Cpt Code 92270 Descriptive Essay

Like ICD codes, CPT codes communicate uniform information about medical services and procedures to healthcare payers. The difference is that on claim forms, CPT codes identify services rendered rather than patient diagnoses.

What are the Most Common Physical Therapy CPT Codes?

Below are the most common CPT codes recorded within WebPT:

97110Therapeutic exercises to develop strength and endurance, range of motion, and flexibility (15 minutes)
97140Manual therapy techniques (e.g., connective tissue massage, joint mobilization and manipulation, and manual traction) (15 minutes)
97010Hot or cold pack application
97014Electrical stimulation (unattended)
97112Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (15 minutes)
97001Physical therapy evaluation (please note that this code is no longer in use as of January 1, 2017)
97530Dynamic activities to improve functional performance, direct (one-on-one) with the patient (15 minutes)
97035Ultrasound (15 minutes)
97002Physical therapy re-evaluation (please note that this code is no longer in use as of January 1, 2017)
97032Electrical stimulation (manual) (15 minutes)
97116Gait training (includes stair climbing) (15 minutes)
97012Mechanical traction
97016Vasopneumatic devices
97535Self-care/home management training (e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact (15 minutes)
97113Aquatic therapy with therapeutic exercises (15 minutes)
97124Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) (15 minutes)
97033Iontophoresis (15 minutes)
97150Group therapeutic procedure(s) (two or more individuals)
97026Infrared
97039Unlisted modality (specify type and time if constant attendance)
92507Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
97250Myofascial release (no longer a CPT code, but billable under the California workers compensation system in lieu of 97140)
97003Occupational therapy evaluation (please note that this code is no longer in use as of January 1, 2017)
97018Paraffin bath
97022Whirlpool
98960Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the individual patient (could include caregiver/family) (30 minutes)
29530Knee strapping
98941Chiropractic manipulative treatment (CMT) of the spine (three to four regions)
29540Ankle and/or foot strapping
29240Shoulder strapping (e.g., Velpeau)
97139Unlisted therapeutic procedure (specify)
97750Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report (15 minutes)
97004Occupational therapy re-evaluation (please note that this code is no longer in use as of January 1, 2017)
95831Extremity (excluding hand) or trunk muscle testing, manual (separate procedure) with report
90901Biofeedback training by any modality
97799Unlisted physical medicine/rehabilitation service or procedure

CPT codes are copyright 1995-2018 American Medical Association. All rights reserved.

What’s the Difference Between ICD-10 and CPT Codes?

As mentioned in the intro above, while CPT codes are similar to ICD-10 codes in that they both communicate uniform information about medical services and procedures, CPT codes identify services rendered rather than diagnoses. In short, CPT codes are procedure codes and ICD-10 codes are patient diagnosis codes.

Here is an example of ICD-10 and CPT codes in use: Today, if you diagnose a patient with “Benign paroxysmal vertigo, bilateral,” you would use the ICD-10 code H81.13 to indicate your diagnosis. Then, you might complete standard canalith repositioning on your patient, in which case you would include CPT procedural code 95992 on your claim.

What is Modifier 59? How Do I Use It?

The CPT Manual defines modifier 59 as the following:

“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

That explanation is a bit dense, and it’s not super relatable. But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way.

So, how does modifier 59 come into play in the therapy setting? If you’re providing two wholly separate and distinct services during the same treatment period, it might be modifier 59 time. The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes. It’s therefore your responsibility as the therapist to determine whether you’re providing linked services or wholly separate services. This, in turn, determines whether modifier 59 is appropriate.

Modifier 59 Example

For example, let’s look at one of the most commonly billed codes: 97140 (manual therapy techniques like mobilization/manipulation, manual lymphatic drainage, or manual traction on one or more regions, each for 15 minutes). According to NCCI, the following are considered linked services when billed in combination with 97140: 95851, 95852, 97164, 97168, 97018, 97124, 97530, 97750, and 99186. So, if you bill any of these codes with 97140, you’ll receive payment for only 97140. Medicare actually uses this example on its site to explain appropriate use of modifier 59 among rehab therapists.

CMS states that when billing 97140 and 97530 (therapeutic activities; direct, one-on-one patient contact by the provider; or use of dynamic activities to improve functional performance, each for 15 minutes) for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15-minute intervals. This means that you cannot report the two codes together if you performed them during the same 15-minute time interval.

