Parathyroid
– etc.

Neoplasms (Chapter 2)
– Report neoplasm first
– Additional dx. as a result of neoplasm are secondary

CPC® Certification Review

213

71

ICD-9-CM: Endocrine
• Addison’s disease
• Primary hyperparathyroidism
• Diabetes (250.xx)
– 4th digit complications/manifestations
• Report complications/manifestations as secondary

– 5th digit type I/II and controlled/uncontrolled

• Secondary diabetes (249.xx)
– Always has an underlying cause

CPC® Certification Review

214

ICD-9-CM: Nervous System
• Inflammation
–
–
–
–

Meningitis (lining of brain/spinal cord)
Encephalitis (brain)
Myelitis (spinal cord)
Encephaolomyelitis (brain and spinal cord)

• Sleep disorders
• Hereditary/degenerative disease of CNS
– Report underlying disease when instructed

CPC® Certification Review

215

ICD-9-CM: Nervous System
• Pain (NEC)
– Pain control is reason for visit
– Do not report as primary if you know the underlying cause, and
visit is to manage that dx.
– Acute vs. Chronic

• Disorders of CNS
– Migraine
• Fifth digit for status migrainosus
• Headache NOS
CPC® Certification Review

216

72

ICD-9-CM: Nervous System
• Disorders of PNS
– Trigeminal nerve disorder
– Neuritis
• CTS

• Neoplasms
– Search in Vol. 2
– Use neoplasm table, by location and type

CPC® Certification Review

217

CPT®: Endocrine
•
•
•
•

Thyroid
Parathyroid, Thymus, Adrenals, Pancreas
Unlisted
Endocrinology

CPC® Certification Review

218

CPT®: Nervous System
• Skull, Meninges, and Brain
– Twist drill
– Burr holes
– Craniectomy/craniotomy

• Skull base surgery
– Approach
– Definitive procedure
– Repair/reconstruction

• Endovascular therapy
– Balloons or stents to treat arterial disease
CPC® Certification Review

219

73

CPT®: Nervous System
• AV malformation
– Simple vs. complex

• Intracranial aneurysm
– Simple vs. complex

• Other techniques
• Anastomosis to bypass aneurysm
• Stereotaxis/Radiosurgery
– Lesion treatment
CPC® Certification Review

220

CPT®: Nervous System
• Cranial neurostimulators
– Pulse generator
– Electrodes
• eg, for Parkinson's, epilepsy

• Neuroendoscopy
• CSF Shunt
– Drain accumulation of CSF
– May require revision

• Repair of skull
– Skull fracture
– Encephalocele

CPC® Certification Review

221

CPT®: Nervous System
• Spine and Spinal Cord
– Injection, Drainage, Aspiration
• Pay careful attention to notes and parentheticals
• Spinal tap (diagnostic /thereaputic)
• Neurolytic injections

– ―Pain pumps‖
– Intrathecal catheter
– Laminectomy vs. Laminotomy
• Complete vs. partial excision of lamina
• Code by spinal region
• Include decompression
CPC® Certification Review

222

74

CPT®: Nervous System
• Decompression
–
–
–
–

Must consider approach
Discectomy
Osteophytectomy (removal of bony outgrowth)
Corpectomy (vertebral body resection)

• Intra/extradural excision of intraspinal lesion
• Stereotaxis/radiosurgery
• Spinal Neurostimulators
– Electrodes
– Pulse generator
CPC® Certification Review

223

CPT®: Nervous System
• Extracranial nerves, PNS, Autonomic
– 12 pair cranial nerves
– 31 pair spinal nerves
– Autonomic ganglia/plexi

• PNS
– Somatic nerves
– Autonomic nerves
• Sympathetic and parasympathetic

CPC® Certification Review

224

CPT®: Nervous System
• Facet Joint injections
– Nerve block
• Unilateral
• Focus on ―joint‖ between vertebrae

–
–
–
–

Nerve ―destruction‖
Somatic or sympathetic nerve
Number of levels
If infused, duration

CPC® Certification Review

225

75

CPT®: Nervous System
• Injection of sympathetic nerves
• Peripheral Neurostimulators
– surface or percutaneous

• Destruction by neurolytic agent
• Neuroplasty
– Freeing of nerves from scar tissue

• Transection/avulsion (divide/tear away)

CPC® Certification Review

226

CPT®: Nervous System
• Excision
– By nerve

• Neurorrhaphy
– Suturing of nerve
– Without or with graft
– By nerve

• Operating microscope
– Beware bundling issues

CPC® Certification Review

227

CPT®: Nervous System
Neurology/Neuromuscular
•
•
•
•
•
•
•

Sleep studies
EEG
Muscle/ROM testing
EMG
Chemo guidance
EP/Reflex testing
Neurostimulator analysis/programming

CPC® Certification Review

228

76

Eye and Ocular Adnexa, Auditory
Systems

CPC® Certification Review

229

Anatomy: Eye and Ocular Adnexa
• Eyeball
–
–
–
–
–

Sclera
Cornea
Pupil and Iris
Choroid – vascular layer
Retina – pigmented nerve layer

• Optic nerve and Optic disc

CPC® Certification Review

230

Anatomy: Ear and Auditory System
• Middle ear
– Tympanic membrane
– Ossicles – malleus, incus,
stapes
– Eustachian tube

