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This course is designed for individuals working in medical coding, billing, medical fee contracting, insurance, auditing, or other positions related to medical billing & coding. This course is a review of the basics of CPT coding for medical services. The student will gain a fundamental knowledge of the history, purpose, and utilization of CPT coding to receive payment from insurance carriers.
Recommended Prerequisites: Medical Terminology Recommended Additional Resources: Current year CPT manual Medical Dictionary and/or Medical Abbreviations
Rev 1.0 October 2008
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COURSE TITLE: Introduction to CPT Author: James D. Rigdon, CPC, NCICS, BS-HA Coding Analyst University Physicians, Inc. Aurora, Colorado Number of Clock Hours Credit: 4 Course # 1220409 P.A.C.E. ® Approved: Yes
Upon completion of this continuing education course, the professional should be able to: 1. 2. 3. 4. 5. Define CPT code. Describe the history of CPT codes. Identify the differences between CPT, HCPCS, and ICD-9 codes. Describe the purpose of CPT codes. Apply accurate CPT coding fundamentals to medical billing practices in everyday medical office or insurance company operations.
Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions.
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WHAT IS MEDICAL CODING?
Medical coding is a complex but necessary task in medical billing offices used to report, track, and bill for services rendered by medical practitioners (e.g. physicians, nurse practitioners), ancillary providers (e.g. chiropractors, psychologists), or facilities (e.g. hospitals, nursing homes). Varieties of codes are used to consistently report medical services, procedures, supplies and equipment, and diagnoses. Codes are used to convey complex medical language quickly and effectively to insurance companies, as well as to other organizations such as Medicare, the American Medical Association, and the World Health Organization. Many organizations utilize statistics mined from billing information for tracking purposes, such as frequency of office visits, severity of diseases, or even disease progression.
WHAT ARE MEDICAL CODES?
There are six basic types of medical codes used in various aspects of medical billing: • Current Procedural Terminology, Fourth Revision (CPT-4®) – identifies services and procedures • International Classification of Diseases, Ninth Revision (ICD-9) – identifies diagnoses • Healthcare Common Procedure Coding System (HCPCS) – identifies additional services and procedures not listed in CPT; drugs dispensed in the physician’s office or other facility (including injectables, topicals, and orally administered); supplies and equipment dispensed to the patient • National Drug Codes (NDC) – identifies pharmaceuticals dispensed to a patient via a pharmacy • Revenue Codes – identifies bundled facility and technical services (e.g. nursing care, radiology or laboratory rendered in a facility setting, and room and board) • American Dental Association (ADA) Dental Billing Codes – identifies services rendered by dental practitioners (usually bundled into the HCPCS ‘D’ section) The focus of this course is CPT codes.
HISTORY OF CPT CODES
The American Medical Association (AMA) developed the CPT manual in 1966. The first edition contained a mere 3,534 codes. To this day, the AMA maintains the CPT manual, and it has been revised and updated on a yearly basis since 1977. The Health Insurance Portability & Accountability Act (HIPAA) and Centers for Medicare & Medicaid Services (CMS) require the use of standard code sets to be used when reporting any service rendered to a patient. CPT is one of those standard code sets. The 2008 CPT manual contains six sections with over 8,600 numeric, five-digit codes. To conserve space, some CPT codes are indented or cross-referenced. A coder using the CPT manual to report services should always look up the codes in the index first, and not rely on the structure of the manual to be ‘led’ to a code.
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Example of CPT code: 99213 = Outpatient or office visit, established patient, level 3 service (see below for information on Evaluation & Management services) CPT codes are considered Level I HCPCS (Health Care Financing Administration Common Procedural Coding System) codes. Level II HCPCS codes are called “HCPCS codes” (pronounced “Hicks-Picks”). Level II HCPCS codes are alphanumeric. Level II codes were developed in the early 1980s and are maintained by CMS. Example of Level II HCPCS code: A4550 = Surgical Tray
PURPOSE OF CPT
The main purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services. The codes were developed as a stand-alone description of medical services. The codes systematically list services rendered to patients by physicians, physical therapists, chiropractors, psychologists, or any number of other practitioners. All codes are used on standardized billing forms, such as the CMS1500 form (see following page). CPT codes provide consistent communication among practitioners, patients, and payers, and assure consistency in reimbursement (payment).
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This illustration is a CMS1500 form used for billing insurance carriers. Other standard billing forms include UB92 and the ADA dental billing form.