If the care you provide meets the appropriate criteria, you can add modifier 59 to 97530 to indicate it was a separate service and should be payable in addition to the 97140. The same holds true for billing 97140 with 95851, 95852, 97164, 97168, 97018, 97530, or 97750. However, you can never bill 97124 with 97140—and you cannot add any modifier to change this restriction, because these codes are mutually exclusive procedures, according to CMS.

When Should I Use Modifier 59?

Modifier 59 can monumentally impact your Medicare reimbursements, and unfortunately, it’s the modifier physical therapists struggle with most. Perhaps that’s because the CPT Manual doesn’t offer the most helpful guidance. Therefore, we recommend asking the following questions to decide if and when you should use modifier 59.

Are you billing for two services that form an NCCI edit pair?

There are instances in which it’s appropriate to use modifier 59 in conjunction with physical therapy services. Recognizing those instances, though, requires you to recognize NCCI edit pairs. To make a long story short, edit pairs—also called linked services—are sets of procedures that therapists commonly perform together. If you submit a claim containing both of the codes in an edit pair, you’ll only receive payment for one of the procedures, because the payer will assume that one of the services was essentially “built into” the other.

Did you perform those two services separately and independently of one another?

Okay, so you’re dealing with an edit pair. But what if—for whatever reason—you actually didn’t perform those services together? That’s where modifier 59 comes into the picture. Basically, when you append modifier 59 to one of the CPT codes in an edit pair, it signals to the payer that you provided both services in the pair separately and independently of one another—meaning that you also should receive separate payment for each procedure.

Does your documentation support your assertion that you performed the two services separately and independently of one another?

When it comes to telling your patients’ stories, codes and modifiers can only say so much. It’s on you to fill in the plot holes with detailed, defensible documentation. After all, your documentation justifies your billing decisions—and if you’re ever faced with an audit, your notes will be your main source of proof that those decisions were the right ones. That means you should never:

  • append modifier 59 simply because you know it will guarantee payment.
  • skimp on your documentation—or intentionally document vaguely or misleadingly.
  • routinely use the 59 modifier in conjunction with re-evaluation codes. (Doing so could throw up a red flag to your payers.)

Let’s assume that, yes, your documentation does support your assertion that you performed the two services separately and independently of one another. So, next you’d ask:

Is a more descriptive modifier available?

Clinicians, coders, and billers should only use modifier 59 as a last resort (i.e., when there’s not a better option). As the CPT Manual states, “...when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

Now, you’ve probably heard talk about the new set of modifiers that CMS created for providers to use in place of modifier 59, when appropriate. The new modifiers—XE, XP, XS, and XU—are intended to bypass a CCI edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service. However, even though these modifiers went into effect January 1, 2015, the APTA has stated that therapists do not need to start using them in place of modifier 59—at least not yet. That being said, therapists may be required to use the new modifiers in the future, so keep an eye—or an ear—out for further instruction regarding modifier 59 usage.

Download your modifier 59 decision chart.

Enter your email address below, and we’ll send you a super-simple flow chart to help you decide whether it’s appropriate to use modifier 59 in any given billing situation.

What are the Most Commonly Used CCI Edits for PT, OT, and SLP Private Practice Settings?

Below is a table with all of the common CCI edit pairs related to different therapy types, courtesy of PT compliance expert Rick Gawenda, owner of Gawenda Seminars & Consulting. Here’s how to use the chart:

  1. Look for the primary CPT code you are billing in Column 1.
  2. Check Column 2. If you are billing any of the codes listed, they will be considered mutually exclusive or linked.
    1. If the code in Column 2 has a “y” next to it, you can add modifier 59.
    2. If there’s an “n,” then you should not bill the code in combination with the code in Column 1.

Note that this is the CCI edit list from Medicare. Most government payers—like Medicare, Tricare, and Medicaid—use this same list. However, private payers often create their own edit pairs; therefore, there is no guarantee they will pay, even with an applied modifier 59.

Download your CCI Edit Chart.

Want the below table in a printable, easy-to-reference PDF? Enter your email address, and we’ll send it your way.