• Inner ear
– Labyrinth
– Membranous labyrinth – hair
cells
– Vibrations into nerve
impulse
– Cochlea, Vestibule,
Semicircular canal
– Balance – utricle, saccule
– Oval window, round window
CPC® Certification Review

231

77

ICD-9-CM: Sense Organs
• Alphabetic index ; Tabular List
• Chapter 6: Diseases of Nervous System and Sense Organs
– Disorders of the Eye and Adnexa
– Diseases of the Ear and Mastoid Process

• Chapter 2: Neoplasms

CPC® Certification Review

232

Eye and Ocular Adnexa
•
•
•
•
•
•
•
•

Infection and Inflammation
Neoplastic disease
Injury
Glaucoma
Cataracts
Retinopathy
Retinal detachment
Strabismus
CPC® Certification Review

233

Ear and Mastoid Process
•
•
•
•
•
•
•

Diseases of the Ear and Mastoid Process
Infectious and inflammation
Neoplastic disease
Injury
Vertigo
Hearing loss
Congenital disorders
CPC® Certification Review

234

78

CPT®: Eye and Ocular Adnexa
• Eyeball
-evisceration
-exenteration
-enucleation

• Secondary Implant(s) Procedures

CPC® Certification Review

235

CPT®: Eye and Ocular Adnexa
• Intraocular Lens Procedures (IOL)
–
–
–
–

Cataract removal with IOL
Intracapsular
Extracapsular
IOL exchange

CPC® Certification Review

236

CPT®: Eye and Ocular Adnexa
• Ocular Adnexa
– Strabismus
• horizontal
• vertical
• transposition

CPC® Certification Review

237

79

CPT®: Eye and Ocular Adnexa
• Operating Microscope
– Most procedures on the eye are performed with a microscope and
are included in the procedure code.
– Do not report 69990 with 65091-68850

CPC® Certification Review

238

CPT®: Auditory System
Auditory System
• Removal foreign body from external auditory canal
- both ears

CPC® Certification Review

239

CPT®: Auditory System
Middle Ear
• Tympanostomy
• Mastoidectomy; complete
-modified radical
-radical

• Tympanoplasty

CPC® Certification Review

240

80

CPT®: Auditory System
Inner Ear
•
•
•

Labyrinthectomy
Temporal Bone, Middle Fossa Approach
Microsurgery

CPC® Certification Review

241

CPT®: Auditory System Medicine Section
•
•
•
•

Special Otorhinolaryngolocic Services
Otolaryngologic examination under general anesthesia
Vestibular Function Tests
Audiologic Function Tests with Medical Diagnostic Evaluation

CPC® Certification Review

242

CPC® Certification Review

243

Anesthesia

81

Definition

Anesthesia is a state in which
the patient feels no pain

CPC® Certification Review

244

Organization of Codes
Organized by anatomical location
•
•
•
•
•
•
•
•
•
•

Head
Neck
Thorax
Intrathoracic
Spine and Spinal Cord
Upper Abdomen
Lower Abdomen
Perineum
Pelvis
Upper Leg

•
•
•
•
•
•
•
•
•

Knee and Popliteal Area
Lower Leg
Shoulder and Axilla
Upper Arm and Elbow
Forearm, Wrist, and Hand
Radiological Procedures
Burn Excisions or Debridement
Obstetric
Other Procedures

CPC® Certification Review

245

Finding the CPT® Code
• Start in the Index
• Look up Anesthesia
• Anatomical location
• Type of surgery
• Surgical approach

CPC® Certification Review

82

Types of Anesthesia
• Local
– Included in CPT® code
– No separate anesthesia code

• MAC - Monitored Anesthesia Care
– Decreased awareness

• Regional
– Blocks
– Spinals
– Epidurals

• General
– Unconscious

CPC® Certification Review
247

Anesthesia Terminology
•
•
•
•

One-Lung Ventilation (OLV)
Pump Oxygenator
Intraperitoneal – within the peritoneum
Extraperitoneal/Retroperitoneal - space in the abdominal
cavity behind the peritoneum

CPC® Certification Review

248

Anesthesia Guidelines
• Services included with the anesthesia code:
–
–
–
–
–

Preoperative visits
Postoperative visits
Anesthesia during the procedure
Administration of fluids/blood
Usual monitoring
• Unusual forms include CVP, Arterial line insertion, and Swanz-Ganz and
are coded separately

CPC® Certification Review

249

83

Physical Status Modifiers
• Assigned by the provider
• Coder would need to look for a diagnosis to report it
• Documented in anesthesia record
P1 P2 P3 P4 P5 P6 -

normal healthy
mild systemic disease
severe systemic disease (1 unit)
constant threat to patients life (2 units)
not expected to survive w/o surgery (3 units)
declared brain-dead patient
CPC® Certification Review

250

Qualifying Circumstances
•
•
•
•

+ 99100 – under 1 or over 70
+ 99116 - complicated by hypothermia
+ 99135 - complicated by controlled hypotension
+ 99140 - complicated by emergency

CPC® Certification Review

251

Modifiers
HCPCS Level II
AA - Performed by anesthesiologist
AD - Medically supervised by physician
QK - Medically directing 2-4 concurrent procedures (cases happening
at the same time)
QS - MAC (deep sedation)
QX - CRNA service medically directed
QY - medically directing CRNA single case
QZ - CRNA w/o medical direction

CPC® Certification Review

252

84

CPT® Modifiers
53 – Discontinued Procedures
– Used if surgeon discontinues the procedure

59 - Distinct procedural services
– Example: General anesthesia during surgery, then an epidural is
placed for post op pain management.