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CPT MANUAL CONTENTS
Each CPT manual contains a number of sections. Each code listed within the CPT manual is indexed and cross-referenced. Table 1: Layout of the CPT manual Section Number 1 2 3 4 5 6 Description Contents, preface, and general guidelines Evaluation and Management Services Anesthesia Surgery Radiology Pathology Medicine (not anesthesia or ‘medication’) Category II and III codes Index Appendices Code Range 99201 – 99499 00100 – 01999 99100 – 99140 10000 – 69999 70000 – 79999 80000 – 89999 90000 – 99099 99500 – 99999
CPT Index of Codes
The index of the CPT is organized in a number of different ways. The codes may be indexed by: • Procedure or Service • Organ or Anatomic Site • Condition or Diagnosis • Synonyms, Eponyms, and Abbreviations • Modifying Terms • Code Ranges The following are various examples of CPT index entries showing the different ways the codes are indexed: Procedure or Service: Bunion Repair ............................................. 28296 – 28299 Keller Procedure 28292 Mitchell Procedure 28296 Organ or Anatomic Site: Breast Abscess Incision and Drainage ....................................... 19020 Condition or Diagnosis: Abscess Auditory Canal, External ......................................... 69020 Page 6 of 47
Synonyms, Eponyms, and Abbreviations: Backbone see Spine Fitzgerald Factor 85293 EKG see Electrocardiography Modifying Term: Heart Repair Ventricle Obstruction .................................................. 33619 Code Ranges: Face CT Scan.................................................... 70486 - 70488
There are thirteen useful yet overlooked appendices in the back of the CPT manual. A resourceful coder will reference these appendices frequently. It is recommended that every coder review the appendices annually, especially A, B, and M, as well as any other appendices appropriate to the specialty for which they are coding. The Appendices in the CPT manual are: A – Modifiers B – Summary of Additions, Deletions, and Revisions C – Clinical Examples D – Summary of Add-on Codes E – CPT Codes exempt from Modifier 51 F – CPT Codes exempt from Modifier 63 G – CPT Codes, which Include Moderate (Conscious) Sedation H – Alpha Index of Performance Measures by Clinical Condition or Topic I – Genetic Testing Code Modifiers J – Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves K – Products Pending FDA Approval L – Vascular Families M – Crosswalk to Deleted Codes *New for 2007* Appendix A – Modifiers Modifiers are used to report additional information about a service or procedure, or are used to ‘modify’ how payment will be processed. Modifiers are two-digit codes appended to CPT codes. The modifiers do not change the essential definition of any CPT code, but rather alter the circumstances. Modifiers may be used to report an increase or reduction of service, specific body part, the number of times a procedure was performed, unusual events, or if a particular component of service was not performed. This appendix lists the modifiers that can be used in combination with CPT codes in a variety of scenarios.
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Table 2: Modifiers used for CPT codes (2007 edition) Modifier -21 Description Prolonged Evaluation and Management (E & M) Service Unusual Procedural Service Unusual Anesthesia Usage Use when time spent with patient is greater than 30 minutes beyond time stated in highest level E & M visit in a given category’s CPT code description Use when service provided is greater than what is usually required for a procedure (extra work for the practitioner) Use when general anesthesia is provided for a procedure that ‘usually’ requires no anesthesia, or usually only local or topical anesthesia is required Use when the practitioner provides an E&M service during a postoperative period for reason(s) unrelated to the original procedure Use when the practitioner performs a procedure on the same day as an E & M service beyond the usual preoperative and postoperative care associated with the procedure performed Many procedures are a combination of a physician component (interpretation) and a technical component (exam or test). Use this modifier when only the professional (physician) component is rendered Use when the patient is seen at multiple times by the same practitioner in an outpatient department of a facility Use when a service is ‘mandated’ by an individual or organization (e.g. governmental/legislative/regulatory requirements, third-party payor, etc) Use when regional or general anesthesia is provided by the surgeon, not an anesthesiologist Use when a procedure is provided bilaterally (on both sides of the body), except when the code is explicitly listed as a ‘bilateral’ procedure
Unrelated E & M Service by the Same Physician During a Postoperative Period Significant, Separately identifiable E & M Service by the Same Physician on the Same Day of the Procedure or Other Service Professional Component Only
Multiple Outpatient E & M Encounters on the Same Date Mandated Services
Anesthesia by Surgeon Bilateral Procedure