Correct Coding Initiative (CCI) Edits

Edited to incorporate new PT and OT evaluation codes January 2017
All other edits current as of March 2016

CPT CodeDescriptionTimed?Column 2
y = use 59 modifier
n = do not bill the code in combination with code in column 1
90911Biofeedback for IncontinenceN90901n; 97032y; 97110y; 97112y; 97530y; 97535y; 97550y
G0451Developmental testingN96125y
G0237Therapeutic procedures to increase strength or endurance of respiratory musclesY97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; 97750y; 97530y; 97150y; 97112y; 97110y
G0238Therapeutic procedures to improve respiratory function, other than described by G0237Y97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; 97750y; 97530y; 97150y; 97112y; 97110y
G0239Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individualsN97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; 97750y; 97530y; 97150y; 97112y; 97110y
92507Speech TreatmentN97110y; 97112y; 97150y; 97530y; 97532y; 97533y
92508Speech GroupN92507y; 97110y; 97112y; 97150y; 97530y; 97532y; 97533y
92521Evaluation of Speech FluencyN96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92522Evaluation of Speech ProductionN96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92523Evaluation of Speech Production with Evaluation of Language Comprehension and ExpressionN92522n; 96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92524Behavioral and Qualitative Analysis of Voice ResonanceN96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92526Treatment of Swallowing DysfunctionN92511y; 92520y; 97032n; 97110y; 97112y; 97150y; 97530y; 97532y; G0283n
92597Evaluation of Voice ProstheticN97755n
92607Evaluation of Speech Generating DeviceY92506y; 92507y; 92508y; 92597n; 92609y; 97755n
92608Eval of Speech Device (additional half-hour)Y97755n
92609Training and Fitting for DeviceN92506y; 92507y; 92508y; 97755n
92610Evaluation of SwallowingN92511y
92611Radiopaque Swallow StudyN92511y; 92610y
92612Flexible Fiberoptic Endoscopic Swallow EvaluationN92511n; 92520n; 92610y; 92611y; 92614n
92614Flexible Fiberoptic Endoscopic Evaluation, laryngeal sensory testing by cine or video recordingN31575n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; C9742n
92616Flexible Fiberoptic Endoscopic Evaluation of swallowing and laryngeal sensory testing by cine or video recordingN31575n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; C9742n
95831Muscle testing, extremity (excluding hand) or trunkN95851n; 97140y
95832Muscle testing, handN95852n; 97140y
95833Muscle testing, total eval body, excluding handsN95831n; 95832n; 95851n; 97140y
95834Muscle testing, total eval body, including handsN95831n; 95832n; 95833n; 95851n; 95852n; 97140y
95992Canalith Re-positioningN97110y; 97112y; 97140y; 97530y
96105Assessment of AphasiaY96110y; 96125y; G0451y
96110Developmental testing, limitedN96125y
96111Developmental testing, extendedN96125y; 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; G0451n; G0459n
96125Standardized Cognitive Performance TestingY96127n
29581Multi-Layer Compression System, Below KneeN29540y; 29550y; 29580y; 97140y; 97535y
29582Multi-Layer Compression System, Entire LegN29540y; 29550y; 29581y; 97140y; 97535y
29583Multi-Layer Compression System, Upper Arm & ForearmN29105y; 29125y; 29126y; 97140y; 97535y
29584Multi-Layer Compression System, Entire ArmN29125y; 29126y; 29130y; 29131y; 97140y; 97535y
97012Mechanical TractionN97164y; 97168y; 97018y; 97140y
G0281Electrical Stimulation, Stage 3-4 WoundsN97164y; 97168y; 97032y; G0283y
G0283Electrical Stimulation, Other Than Wound CareN97164y; 97168y; 97032y
97016Vasopneumatic deviceN97164y; 97168y; 97018y; 97026y
97018Paraffin BathN97164y; 97168y; 97022y
97022WhirlpoolN97164y; 97168y
97024DiathermyN97164y; 97168y; 97018y; 97026y