CPC® Certification Review

253

Additional Procedures
• CVP – central venous catheter
– Monitoring
– Quick administration

• Arterial Line Insertion
– Based on technique used

• Swan-Ganz
– Included if done through the CVP
– Separate vessels code for both
CPC® Certification Review

254

CPC® Certification Review

255

Radiology

85

Radiologic Projections
• Oblique – slanting, neither frontal or lateral
• Lateral – side view, X-ray beam travels through the side of
the body
• Anteroposterior – X-ray beam enters the body through the
front and exits through the back
• Posteroanterior – X-ray beam enters the body through the
back and exits through the front
• Cone – focused or spot view
CPC® Certification Review

256

Additional Terms
•
•
•
•

Proximal – closer to the point of attachment to the body
Distal – away from the point of attachment to the body
Flexion – bending
Extension – straightening

CPC® Certification Review

257

Diagnosis Coding
• Code the definitive diagnosis
• Code signs and symptoms if no definitive diagnosis is
available
• Diagnostic tests
– Code sign or symptom that prompted the test
– Do not code questionable, rule out, or probably diagnoses.

• Routine radiology
– V72.5 Radiological examination, NEC
CPC® Certification Review

258

86

CPT® Subsections
•
•
•
•
•
•
•

Diagnostic Radiology (Diagnostic Imaging)
Diagnostic Ultrasound
Radiologic Guidance
Breast, Mammography
Bone/Joint Studies
Radiation Oncology
Nuclear Medicine
CPC® Certification Review

259

Guidelines
• Supervision and Interpretation (S & I)
– Interventional radiologic procedures
– Report two codes:
• Surgical code; or code from the medicine section
• Radiologic supervision and interpretation

• Administration of Contrast Material
– Contrast material administered intravascularly, intra-articularly or
intrathecally
– Oral and/or rectal contrast does not qualify
CPC® Certification Review

260

CPC® Certification Review

261

Modifiers
• Technical Component (TC)
– Equipment
– Overhead
• Supplies
• Room
• Gowns

• Professional Component (26)
– Reading and interpretation

87

Diagnostic Radiology
(Diagnostic Imaging)
• Anatomical organization
• Radiologic procedures include:
– Standard X-rays
– MRIs
– CTs

CPC® Certification Review

262

Diagnostic Radiology
(Diagnostic Imaging)
• Code Selection:
–
–
–
–
–
–

Anatomical location
Type of procedure
Number of views
Type of view (AP, PA, etc)
Laterality (unilateral, bilateral)
Contrast material

CPC® Certification Review

263

Heart – Subsection Guidelines
• Heart
– Stress
• Cause the heart to work harder

– Cardiac MRI
• Physiologic evaluation of the cardiac function
• Velocity flow mapping

– Cardiac CT
• Coronary calcium
• Congenital heart disease

CPC® Certification Review

264

88

Vascular Procedures – Subsection Guidelines
• Aorta and arteries
– Aortography – imaging of aorta and branches
– Angiography – imaging of arteries

• Veins and lymphatics
– Lymphangiography – visualization of lymphatics
– Splenoportography – injection of contrast into the spleen to
visualize the port vessel of the portal circulation
– Venography – imaging of veins
CPC® Certification Review

265

Vascular Procedures
• Transcatheter procedures
– Supervision and interpretation codes
– Code with codes from:
• Cardiovascular section
• Medicine section

CPC® Certification Review

266

Other Procedures
76000

76001

Fluoroscopy (separate procedure), up to one hour
physician or other healthcare professional time,
other than 71023 or 71034 (eg, cardiac fluoroscopy)
Fluoroscopy, physician or other healthcare
professional time more than 1 hour, assisting a
nonradiologic physician (eg, nephrolithotomy,
ERCP, bronchoscopy, transbronchial biopsy)

CPC® Certification Review

267

89

Diagnostic Ultrasound
• High frequency sound waves to look at organs and other
structures inside the body
• Used to view:
–
–
–
–
–

Heart
Blood vessels
Kidneys
Other organs
Fetus (during pregnancy)
CPC® Certification Review

268

Diagnostic Ultrasound
• Required:
– Permanently recorded images with measurements
– Final written report for the patient’s medical record
– Exception – biometric measure

CPC® Certification Review

269

Diagnostic Ultrasound
• Anatomic regions
– Complete – each element listed in parenthesis within the code
description
– Limited – reported if less than complete is performed.
– Not reported together

• Definitions
–
–
–
–

A-mode
M-mode
B-scan
Real-time scan
CPC® Certification Review

270

90

Pelvis Ultrasound
• Obstetrical
– Pregnant uterus
• Review definitions in guidelines

– Fetal
• Look for what specifically is being looked at (eg, umbilical artery in 76820)