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Table 2: Modifiers used for CPT codes (2007 edition) (continued) Modifier -51 Description Multiple Procedures Usage Use when more than one procedure is performed at the same operative session, by the same provider. Append this modifier to ‘secondary’ procedures, not the ‘primary’ procedure. Note: Some CPT codes are modifier –51 exempt. See Appendix E Reduced Services Use when a procedure is partially reduced or eliminated at the physician’s discretion, as documented in the medical record. This provides a means of reporting the reduced services without disturbing the primary identification of the basic service as described in CPT Discontinued Procedure Use when a procedure is stopped abruptly due to extenuating circumstances, or those that threaten the well-being of the patient. Do not use this modifier when the patient elects to cancel the procedure prior to anesthesia or preparation in the operating suite. Used for inpatient settings only. Surgical Care Only Use when the practitioner performs only the surgical procedure, and not the preoperative or postoperative care Postoperative Use when the practitioner performs only Management Only postoperative care, and not the surgical procedure or postoperative management Preoperative Management Use when the practitioner performs only Only preoperative care, and not the surgical procedure or postoperative management Decision for Surgery Use on E & M services that resulted in the initial decision to perform a major surgery on the day before, or on the day of the surgery Staged or Related Use when a procedure or surgery: Procedure or Service by a) was planned in advance to be the Same Physician During performed at a different time from the basic the Postoperative Period procedure or surgery, b) is more extensive than the basic procedure or surgery, or c) is therapeutic in nature, following a diagnostic procedure
-54 -55 -56 -57
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Table 2: Modifiers used for CPT codes (2007 edition) (continued) Modifier -59 Description Distinct Procedural Service Usage Use when the practitioner renders a procedure or service distinct or independent from other services performed on the same day by the same practitioner, not normally reported together, but appropriate under the circumstances Use when two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon reporting their distinct operative work, and both surgeons report the same CPT code Use when a surgical procedure is performed on neonates and infants that are less than a present body weight of 4 kg (8 lbs 13 oz, or 141 oz, or 4000 gm) and may involve significantly increased complexity and work by the practitioner – NOT for use with procedures correcting congenital anomalies Use when a highly complex procedure or surgery requires the related services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and/or various types of specialized and complex equipment Use when a procedure is stopped abruptly prior to administration of anesthesia due to extenuating circumstances, or those that threaten the well-being of the patient; use only in an outpatient surgery setting or ambulatory surgical center Use when a procedure is stopped abruptly after administration of anesthesia due to extenuating circumstances, or those that threaten the well-being of the patient; use only in an outpatient surgery setting or ambulatory surgical center Use when the same practitioner repeats a procedure or service on the same day Use when a different practitioner repeats a procedure or service on the same day Use when the practitioner performs another procedure during the postoperative period, related to the initial procedure, and requires the use of the operating room
Procedure Performed on Infants Less than 4 kg
Discontinued Outpatient or ASC Procedure Prior to Administration of Anesthesia Discontinued Outpatient or ASC Procedure After Administration of Anesthesia Repeat Procedure by Same Physician Repeat Procedure by Another Physician Return to the Operating Room for a Related Procedure During the Postoperative Period
-76 -77 -78
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Table 2: Modifiers used for CPT codes (2007 edition) (continued) Modifier -79 Description Unrelated Procedure or Service by the Same Physician During the Postoperative Period Assistant Surgeon Minimum Assistant Surgeon Assistant Surgeon, When Qualified Resident Surgeon Not Available Reference (Outside) Laboratory Repeat Clinical Diagnostic Testing Usage Use when the practitioner performs another procedure during the postoperative period, NOT related to the initial procedure, and requires the use of the operating room Use when a surgical assistant is present for the entire procedure or substantial portion of the procedure Use when a surgical assistant is present for a relatively short time during a procedure Use in a teaching setting when a surgical assistant is present for the entire procedure or substantial portion of the procedure, but a resident (trainee) surgeon is not available to assist in the procedure Use when laboratory services are performed by an outside laboratory, but the service is billed by the practitioner Use when the same laboratory test is performed multiple times on the same day when a normal, one-time, reportable result is all that is usually required (not to be used because of testing problems, specimen contamination, or confirmatory results) When multiple modifiers are used on a claim, use this modifier to tell the insurance company that more are to follow. Note: Modifier –99 is not widely accepted by any third party payer (insurance company) and therefore will not be addressed further in this course.
-80 -81 -82
Appendix B - Summary of Additions, Deletions, and Revisions This section of the CPT manual outlines new codes, deleted codes, and revised codes for the year of publication. It is advised to thoroughly review Appendix B annually and take note of any code changes in effect for the current year. New codes are preceded with a bullet ( ), revised codes are preceded with a triangle ( ), deleted language appears with a strikethrough, and new text appears underlined. Codes with Conscious (Moderate) sedation included are denoted with a bull’s-eye ( ), add-on codes are denoted with a plus sign (+), and vaccines pending FDA approval are denoted with a lightning bolt symbol ( ) (see “Appendix K”).