97026InfraredN97164y; 97168y; 97018y; 97022y
97028UltravioletN97164y; 97168y; 97018y; 97022y; 97026y
97032Electrical StimulationY64550y; 97164y; 97168y
97033Electrical CurrentY97164y; 97168y
97034Contrast BathY97164y; 97168y
97035UltrasoundY97164y; 97168y
97036Hubbard TankY97164y; 97168y
97039Physical Therapy TreatmentY97164y; 97168y
97110Therapeutic ExercisesY97164y; 97168y
97112Neuromuscular Re-educationY97164y; 97168y; 97022y; 97036y
97113Aquatic Therapy/ExercisesY97164y; 97168y; 97022y; 97036n; 97110y
97116Gait TrainingY97164y; 97168y
97124MassageY97164y; 97168y
97139Physical Medicine ProcedureY97164y; 97168y
97140Manual TherapyY95851y; 95852y; 97164y; 97168y; 97018y; 97124n; 97530y; 97750y
97150Group Therapeutic ProceduresN97164y; 97168y; 97110y; 97112y; 97113y; 97116y; 97124y; 97140y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97760y; 97761y
97161Physical therapy evaluation: low complexityN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97165n; 97166n; 97167n; 97168n
97162Physical therapy evaluation: moderate complexityN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97161n; 97164n; 97165n; 97166n; 97167n; 97168n
97163Physical therapy evaluation: high complexityN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97161n; 97162n; 97164n; 97165n; 97166n; 97167n; 97168n
97164Re-evaluation of physical therapy established plan of careN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97165n; 97168n
97165Occupational therapy evaluation: low complexityN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97168n
97166Occupational therapy evaluation: moderate complexityN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97165n; 97168n
97167Occupational therapy evaluation: high complexityN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97165n; 97166n; 97168n
97168Re-evaluation of occupational therapy established plan of careN95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n
97530Therapeutic ActivitiesY95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 97164y; 97168y; 97113y; 97116y; 97532y; 97533y; 97535y; 97537y; 97542y; 97750y
97532Cognitive Skills DevelopmentY97164y; 97168y
97533Sensory IntegrationY97164y; 97168y
97535Self Care Management TrainingY97164y; 97168y
97537Community/work ReintegrationY97164y; 97168y
97542Wheelchair Management TrainingY97164y; 97168y
97545Work HardeningY97164y; 97168y; 97140n
97597Wound Care Selective, first 20 sq centimetersN29105y; 29125y; 29130y; 29260y; 29345y; 29405y; 29425y; 29445y; 29515y; 29540y; 29550y; 29580y; 29581y; 29582y; 29584y; 97164y; 97022y; 97602n; 97605y; 97606y; 97610y
97598Wound Care Selective, each additional 20 sq centimetersN29580y; 29581y; 29582y; 97164y; 97022y; 97602n; 97605y; 97606y; 97610y
97602Wound Care Non-SelectiveN29580y; 29581y; 97164y
97605Negative pressure wound therapy utilizing DME (surface area less than or equal to 50 square centimeters)N97164y
97606Negative pressure wound therapy utilizing DME (surface area greater than 50 square centimeters)N97164y
97608Negative pressure wound therapy utilizing disposable, non-durable medical equipment (surface area greater than 50 square centimeters)N97164y
97610Low Frequency, Non-Contact, Non-Thermal UltrasoundN97035y; 97602n
97750Physical Performance TestY95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 97150n
97755Assistive Technology AssessmentY97035y; 97110y; 97112y; 97140y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97545y; 97750n; 97760y; 97761y; 97762n
97760Orthotic Management and TrainingY29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29582y; 29583y; 29584y; 97164y; 97168y; 97016y; 97110y; 97112y; 97116y; 97124y; 97140y; 97662y
97761Prosthetic TrainingY97164y; 97168y; 97016y; 97110y; 97112y; 97116y; 97124y; 97140y; 97760y; 97762y