• Nonobstetrical

CPC® Certification Review

271

Ultrasonic Guidance
Includes guidance for:
–
–
–
–
–
–
–
–
–
–

Pericardiocentesis
Endomyocardial biopsy
Vascular access
Parenchymal tissue ablation
Intrauterine fetal transfusion or cordocentesis
Needle placement
Chorionic villus sampling
Amniocentesis
Aspiration of ova
Placement of radiation therapy fields
CPC® Certification Review

272

Radiologic Guidance
• Fluoroscopic
• Computed Tomography (CT)
• Magnetic Resonance (MRI)
• Other

CPC® Certification Review

273

91

Breast, Mammography
• Computer aided detection (CAD)
• Mammary ductogram or galactogram
• Mammography
– Screening
– Diagnostic
CPC® Certification Review

274

Bone/Joint Studies
• Bone age studies
• Bone length studies
• Osseous survey
• Joint survey
• Bone mineral density studies
• Bone marrow blood supply
CPC® Certification Review

275

Radiation Oncology
•
•
•
•
•
•
•
•
•
•
•
•

Consultation: Clinical Management
Clinical Treatment Planning
Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services
Stereotactic Radiation Treatment Delivery
Other Procedures
Radiation Treatment Delivery
Neutron Beam Treatment Delivery
Radiation Treatment Management
Proton Beam Treatment Delivery
Hyperthermia
Clinical Intracavitary Hyperthermia
Clinical Brachytherapy
CPC® Certification Review

276

92

Nuclear Medicine
• Diagnostic - Use of small amounts of radioactive material
to examine organ function
–
–
–
–
–

Thyroid function (endocrine)
Renal (Gastrointestinal System)
Bone (Musculoskeletal System)
Heart (Cardiovascular system)
Brain (Nervous System)

• Therapeutic – uses radioactive material to treat cancer and
other medical conditions affecting the thyroid gland
CPC® Certification Review

277

Pathology and Laboratory

CPC® Certification Review

278

Regulatory Terms
Clinical Laboratory Improvement Amendment (CLIA)
• CMS issues a waiver
• Approximately 80 tests
• Little risk of error
• For more info., see
http://www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp

Advance Beneficiary Notice (ABN)
• Non covered laboratory tests
• Patient is responsible for payment
• For more info., Web search ―CMS-R-131‖
CPC® Certification Review

279

93

Modifiers
•

90

Reference or Outside Laboratory

•

91

Repeat clinical diagnostic lab test

• Billed by physician but performed by an outside laboratory
• Same test same day
• Not used if due to error
• Not used if there is a better code for a series of tests

•

92

Alternative laboratory platform testing
• Portable test kit
• Single use disposable chamber

•

99

Multiple modifiers

CPC® Certification Review

280

Organ or Disease-Oriented Panels
•
•
•
•

Group of test commonly ordered together
All test in the panel must be performed
Additional tests can be coded also
Some panels are included in other panels and should not
be coded separately
• Be on the look out for ―or‖ ―and‖

CPC® Certification Review

281

Definitions
• Qualitative
– What is present

• Quantitative
– How much is present

• Chromatography
– Laboratory technique used to separate mixtures
• Mobile phase
• Stationary phase
CPC® Certification Review

282

94

Evocative Suppression Testing
• Baseline and subsequent measurement
• Supplies and drug billed separately
• Physician attendance

– Use Prolonged care codes
• Prolonged infusion codes from Medicine section
CPC® Certification Review

283

CPC® Certification Review

284

CPC® Certification Review

285

Consultations
•
•
•
•

Requested by attending physician
Rendered by pathologist
Written report provided
Patient not present
– Lab test
– Specimen
– Slide

Chemistry
•
•
•
•

Quantitative unless specified otherwise
Same analyte in multiple specimens
Same analyte in multiple specimens
Molecular diagnostics
– Coded by procedure not analyte

95

Laboratory Tests
•
•
•
•

Hematology and Coagulation
Immunology
Microbiology
Anatomic Pathology

CPC® Certification Review

286

CPC® Certification Review

287

Cytopathology
• Study of cells for disease
• Obtained by several methods
– Washing or brushing
– Smears
– Fine needle aspiration

Cytogenetic Studies
• Study of cells for inherited disorders
• Must use modifiers from Appendix I ―Genetic Testing Code
Modifiers,‖ also

CPC® Certification Review

288

96

Surgical Pathology
• Specimen – tissue sample
– Has to be separately identifiable

• Divided into levels of progressive complexity
– Level I – gross
– Level II-IV gross and microscopic

• Additional codes for special stains

CPC® Certification Review

289

Pathology Consultation
Four types of consultations:
1.
2.
3.
4.