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Examples of entries in Appendix B (2007 entries): 00625 Code Added +27315 Neurotomy, hamstring muscle 37210 Code Added + 49326 Code Added 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver Appendix C – Clinical Examples This appendix lists some scenarios to assist the coder in selecting the most appropriate code for the service or procedure rendered. While this invaluable resource is by no means comprehensive in nature, it does provide guidance to the coder when stumped by which code to select. The Clinical Examples are to be used only as a guide and never as the primary source of information – always refer to the CPT manual text for coding guidelines and code descriptions. An example of a Clinical Example listed in Appendix C: 99291 First hour of critical care of a 65 year-old man with septic shock following relief of urethral obstruction caused by a stone Appendix D – Summary of Add-on Codes This appendix lists all codes listed in CPT that are classified as “add-ons.” Add-on codes are codes that require another code to be billed in conjunction with it. Add-on codes are NEVER billed alone. To determine which code must be billed in conjunction with the add-on code, the coder will reference the beginning of the section where the add-on code is found. Add-on codes usually do not require the usage of modifiers (e.g. –51, -59, -76, etc) except in very rare and bizarre circumstances. In the main listing of the CPT, the symbol (+) denotes which codes are classified as add-ons. Table 3: Example of an Add-on code Base CPT Code 11200 Add-on CPT Code Description Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions each additional ten lesions (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar each additional interspace (List separately in addition to code for primary procedure)
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Example: A doctor removes 25 skin tags from a patient. The codes reported for the service are: 11200 (x1 unit) Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions +11201 (x1 unit) –each additional 10 lesions (list separately in addition to code for primary procedure) Note: If the provider had removed a total of 35 lesions at the same session, an additional unit of 11201 would be added to the bill (11201 x2 units). Appendix E – CPT Codes exempt from Modifier -51 Sometimes a practitioner will elect to perform multiple procedures on the same day. In some cases, the procedures can be billed at the same time and not require the use of modifier –51. Appendix E lists the codes that do not require a modifier -51 Some examples of CPT codes exempt from Modifier –51: 17004 Destruction, premalignant lesions, 15 or more lesions 32000 Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent 90632 Hepatitis A vaccine, adult dosage, for intramuscular use 99143 Moderate (conscious) sedation services…younger than 5 years old, first 30 minutes Appendix F – CPT Codes exempt from Modifier -63 As noted above, modifier –63 is used on CPT codes for procedures performed on infants less than 4 kg. There are, however, some codes that are specifically for infants, especially those under 4kg. In that case, it is not necessary to append a modifier –63. The coder should always check appendix F if the patient’s weight is less than 4 kg (8 lbs, 13 oz, or 141 oz, or 4000 gm). Some examples of CPT codes exempt from Modifier –63: 47700 Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with or without cholangiography (Do not report modifier 63 in conjunction with 47700) 63700 Repair of meningocele; less than 5cm diameter (Do not report modifier 63 in conjunction with 63700) Appendix G – CPT Codes that Include Moderate (Conscious) Sedation For some surgical procedures, the patient may not be under general anesthesia (fully sedated). In the case where the patient is not fully sedated, they may be under moderate (or conscious) sedation. Some codes may include the moderate (conscious) sedation, and therefore the moderate (conscious) sedation cannot be billed separately. The CPT codes including Moderate (Conscious) sedation are denoted in the main CPT section with a ( ) symbol. If the coder is coding for surgeries, they should reference Appendix G to find out if the moderate (conscious) sedation can be billed separately. Page 13 of 47
Examples of CPT codes that include Moderate (Conscious) Sedation: 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 77600 Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4cm or less) Appendix H – Alpha Index of Performance Measures by Clinical Condition or Topic Appendix H is used in conjunction with the voluntary Physician Quality Reporting Initiative (PQRI) for Medicare patients and possibly other carriers in the future. Note: This course does not address PQRI. Appendix I – Genetic Testing Code Modifiers Laboratories performing genetic testing are required to submit modifiers that describe any genetic mutations found. The first character (always numeric) identifies the disease category; the second character (always alpha) identifies the gene type. The modifiers are divided into groups as follows: • • • • • • • • • • • Neoplasia (solid tumor, excluding sarcoma and lymphoma) Neoplasia (sarcoma) Neoplasia (lymphoid/hematopoietic) Non-Neoplastic Hematology & Coagulation Histocompatibility / Blood Typing / Identity / Microsatellite Neurologic, non-neoplastic Muscular, non-neoplastic Metabolic, other Metabolic, transport Metabolic – Pharmacogenetics Dysmorphology