How Do I Bill for an Initial Evaluation or Re-Evaluation?

As of January 1, 2017, PTs and OTs should no longer use the CPT codes 97001, 97002, 97003, and 97004 to bill for initial evaluations and re-evaluations. That’s because these codes have been replaced by a new set of eight evaluative codes: two for re-evaluations and six for evaluations.

But, this isn’t a simple swap-out. That’s because the new codes for initial evaluations are tiered according to the complexity of the evaluation performed. So, PTs and OTs now must determine whether a patient evaluation is low complexity, moderate complexity, or high complexity—and then select the CPT code that correctly represents that level of complexity. Here’s a brief breakdown of the new codes:

Replacement CPT Codes for 97001

97161Physical therapy evaluation: low complexity
97162Physical therapy evaluation: moderate complexity
97163Physical therapy evaluation: high complexity

Replacement CPT Codes for 97003

97165Occupational therapy evaluation: low complexity
97166Occupational therapy evaluation: moderate complexity
97167Occupational therapy evaluation: high complexity

Replacement CPT Codes for 97002 and 97004

97164Re-evaluation of physical therapy established plan of care requiring:
  1. An examination (including a review of history and use of standardized tests and measures)
  2. A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)
97168Re-evaluation of occupational therapy established plan of care requiring:
  1. An assessment of changes in patient functional or medical status, along with a revised plan of care
  2. An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals
  3. A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required)

Looking for more in-depth guidance on how to select the correct level of complexity for each PT or OT evaluation? Check out this blog post, this blog post, and this webinar.

Should I bill for a re-evaluation each time I complete a progress note?

A typical progress note, even one with functional limitation reporting, does not require a re-evaluation CPT code (97164 or 97168). In fact, you should only ever bill for a re-evaluation if one of the following situations apply:

  • The professional assessment indicates a significant improvement or decline or change in the patient’s condition or functional status that was not anticipated in the plan of care for that interval.
  • There are new clinical findings.
  • The patient fails to respond to the treatment outlined in the current plan of care.

Where Can I Find the Physician Fee Schedule Final Rule?

The CY 2017 Physician Fee Schedule Final Rule is available here.


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By Heidi Jannenga

January 25, 2016

Earlier, we introduced you to Current Procedural Terminology, or CPT. This expansive, important code set is published and maintained by the American Medical Association (AMA), and it is, with ICD, one of the most important code sets for medical coders to become familiar with. Note also that all the codes featured in this course, and every course that touches on CPT codes, are copyrighted by the AMA.

CPT codes are used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient. As you might imagine, this code set is extremely large, and includes the codes for thousands upon thousands of medical procedures.

CPT codes are an integral part of the billing process. CPT codes tell the insurance payer what procedures the healthcare provider would like to be reimbursed for. As such, CPT codes work in tandem with ICD codes to create a full picture of the medical process for the payer. “This patient arrived with these symptoms (as represented by the ICD code) and we performed these procedures (represented by the CPT code).

Like ICD codes, CPT codes are also used to track important health data and measure performance and efficiency. Government agencies can use CPT codes to track the prevalence and value of certain procedures, and hospitals may use CPT codes to evaluate the efficiency and abilities of individuals or divisions within their facility.

Format

Let’s look a little closer at what these codes look like and how they’re organized. Each CPT code is five characters long, and may be numeric or alphanumeric, depending on which category the CPT code is in. Don’t confuse this with the ‘category’ in ICD. Remember that in ICD codes the ‘category’ refers to the first three characters of the code, which describe the injury or disease documented by the healthcare provider.

With CPT, ‘Category’ refers to the division of the code set. CPT codes are divided into three Categories. Category I is the most common and widely used set of codes within CPT. It describes most of the procedures performed by healthcare providers in inpatient and outpatient offices and hospitals. Category II codes are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures.

Note that while CPT codes have five digits, there are not 99,000-plus codes. CPT is designed for flexibility and revision, and so there is often a lot of “space” between codes. Unlike ICD, each number in the CPT code does not correspond to a particular procedure or technology.

Here’s a closer look at the three categories of CPT codes.

Category I

Medical coders will spend the vast majority of their time working with Category I CPT codes. For the sake of simplicity, we’ll refer to the CPT codebook when we’re describing the code set. This book, which is updated yearly by the AMA and the CPT Editorial Board, is an essential tool for every medical coder. In the next few minutes, you’ll learn the basic layout, format, and instructions found in the CPT codebook.

Like the ICD code set and its division into chapters by type of injury or illness, Category I CPT codes are divided into six large sections based on which field of health care they directly pertain to. The six sections of the CPT codebook are, in order:

  • Evaluation and Management
  • Anesthesiology
  • Surgery
  • Radiology
  • Pathology and Laboratory
  • Medicine

CPT codes are, for the most part, grouped numerically. The codes for surgery, for example, are 10021 through 69990.

In the CPT codebook, these codes are listed in mostly numerical order, except for the codes for Evaluation and Management. These Evaluation and Management, or E&M, codes are listed at the front of the codebook for ease of access. Physician’s offices frequently use E&M codes for reporting a number of their services. The code 99214, for a general checkup, is listed in the E&M codes, for example.