Report on prepared slides
Report on tissue requiring prep of slides
Review records and specimen
Consultation during surgery
–
–

Frozen sections
Cytology examination

CPC® Certification Review

290

Evaluation and Management

CPC® Certification Review

291

97

ICD-9-CM Coding
• Primary diagnosis – reason for the visit
• Signs and Symptoms
– Code only if no definitive diagnosis is stated
– Routinely associated with a disease process should not be coded
separately

CPC® Certification Review

292

CPT® Coding
1. Select the category or subcategory of service and review
the guidelines;
2. Review the level of E/M service descriptors and
examples;
3. Determine the level of history;
4. Determine the level of exam;
5. Determine the level of medical decision making; and
6. Select the appropriate level of E/M service.
CPC® Certification Review

293

Categories and Subcategories
Office Visit
New Patient

Established Patient

99201 – Level I

99211 – Level 1

99202 – Level 2

99212 – Level 2

99203 – Level 3

99213 – Level 3

99204 – Level 4

99214 – Level 4

99205 – Level 5

99215 – Level 5

CPC® Certification Review

294

98

New vs. Established Patients
• New – has not received any face-to-face professional
services from the physician/qualified health care
professional, or another physician/qualified health care of the
exact same specialty/subspecialty within the group practice,
within the last three years
• Established – has received face-to-face services in the last
three years

CPC® Certification Review

295

Office or Other Outpatient Services
• Provided in the physician's office or other outpatient clinic or
ambulatory facility
• New patient
• Established patient

CPC® Certification Review

296

Observation
• Hospital Observation Services
– Patient’s designated or admitted to observation status in the
hospital
– No CPT® guideline on length of observation stay

• Observation Care Discharge Services
– If discharge is on date other than date admitted to observation

• Subsequent Observation Care
– Patient is seen on a date other than the date of admit or
discharge to observation
CPC® Certification Review

297

99

Hospital Inpatient Services
• Codes used for inpatient facility and partial hospitalization
• Use codes 99234-99236 for admit/discharge on same
date
• Subsequent hospital care codes used for subsequent
visits while admitted
– Includes reviewing medical record, test results, etc

CPC® Certification Review

298

Hospital Discharge Services
• Codes are based on time
• Includes time spent with the final exam, paper work,
writing prescriptions, talking with patient’s family, etc.
• Parenthetical notes
– How to code for concurrent care on the discharge date
– Discharge of a Newborn see code 99463

CPC® Certification Review

299

Consultations
• Consultations
– Service provided by a physician whose opinion or advice
regarding evaluation and/or management of a specific problem
is requested by another physician or appropriate source

• Divided by location
• Three R’s to meet consultation criteria

CPC® Certification Review

300

100

Consultations
Medicare:
– Office Consultations
• Report with new and established patient codes

– Inpatient Consultations
• Report with initial hospital care codes for the first encounter regardless if
performed by the admitting physician.
• Use Modifier AI for the Principal Physician of Record

CPC® Certification Review

301

Emergency Department
• Does not distinguish between new/established
• Facility must be hospital-based and available 24
hours a day
• Physician direction of EMS emergency care,
advanced life support

CPC® Certification Review

302

Critical Care Services
•

Critically ill or injured
– Acutely impairs one or more vital organ systems such that there
is a high probability of imminent or life threatening deterioration
in the patient condition.
– Services included in critical care described in critical care
guidelines.

CPC® Certification Review

303

101

Critical Care Services
• Services provided in a critical care unit to a patient who is
not considered critically ill are report with other E/M codes.
• Guidelines contain instructions for coding
– Pediatric Critical Care
– Neonatal Critical Care

• Critical Care and other E/M services may be coded on
same date by the same provider.

CPC® Certification Review

304

Critical Care Services
• Guidelines list services inclusive to critical care
– May not be reported separately
– Refer back to list to avoid unbundling services
– Beneficial to highlight each of the CPT® codes listed in the
guidelines

CPC® Certification Review

305

Nursing Facility Services
• Nursing Facility Services
– Nursing facility
– Psychiatric residential treatment center
– Divided into Initial and Subsequent

• Nursing Facility Discharge
– Similar to hospital discharge – instructions for care,
prescriptions, etc.

• Annual Assessment
– Annual assessment required by law
CPC® Certification Review

306

102

Domiciliary, Rest Home, or Custodial Care
Services
• Also includes Assisted Living
• Physician see patient in one of these types of facilities
– No medical component

• Either new patient or established patient

CPC® Certification Review

307

Domiciliary, Rest Home, or Home Care Plan
Oversight Services
• Physician provides oversight of the patient’s care plan
• Review the case management plan
• Write new orders
• Make a new care plan
CPC® Certification Review

308

Home Services &
Prolonged Services
• Home Services
– Seen in home by physician
– Separated by new and established patient

• Prolonged Services
– Direct patient contact or without direct patient contact
– Settings are office/outpatient and inpatient
– Most are add-on codes
• Exception is Standby Code
CPC® Certification Review

309

103

Standby Services
• Used to report time when a provider is on standby at the
request of another provider
• Only report for more than 30 minutes duration
• Reported with additional units for each additional 30
minutes
• Do not report if the period of standby results in the
performance of a procedure

CPC® Certification Review

310

Case Management &
Medical Team Conference
• Case Management Services
– Anticoagulant Management
• Receive INR testing
• Alter dosage

• Medical Team Conference
– Requires three healthcare professionals
– Divided by direct contact or without direct contact
CPC® Certification Review

311

Care Plan Oversight Services
• Home Health Agency
• Hospice
• Nursing Facility
– Billed on a monthly basis
– For the amount of time physician spends overseeing care of
patient
CPC® Certification Review