Genetic Testing Code Modifiers are not addressed any further in this course. Appendix J – Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix J is useful when coding for Neurological testing. This appendix helps the coder identify nerve branches and their assignments to some CPT codes used to report services rendered by a Neurologist or other provider rendering nerve conduction studies, reported with CPT codes 959000, 95903, and 95904. Appendix J will not be addressed any further in this course. Appendix K – Products Pending FDA Approval Appendix K is a cross reference to codes listed in the main CPT Category I section. The codes listed identify products listed in the Medicine section of Category I, which are pending FDA approval. Codes with this designation are denoted in the Category I section of the CPT manual with the ( ) symbol. Additional products pending FDA Page 14 of 47
approval and their respective CPT codes are listed at www.amaassn.org/ama/pub/category/10902.html. In 2007, only one vaccine had been assigned a CPT code that was pending FDA approval at the time of the publication. Insurance company policies for this CPT code will vary until FDA approval is final. Once FDA approval has been obtained, insurance companies may change coverage policies again. It is advised to contact the respective insurance company about payment policy. 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DtaP/Hib/IPV) combination vaccine for intramuscular use. Appendix L – Vascular Families Coders in cardiovascular specialties will find Appendix L useful not only in selecting CPT codes, but in also appropriate diagnosis (ICD-9) codes. The appendix breaks out vascular families by branch order. Example of an entry in Appendix L: To find the order of the Lateral Circumflex Artery: Common Iliac Common Femoral Profunda Femoris Lateral Circumflex
The Lateral Circumflex Artery is of the Common Iliac Vascular Family. Appendix M – Crosswalk to Deleted Codes *New for 2007* If a code has been deleted and replaced with a new code or a modified code, the code will be referenced in this appendix. Coders are advised to review this appendix every year and check for code changes appropriate to their specialty. An example of an entry listed in Appendix M Deleted CPT 2006 Code 15000 CPT 2007 Code 15002, 15004 CPT 2006 Code Descriptor Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture; first 100sq cm or one percent of body area of infants and children
This entry means in 2006 the description on the right was identified by a single code listed on the left but in 2007, the CPT code 15000 was deleted, and the CPT descriptions for codes 15002 and 15004 changed to include what was described by 15000 in 2006. Page 15 of 47
The CPT manual uses a series of symbols to convey information to the user. This information is very important to watch for when selecting CPT codes when reporting medical services. Table 4: Symbols used in CPT Symbol Definition New code for service or procedure a. Revised code 8w Indicates new or revised text Add-on codes + Modifier –51 exempt Reference Material Conscious Sedation Included Codes for vaccines pending FDA approval Corresponding Appendix Appendix B Appendix B Appendix B Appendix D Appendix E N/A Appendix G Appendix K
Specific guidelines appear at the beginning of each of the sections of the CPT manual. Guidelines give direction to interpret appropriately and report procedures and services contained in each section. Before searching for any code in any section, be sure to thoroughly read and understand the guidelines printed at the beginning of each section. Additionally, be sure to read the entire code description before selecting it for reporting or billing purposes. Each section of the CPT manual contains Unlisted Procedures or Services. When a specific code has not been defined within the CPT manual, nor can an appropriate modifier be appended to an existing code to appropriately and accurately report the service or procedure rendered to the patient, an unlisted code may be used. When selecting an unlisted code, the payer (insurance company) will undoubtedly require the biller/coder to send a copy of the documentation (SOAP note, surgical report, pathology report, etc.) along with the bill. Note not all medical services or procedures are assigned CPT codes. The CPT book does not contain codes for infrequently used, new, and experimental procedures. Each code section contains codes that have been set aside specifically for reporting unlisted procedures. Before choosing an unlisted procedure code, review the CPT manual carefully to ensure a more specific code is not available, and then check the Category III section for an appropriate code. If after the coder has checked the CPT manual and Category III section, a look in the HCPCS manual is advised to see if a temporary code has been assigned. Once all these resources have been exhausted, an unlisted code may be reported. Special reports may be required of the provider by various payors, agencies, or firms (e.g. Worker’s Compensation, Social Services, Schools, etc.). If a special report is required, sometimes an additional code can be reported in addition to the Evaluation and Management code. Check with the report requester prior to billing, on how Page 16 of 47
payment will be made. You may have to bill the insurance company, patient, lawyer, or other individual or entity. Often the requesting party (e.g. lawyer) will pay in advance for the special report and therefore the report should not be billed to the patient or insurance company.