Note also that some codes appear out of numerical sequence but near similar procedures. This may seems slightly confusing, but having these codes clustered near similar procedures prevents having to delete and resequence codes, and so is seen as a sort of necessary evil.

Here’s a quick look at the sections of Category I CPT codes, as arranged by their numerical range.

  • Evaluation and Management: 99201 – 99499
  • Anesthesia: 00100 – 01999; 99100 – 99140
  • Surgery: 10021 – 69990
  • Radiology: 70010 – 79999
  • Pathology and Laboratory: 80047 – 89398
  • Medicine: 90281 – 99199; 99500 – 99607

Within each of these code fields, there are subfields that correspond to how that topic—say, Anesthesia—applies to a particular field of healthcare. For instance, the Surgery section, which is by far the largest, is organized by what part of the human body the surgery would be performed on. If you’d like to learn more about the anatomy and physiology terms used in the Surgery section, follow this link to Course 2-10. Likewise, the Radiology section is organized into sections on diagnostic ultrasound, bone and joint studies, radiation oncology, and other fields. Please refer to the eBook for a complete breakdown of the subfields used in each of the code fields.

Each of these fields has its own particular guidelines when it comes to use. For example, the Surgery section has a guideline for how to report extra materials used (such as sterile trays or drugs) and how to report follow-up care in the case of surgical procedures.

Like ICD codes, many CPT codes are arranged by indentation. If a procedure is indented below another code, the indented procedure is an important or noteworthy variation on the above procedure, and would replace the first code. Let’s take a look at an example of an indented code.

The code for “management of liver hemorrhage; simple suture of liver wound or injury” is 47350. This is a surgical procedure, and would be found in the surgery/digestive system portion of the CPT book.

It’s helpful to look at a code like this in two parts. The first, which comes before the semicolon, is the general procedure. In this case, that’d be “liver management.” The phrase that comes after the semicolon is additional, specific information. In this example, we could read the code as “liver management, with a simple suture of liver wound or injury.”

If, however, a doctor performed a more complicated procedure on a patient’s liver, 47350 would no longer be the correct code to use. If we look in the CPT manual, we find the code 47360 below 47350. Code 47360 reads “complex suture of liver wound or injury, with or without hepatic artery ligation.” That phrase is meant to take the place of the phrase that comes after the semicolon in code 47350.

You could therefore read code 47360 as “liver management, with complex suture of liver wound or injury, with or without hepatic artery ligation.”

CPT codes also have a number of modifiers. These modifiers are two-digit additions to the CPT code that describe certain important facets of the procedure, like whether the procedure was bilateral or was one of multiple procedures performed at the same time. CPT modifiers are relatively straightforward, but are very important for coding accurately. For this reason, we’ll cover them in a later video.

Like ICD codes, many CPT codes also have additional instructions featured below the code. These instructions, which are in parentheses below the code you’ve looked up, tell the coder that, in certain situations, another code might be better suited than the present code. For now, just recognize that the CPT code set has a number of instructions that inform the medical coder on how to best code the procedure performed. Remember that you always need to code to the highest level of specificity, and a miscoded procedure can be the difference between an accepted and rejected claim.

The CPT code set also instructs coders on when to use multiple codes, when to use codes in tandem with one another (add-on codes), and which codes are “modifier exempt.”

This is an awful lot of information to take in regarding Category I CPT codes, so let’s review briefly.

Category I CPT codes are numeric, and are five digits long.

They are divided into six sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.

Each of these sections has its own subdivisions, which correspond to what type of procedure, or what part of the body, that particular procedure relates to.

The sections are grouped numerically, and, aside from Evaluation and Management, are in numerical order. That is, the codes for Anesthesia come before, or are “lower” than the codes for Pathology and Laboratory.

Each of these sections also has specific guidelines for how to use the codes in that section.

Certain codes have related procedures indented below them. These indented codes are important variations on the code above them, and denote different methods, outcomes, or approaches to the same procedure. For example, the code for the elevation of a simple, extradural depressed skull fracture is 62000. The code for the elevation of a compound or comminuted, extradural depressed skull fracture is 62005.

There are a few important CPT Modifiers, which provide additional information about the procedure performed. We’ll cover these in just a little bit.

Some codes have instructions for coders below them. These instructions are found in parentheses below the code, and they instruct the coder that there may be another, more accurate code to use.