312

104

Preventive Medicine Services
• Annual Physical Exam
• Divided by new and established patient and by patient’s
age
• If abnormality is encountered and is significant to require
additional work
– Appropriate code from 99201-99215 reported with modifier 25
appended to the office/outpatient code
CPC® Certification Review

313

Counseling Risk Factor Reduction and Behavior
Change Intervention
•
•
•
•
•

For patient without symptoms or established illness
No distinction between new and established patient
Preventive Medicine, Individual Counseling
Behavior Change Intervention
Preventive Medicine, Group Counseling

CPC® Certification Review

314

Non-Face-to-Face
Physician Services
• Telephone Services
– Must be provided by a physician
– Based on amount of time
– Patient must be established

• On-Line Medical Evaluation
– Reported only once for the same episode of care during a 7-day
period
– Must be provided by a physician
CPC® Certification Review

315

105

Special Evaluation and Management Services
• Basic Life and/or Disability Evaluation Services
• Work Related or Medical Disability Evaluation Services
• Specific guidelines under each code

CPC® Certification Review

316

Newborn Care Services
• Newborn Care Services
– Newborn care age 28 days or less
– Separated by location and by initial or subsequent visits

• Delivery or Birthing Room Attendance and Resuscitation
Services
– Attendance at delivery at request of delivering physician

CPC® Certification Review

317

Inpatient Neonatal Intensive Care
Pediatric & Neonatal Critical Care
• Pediatric Critical Care Patient Transport
• Inpatient Neonatal and Pediatric Critical Care
• Initial and Continuing Intensive Care Services

CPC® Certification Review

318

106

Inpatient Neonatal and Pediatric Care
Services
Defined by age of patient:
– Neonates 28 days of age or less
– Infant or young child 29 days through 24 months of age
– Young child two through five years of age

CPC® Certification Review

319

Initial and Continuing Intensive Care
Services
• Used to report services to a child who is not critically ill –
but requires intensive observation and frequent
interventions
• 99477 used for Initial Hospital Care
• 99478-99480 used for Subsequent Intensive Care
– Code selection based on the present body weight of the child

CPC® Certification Review

320

Evaluation and Management Coding Leveling
1. Select the category or subcategory of service and review
the guidelines;
2. Review the level of E/M service descriptors and
examples;
3. Determine the level of history;
4. Determine the level of exam;
5. Determine the level of medical decision making; and
6. Select the appropriate level of
E/M service.
CPC® Certification Review

321

107

E/M Leveling
• 1995 vs. 1997 Guidelines
– Main difference – exam component

• Seven components to consider
– Relates to the level of work performed by the physician
•
•
•
•
•
•
•

History
Exam
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time
CPC® Certification Review

322

E/M Leveling
Key Components
–
–
–
–

Generally the influential factors in determining level of service
History
Exam
Medical Decision Making
• Influential in the level of service unless counseling dominates the
encounter
• Categories/subcategories describe the number of key components
required

CPC® Certification Review

323

History
• History of Present Illness (HPI)
• Chronological description of the patient’s illness
–
–
–
–
–
–
–

Location
Quality
Severity
Timing
Context
Modifying factors
Associated sign and symptoms
CPC® Certification Review

324

108

History
Review of Systems
(Inventory of Body Systems)
•
•
•
•
•
•
•

Constitutional
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary

•
•
•
•
•
•
•

Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/
lymphatic
Allergic/
Immunologic
CPC® Certification Review

325

History
• A single element cannot count towards the HPI and the
ROS for the same patient encounter
• Example
– Knee pain counted as location for HPI
– Knee pain cannot count as musculoskeletal for ROS

CPC® Certification Review

326

History
• Past, Family and/or Social History (PFSH)
– Past History
• Review of patient’s past illnesses, operations, etc

– Family History
• Review of patient’s parents/siblings

– Social History
• Review of social factors, marital status, alcohol/drug habits

CPC® Certification Review

327

109

History
History of Present Illness (HPI)

Review of Systems
(ROS)

Past, Family, and/or Social
History (PFSH)

Level of History

Brief (1-3 elements)

No ROS

No PFSH

Problem Focused

Brief (1-3 elements)

Problem Pertinent (1
system)

No PFSH

Expanded Problem
Focused

Extended (4 or more)

Extended
(2-9 systems)

Pertinent
(1 history)

Detailed

Extended (4 or more)

Complete
(10 or more)

Complete
(2-3 history areas)

Comprehensive

CPC® Certification Review

328

Exam
• Examination – may be body areas or organ systems
• Body Areas
•
•
•
•
•
•
•

Head, including face
Neck
Chest, including breasts
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity

CPC® Certification Review

329

CPC® Certification Review

330

Exam
– Organ Systems
•
•
•
•
•
•
•
•
•
•
•

Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic

110

Exam
Problem Focused – a limited examination of the affected
body area or organ system.

1 body area or organ system

Expanded Problem Focused – a limited examination of the
affected body area or organ system and other symptomatic or
related organ system(s).