PLACES OF SERVICE (POS)
The place of service code is a two-digit code that describes where the services were performed. Examples of place of service are physician’s office, outpatient hospital, inpatient hospital, land ambulance, rural health clinic, or independent laboratory. A complete list of Place-of-Service Codes for Professional Claims is listed in the front of the CPT manual. Some codes are “Unassigned,” which means they are reserved for future expansion. An example of an “Unassigned” code is POS 02. POS code 02 has no description because the AMA has reserved it for future use. Place of Service codes are listed on the next page.
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Table 5: POS Codes
POS Codes 01 POS Codes 21 POS Codes 51
POS Name Inpatient psychiatric facility Psychiatric facilitypartial hospitalization Community mental health center Intermediate care facility for the mentally retarded Residential substance abuse treatment facility Psychiatric residential treatment center Mass immunization center Comprehensive inpatient rehabilitation facility Comprehensive outpatient rehabilitation facility End-stage renal disease treatment facility Public health clinic
Outpatient hospital Emergency roomhospital Ambulatory surgical center Birthing center Military treatment facility Skilled nursing facility
Homeless Shelter Indian Health Servicefreestanding facility Indian Health Serviceprovider-based facility Tribal 638 freestanding facility Tribal 638 providerbased facility Prison-correctional facility Office
Custodial care facility
Assisted living facility
Ambulance - land Ambulance - air or water Independent clinic Federally qualified health center
Rural health clinic Independent laboratory Other place of service
Urgent care facility
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DIVISIONS OF THE CPT MANUAL
Evaluation and Management (E&M) Services (99201 – 99499) The first section of the CPT manual is one of the most commonly used sections and is listed first as a matter of convenience. Evaluation and Management (E&M) services are often referred to as “visits.” When a provider sees a patient in any setting (except OR) the provider will obtain a history, perform an examination, and make a medical decision about the patient. The appropriate way to bill for these services is with E&M codes. The E&M codes listed in the CPT manual are always located at the beginning of the book, but the codes begin with “99” (e.g. 99214). The E&M codes were first established in 1992 to give providers guidance in reporting and billing for visits. The first set of codes were very confusing and vague; the codes were called “Brief,” “Intermediate,” and “Comprehensive” with no consistency between settings. In 1995 the American Medical Association (AMA) revised the codes and established the codes and guidelines used today. In 1997, the AMA set out to revise the codes again in hopes to make the guidelines easier to understand. However, many providers only found the 1997 guidelines too cumbersome to use, and the 1997 guidelines did not address certain specialties such as Pediatrics. It was determined by Medicare that providers may use either the 1995 guidelines or 1997 guidelines when reporting and billing for services rendered, regardless of specialty or setting (http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp). Any billable provider regardless of specialty may report E&M services, just be aware of any local requirements for non-physician providers (e.g. Nurse Practitioners, Physician Assistants, Chiropractors, etc). The extent of the service provided must be clearly documented in the medical record. Some E&M Services are classified as the following: • New Patient – A new patient is one who has not received any professional services from a physician or another physician of the same specialty in the same group practice within three years. • Established Patient – An established patient is one who has received professional services from a physician or another physician of the same specialty in the same group practice within three years. o Example: Drs. Johnson & Smith are cardiologists in the same office. If a patient sees Dr. Johnson and the visit in just a few weeks he sees Dr. Smith, the patient is not classified as a “new” patient to Dr. Smith. • Initial Visit – An initial visit is the first visit by a practitioner to a patient in certain settings • Subsequent Visit – A subsequent visit is any visit after the initial visit by a practitioner in certain settings • Discharge Service – A discharge is performed in certain settings on the last day a patient is seen in a facility