Now that we’ve given you a brief glimpse of Category I CPT codes, let’s take a look at the next section of CPT.

Category II

These codes are five character-long, alphanumeric codes that provide additional information to the Category I codes. These codes are formatted to have four digits, followed by the character F. These codes are optional, but can provide important information that can be used in performance management and future patient care.

Here’s a quick example. If a doctor records a patient’s Body Mass Index (BMI) during a routine checkup, we could use Category II code 3008F, “Body Mass Index (BMI), documented.”

These codes never replace Category I or Category III codes, and instead simply provide extra information. They are divided into numerical fields, each of which corresponds with a certain element of patient care. For a list of these fields in oder as well as examples, please refer to our ebook and powerpoints.

  • Composite codes
    • These codes combine a number of procedures that typically occur in conjunction with one main procedure.
      • Example: 0001F: heart failure assessed (includes all of the following):
        • Blood pressure measured
        • Level of activity assessed
        • Clinical symptoms of volume overload assessed
        • Weight recorded
        • Clinical signs of volume overload assessed
    • Patient Management
      • Includes patient care provided for specific clinical purposes like pre- and postnatal care.
        • Example: 0503F: Postpartum care visit
    • Patient History
      • Describes measures for select elements of patient history or symptom review
        • Example: 1030F: Pneumococcus immunization status assessed
    • Physical Examination
      • Example: 2014F: Mental status assessed
    • Diagnostic/Screening Processes or Results
      • Includes results of tests ordered, including clinical lab tests and radiological procedures
        • Example: 3006F: Chest X-ray documented and reviewed
    • Therapeutic, Preventive, or Other Interventions
      • Describes pharmacologic, procedural or behavioral therapies
        • Example: 4037F: influenza immunization ordered or administered
    • Follow-up or Other Outcomes
      • These codes describe the review and communication of test results to a patient, patient satisfaction, patient functional status, and patient morbidity or mortality
        • Example: 5005F: patient counseled on self-examination for new or changing moles
    • Patient Safety
      • Includes codes that describe patient safety precautions
        • Example: 6015F: Patient receiving or eligible to receive foods, fluids, or medication by mouth
    • Structural Measures
      • This short section includes codes that describe the setting of the delivered care, and also covers the capabilities of the healthcare provider
        • Example: 7025F: patient information entered into a reminder system with a target due date for the next mammogram

    There are not nearly as many Category II CPT codes as there are in Category I, and in general you will not use Category II nearly as much. Still, it is an important element of the CPT code set, and you should be familiar with the basics of Category II codes as you prepare for a career in the field.

    Category III

    The third category of CPT codes is made up of temporary codes that represent emergent or experimental services, technology, and procedures. In certain cases, you may find that a newer procedure does not have a Category I code. There are codes in Category I for unlisted procedures, but if the procedure, technology, or service is listed in Category III, you are required to use the Category III code.

    Category III codes allow for more specificity in coding, and they also help health facilities and government agencies track the efficacy of new, emergent medical techniques.

    Think of Category III as codes that may become Category I codes, or that just don’t fit in with Category I. Category I codes must be approved by the CPT Editorial Panel. This Panel mandates that procedures or services must be performed by a number of different facilities in different locations, and that the procedure is approved by the FDA. Due to the nature of emerging medical technology and procedures, it’s not always possible for an experimental procedure to meet these criteria, and thus become a Category I code.

    Whether a Category III code becomes a Category I code or not, all Category III codes are archived in the CPT manual for five years. If at the end of this five year period the code has not been converted to Category I, this procedure must be marked with a Category I “unspecified procedure” code. When flipping through the Category III section of the CPT manual, you’ll notice that each of the codes has a phrase listing its sunset date below the code. Think of the sunset dates as expiration dates on the code.

    Like Category II, these codes are five characters long, and are comprised of four digits and a terminal letter. In this case, the last letter of Category III codes is T. For example, the code for the fistulization of sclera for glaucoma, through ciliary body is 0123T.

    Now that you have a better idea of what CPT looks like, how it’s formatted, and when to use which category of codes, let’s dive a little deeper into modifiers and how CPT codes look in action.

Video: Introduction to Cost Procedural Terminology (CPT)

CPT codes allow coders to describe exactly what service a healthcare provider has performed for a patient. Learn more about these invaluable codes in this video.

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