2 – 7 body areas or organ systems –
limited exam

Detailed – an extended examination of the affected body
area(s) and other symptomatic or related organ system(s)

2 – 7 body areas or organ systems –
detailed exam

Comprehensive – a general multi-system examination or
complete examination of a single organ system

8 or more organ systems OR complete
single organ system

CPC® Certification Review

331

Medical Decision Making
• Thought process of the physician throughout the
visit
• Three elements to consider
– Number of management options
• Minimal, limited, multiple, extensive

– Amount and/or complexity of date to be review
• Minimal or none, limited, moderate, extensive

– Risk of complications, morbidity, and/or mortality
• Minimal, low, moderate, high
CPC® Certification Review

332

Medical Decision Making
# of dx or mgmt options

Amt and/or complexity of
data

Risk of Complications

Type of Decision Making

Minimal

Minimal or none

Minimal

Straightforward

Limited

Limited

Low

Low complexity

Multiple

Moderate

Moderate

Moderate complexity

Extensive

Extensive

High

High complexity

CPC® Certification Review

333

111

E/M Leveling
Contributing Components
– Counseling: risk factor reduction, patient/family education
– Coordination of Care: arrange follow up treatment not typically
provided by the provider, eg., physical therapy
– Nature of Presenting Problem: Taken into consideration in the
medical decision making portion of the encounter
– Time: If counseling/coordination of care dominates more than 50
percent of encounter, time may be considered as the controlling
factor

CPC® Certification Review

334

Determine the Level of E/M
Established patient office visit table
HISTORY

Problem focused

Expanded
problem focused

Detailed

Comprehensive

EXAM

Problem focused

Expanded
problem focused

Detailed

Comprehensive

MDM

Straightforward

Low

Moderate

High

LEVEL OF VISIT

99212

99213

99214

99215

CPC® Certification Review

335

Determine the Level of E/M
Category: Office or Other Outpatient Services
Subcategory: Established Patient
Descriptors: ―…which requires at least 2 of these three
components.‖

CPC® Certification Review

336

112

E/M Leveling
• Many factors to consider when determining a level of
Evaluation and Management Service.
• Be sure to Review the Guidelines and code descriptions.

CPC® Certification Review

337

Modifiers
•
•

•
•

Modifier 24 Unrelated evaluation and management service by the
same physician during a postoperative period.
Modifier 25 Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service.
Modifier 32 Mandated Services
Modifier 57 Decision for surgery

CPC® Certification Review

338

CPC® Certification Review

339

Medicine

113

Medicine
•
•
•
•
•
•
•
•

•
•
•
•
•
•
•
•

Immunizations
Vaccines, Toxoids
Psychiatry
Biofeedback
Dialysis
Gastroenterology
Ophthalmology
Otorhinolaryngology

Cardiovascular
Pulmonary
Endocrinology
Neurology
Genetics
Nutritional Therapy
Acupuncture
Moderate Sedation
CPC® Certification Review

340

CPC® Certification Review

341

Medicine
•
•
•
•
•
•

Non-invasive Diagnostic Vascular Studies
Allergy & Clinical Immunology
Special Dermatological Procedures
Physical Medicine & Rehabilitation
Qualifying Circumstances for Anesthesia
Home Health Procedures/Services

Medicine and ICD-9-CM
• Alphabetic Index to Diseases
• Tabular List
• Official Guidelines for Coding and Reporting

CPC® Certification Review

342

114

Medicine Guidelines
•
•
•
•
•
•

Multiple Procedures
Add-on Codes
Separate Procedures
Unlisted Service or Procedure
Special Report
Materials Supplied by Physician

CPC® Certification Review

343

Immune Globulins
•
•
•
•
•
•
•

Immune globulins
Botulinum antitoxin
Cytomegalovirus (CMV) immune globulin
Diphtheria antitoxin
Hepatitis B immune globulin
Rabies immune globulin
Tetanus immune globulin
CPC® Certification Review

344

Vaccines and Toxoids
•
•
•
•
•

Vaccines
Vaccination
Immunization
Toxins
Toxoids

CPC® Certification Review

345

115

Psychiatry
• Consultation
• Follow-up by consultant
office visits
rest home, domicile
home
• Transfer of care – new or established pt.
• Diagnostic psychiatric evaluations

CPC® Certification Review

346

Dialysis
•
•
•
•
•

Hemodialysis
Miscellaneous Dialysis Procedures
End-Stage Renal Disease Services (ESRD)
Other Dialysis Procedures
Age-specific, reported once per month
outpatient; home services

CPC® Certification Review

347

Noninvasive Vascular Diagnostic Studies
•
•
•
•
•
•

Cerebrovascular Arterial Studies
Extremity Arterial Studies (Including Digits)
Extremity Venous Studies (Including Digits)
Visceral and Penile Vascular Studies
Extremity Arterial-Venous Studies
Duplex and Doppler

CPC® Certification Review

348

116

Allergy and Immunology
• Allergy
– Allergy Testing
– Allergen Immunotherapy

• Pulmonary Studies

CPC® Certification Review

349

Medical Genetics and Genetic Counseling Services
•
•
•
•

Chromosome
Gene
Genetics
Genetic counseling

CPC® Certification Review

350

Hydration
• Hydration, Therapeutic,Prophylactic, Diagnostic Injections
and Infusions, and Chemotherapy and Other Highly complex
Drug or Highly Complex Biologic Agent Administration.
• Time based codes