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E&M services may be performed in any setting. Some E&M codes are categorized by locations, while others are categorized by service type: • Office, Clinic, or other Outpatient (e.g. Urgent Care, School, etc) o New Patient o Established Patient • Hospital Observation (outpatient) • Hospital Observation (inpatient) • Hospital Inpatient o Initial – the first visit by the provider for the specified episode o Subsequent – any visit by the provider after the initial visit day, except discharge day o Discharge – a visit by the provider on the day the patient will be discharged • Consultations o Office o Initial Inpatient (note: subsequent inpatient consultations should be reported as Hospital Inpatient Subsequent visits) Note: A consultation is rendered when advice or an opinion is requested by another physician (or other appropriate source such as a Physician Assistant). • Emergency Department • Pediatric Patient Transport • Critical Care o Adult (age 18 years or older) o Pediatric (age 28 days to 18 years) o Neonatal (first 28 days of life) Note: Critical Care rendered to the patient does not necessarily mean the patient was in the ICU or NICU ward. Sometimes Critical Care can be rendered in other settings (e.g. Emergency Room, Inpatient, Office) • Continuing Intensive Care Services for Neonates o Non-critical care service rendered to neonates Very Low Birth Weight (<1500 gm) (<3.3 lbs) Low Birth Weight (1500 – 2500 gm) (≈3.3-5.5 lbs) Normal Birth Weight (>2500 gm) (>5.5 lbs) • Nursing Facility Services o Initial Nursing Facility Care o Subsequent Nursing Facility Care o Discharge from Nursing Facility o Other Nursing Facility Services • Domiciliary, Rest Home, or Custodial Care o New Patient o Established Patient Note: These codes are used to report services rendered to patients in non-medical facilities (e.g. Alzheimer’s home, assisted living, etc)
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• • • • • •
• • •
Home Care o New Patient o Established Patient Prolonged Services o With Direct Patient Contact (face-to-face) o Without Direct Patient Contact (not face-to-face) Physician Standby Services Case Management Services o Team Conferences o Telephone Calls Care Plan Oversight Preventative Services o New Patient o Established Patient o Individual Counseling o Group Counseling o Other Preventative Care Newborn (Neonate) Care Special E&M Services Unlisted E&M Services
Table 6: E&M Modifiers The following modifiers can be used on E&M CPT codes. See Appendix A for modifier descriptions. Modifier -21 -24 -25 -27 -32 -57 Description Prolonged E&M Services Unrelated E&M Services by same physician during post-op period Significant, separately identifiable E&M Service by the same physician on the same day of procedure or service Multiple outpatient hospital E&M encounters on the same date Mandated Services Decision for surgery
Anesthesia (00100 – 01999) Anesthesia codes are used to report anesthesia services rendered by an anesthesiologist, Certified Registered Nurse Anesthetists, or others who are trained to render anesthesia services rendering General Anesthesia (not “Local,” “Topical,” “Digital Block,” or “Conscious Sedation” anesthesia). Taber’s Cyclopedic Medical Dictionary defines anesthesia as “partial or complete loss of sensation, with or without loss of consciousness, as a result of…administration of an anesthetic agent, usually by injection or inhalation.” Taber’s goes on to further define various types of anesthesia as follows.
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1. General Anesthesia: “Anesthesia that is complete and affects the entire body with loss of consciousness when the anesthetic acts on the brain. This type of anesthesia is usually accomplished following administration of inhalation or intravenous anesthetics. It is commonly used for surgical procedures” The following anesthesia terms are taken from Medline Plus Medical Dictionary (http://www.nlm.nih.gov/medlineplus/mplusdictionary.html) 2. Local Anesthesia: loss of sensation in a limited and usually superficial area especially from the effect of an anesthetic administered to a specific site 3. Topical Anesthesia: anesthesia applied to the surface of a part of the body to achieve a numbness of the skin 4. Regional Anesthesia: anesthesia of a region of the body accomplished by a series of encircling injections of anesthetic (compare Block Anesthesia) 5. Block Anesthesia: local anesthesia (as by injection) produced by interruption of the flow of impulses along a nerve trunk (compare Regional Anesthesia) 6. Conscious Sedation: an induced state of sedation characterized by a minimally depressed consciousness such that the patient is able to continuously and independently maintain a patent airway, retain protective reflexes, and remain responsive to verbal commands and physical stimulation (compare Deep Sedation) 7. Deep Sedation: an induced state of sedation characterized by depressed consciousness such that the patient is unable to continuously and independently maintain a patent airway, retain protective reflexes, and remain responsive to verbal commands and physical stimulation (compare Conscious Sedation) Anesthesia services listed in the CPT manual are generally subdivided by anatomical site, with the exception of radiological procedures, burn treatments, and obstetrics. Anesthesia services also require a Physical Status Modifier appended to each code. The Physical Status Modifiers are consistent with the American Society of Anesthesiologists’ (ASA) physical status classifications.