CPC® Certification Review

351

117

Non-Chemotherapy
Complex Drugs and
Substances
• Infusions – therapeutic, prophylactic or diagnostic
• Specific to time, technique, substances added and additional
set-up
• Multiple drugs

CPC® Certification Review

352

Chemotherapy
Services included with chemotherapy:
• Use of local anesthesia
• Iv start
• Access to indwelling IV, subcutaneous catheter or port
• Flush at conclusion of infusion
• Standard tubing, syringes and supplies
• Preparation of chemotherapy agent(s)
CPC® Certification Review

353

CPC® Certification Review

354

Chemotherapy
•
•
•
•
•

Paracentesis
Thoracentesis
Peritoneocentesis
Intrathecal
Ventricular or Intraventricular

118

Physical Medicine and Rehabilitation
Treatment plan
•
•
•

Problem list
Goals
Physician review progress each 30 days
Progress made – recorded
Modify or discontinue therapy

CPC® Certification Review

355

Modalities
• Supervised
• Constant Attendance
• Diathermy, Vasopneumatic Devices, Therapeutic Procedures

CPC® Certification Review

356

Wound Care Management
Orthotic Management and
Prosthetic Management
Active wound care
• Not to be reported with 11040-11047
Orthotic management and Prosthetic Management
• Orthotics
• Prosthetics
CPC® Certification Review

357

119

Medicine Section
• Acupuncture - Face-to-face time
• Osteopathic Manipulative Treatment (O.D.)
• Chiropractic Manipulative Treatment (CMT)

CPC® Certification Review

358

Education and Training for Patient Self-Management
Education and training
•
•

Self Management
How many in the group?

Telephone services – patient, parent, or guardian
•
•

24 hours
7 days

CPC® Certification Review

359

On-line Medical Evaluation
• On-line encounter or other electronic communication mode
of the medical kind
• Includes all services provided

CPC® Certification Review

360

120

Special Services, Procedures and Reports
Miscellaneous services
•
•
•

99024 – ―tracking‖
Mandatory on-call hospital personnel
Patient encounters outside the normal posted business hours or
special circumstances at the request of the patient.

CPC® Certification Review

361

Home Health Procedures/Services
Define home setting:
•
•
•
•
•

Patient’s residence
Assisted living apartments
Group homes
Nontraditional private homes
Custodial care facilities or schools

CPC® Certification Review

362

Medication Therapy Management Services
Performed by a pharmacist
Documentation required:
•
•
•

Patient history
Current medications
Recommendations

CPC® Certification Review

363

121

Category II Codes
•
•
•
•
•

Used for performance measurement
Facilitate data collection
Use of these codes is optional
Used to evaluate quality of care
Alphanumeric: example: four digits and letter ―F‖ – 2001F is
Weight recorded

CPC® Certification Review

364

Category III Codes
• Data collection regarding new technology
• It is preferable to use these codes rather than an unlisted
code.
• Alpha numeric listings, four digits and the letter ―T‖ Example
– 0085T Breath test for heart transplant rejection

CPC® Certification Review

365

CPT® Appendices
Appendix A – modifiers and description
Appendix B – summary of additions and deletions
Appendix C – clinical examples
Appendix D, E F and G are summary lists
Appendix H – empty – refer to website

CPC® Certification Review

366

122

CPT® Appendices
Appendix I – Deleted in 2013
Appendix J – Electrodiagnostic Medicine Listing of Sensory,
Motor, and Mixed Nerves
Appendix K – products pending FDA approval

CPC® Certification Review

367

CPT® Appendices
Appendix L – Vascular families
Appendix M – crosswalk to deleted CPT® codes
Appendix N – Summary of Resequenced CPT Codes
Appendix O –Multianalyte Assays
Index – back of CPT® Book

CPC® Certification Review

368

Tips for Taking an AAPC
Certification Exam

CPC® Certification Review

369

123

ICD-9-CM
• Highlight:
– Code first notes
– Use additional notes
– Excluded codes

• Make notes to reference important guidelines

CPC® Certification Review

370

CPT®
Highlight key words in subsection guidelines:
– New vs established
– Definitions such as simple, intermediate, complex repair
– Musculoskeletal section – open, closed, fixation, percutaneous,
manipulation, etc.
– Parenthetical instructions

CPC® Certification Review

371

Exam Registration
• www.aapc.com
• You will receive a confirmation email including:
– Exam date and location of exam
– Proctor’s name and telephone number
– Start time

• Arrive at the exam on time

CPC® Certification Review

372

124

Day of the Exam
• Arrive 10-15 minutes early
• Bring:
–
–
–
–

Code manuals
Photo ID
#2 pencils and eraser
NO scrap paper (not allowed)

• Eat a healthy breakfast
• Bring light snacks and water (avoid loud and crunchy
snacks)
• Bring a light jacket or sweater
CPC® Certification Review

373

During the Test
• Listen carefully while proctor reads instructions
• Stay relaxed and confident
• Scan the entire test

– Answer the easiest first
• Read all choices before answering
• Pace yourself
• Answer every question

CPC® Certification Review

374

Exam Completion
• Exam results released within 5-7 business days after AAPC
receives the exam package from the proctor
• My AAPC area on the AAPC website
• Official documents mailed to you
• Exam results may NOT be released over the telephone

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125

The End

CPC® Certification Review

376

126



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