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Table 7: Physical Status Modifiers (“P-Status”) P-Status Modifier P1 P2 P3 P4 P5 P6 Description A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A brain-dead patient whose organs are being removed for donor purposes
Example: General anesthesia is performed on a patient with diabetes and diabetic renal manifestations, for a biopsy of intranasal tissue. The anesthesiologist would report CPT code 00164 with P-Status modifier P4 (00164-P4). Check with local regulations on what the requirements are for billing for anesthesia services. Table 8: Other Anesthesia Modifiers The following modifiers can be used on Anesthesia CPT codes. See Appendix A for modifier descriptions. Modifier -22 -23 -32 -51 -53 -59 Description Unusual services Unusual Anesthesia Mandated Services Multiple procedures Discontinued procedures Distinct procedural service
Note: Conscious (Moderate) Sedation is reported with CPT codes 99143 – 99150. Anesthesia CPT categories are: • Procedures on the Head • Procedures on the Neck • Procedures on the Thorax (Chest Wall & Shoulder Girdle) • Intrathoracic Procedures • Procedures on the Spine & Spinal Cord • Procedures on the Upper Abdomen • Procedures on the Lower Abdomen • Procedures on the Perineum • Procedures on the Pelvis (except hip) • Procedures on the Upper Leg (except knee) • Procedures on the Knee and Popliteal Area • Procedures on the Lower Leg (below knee, including ankle & foot) • Procedures on the Shoulder & Axilla • Procedures on the Upper Arm & Elbow • Procedures on the Forearm, Wrist, & Hand Page 23 of 47
• • • •
Radiological Procedures Procedures for Burn Excisions or Debridement Obstetric Anesthesia Other Anesthesia Procedures
Surgery (10000 – 69999) The Surgery section of the CPT manual includes simple procedures (e.g. simple laceration repair, nursemaid’s elbow reduction), moderately complex procedures (e.g. bronchoscopy, amniocentesis), and complex procedures (e.g. hip replacement, ileoanal anastomosis). Do not be fooled about where to find the simplest procedures (e.g. venipuncture, skin tag removal, and foreign body removal from ear canal) – they may be found in the “surgery” section of the CPT manual! Be sure to watch for codes that include Moderate (conscious) sedation, Add-ons, pending FDA approval, or that are Modifier –51 exempt (see table 4 above). Subdivisions of the Surgical section are: • Integumentary System (10021 – 19499) • Musculoskeletal System (20100 – 29999) • Respiratory System (30000 – 32999) • Cardiovascular System (33010 – 39599) • Digestive System (40490 – 49999) • Urinary System (50010 – 59899) o Male Genital System (54000 – 55899) o Intersex Surgery (55970 – 55980) o Female Genital System (56405 – 59899) Perinatal procedures (e.g. delivery) • Endocrine System (60000 – 60699) • Nervous System (61000 – 69979) o Eye (65091 – 68899) o Ear (69000 – 69979) • Operating Microscope Usage (69990) Table 9: Surgery Modifiers The following modifiers can be used on Surgery CPT codes. See Appendix A for modifier descriptions. Modifier -22 -26 -32 -47 -50 -51 -52 Description Unusual Services Professional component (on surgeries that also include a technical component) Mandated Services Anesthesia by surgeon Bilateral procedure Multiple procedures Reduced Services
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Table 9: Surgery Modifiers (continued) Modifier -53 -54 -55 -56 -58 -59 -62 -63 -66 -73 -74 -76 -77 -78 -79 -80 -81 -82 Description Discontinued procedure Surgical care only Postoperative management only Preoperative management only Staged or related procedure by same physician during postoperative period Distinct procedural service Two surgeons Procedure performed on infants less than 4kg (8lb 13oz) Surgical team Discontinued outpatient/ASC procedure prior to anesthesia Discontinued outpatient/ASC procedure after initiation of anesthesia Repeat procedure by the same physician Repeat procedure by another physician Return to operating room for a related procedure during the postoperative period Unrelated procedure or service by the same physician during a postoperative period Assistant surgeon Minimum assistant surgeon Assistant surgeon when qualified resident surgeon is not available
Radiology (70000 – 79999) Radiology includes all types of imaging procedures: X-rays (radiographs), angiogram, Computed Tomography scan (CT), Magnetic Resonance Imaging (MRI), Positron Emission Tomography scan (PET), ultrasound (US), and fluoroscopy. Radiology also includes technical procedures such as Radiation Oncology for cancer treatment, and other radiopharmaceutical administrations. Radiological procedures include two components: technical and professional. Both components must be considered when billing for radiological procedures. The technical component includes the time and expertise of technicians (e.g. Radiographer), while the professional component includes the time and expertise of the provider (Radiologist). The appropriate modifier must be appended when billing for radiological procedures: modifier –TC (not listed above) is appended for the technical fee while modifier –26 is appended for the professional fee. Sometimes the provider will perform both components, which no modifier will be appended to the CPT code. The radiology section, like other sections of the CPT manual, is subdivided into subsections. The subsections are also divided by anatomy (e.g. Head and Neck, Chest, etc), and divided again by technique (Computed Tomography, Magnetic Resonance Imaging), and sometimes divided again by quantity of views (e.g. three views) or contrast material (e.g. without contrast, without contrast followed by contrast).
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Subdivisions of Radiology section are: • Diagnostic Radiology (Diagnostic Imaging) (70010 – 76499) o CT o MRI o PET o Vascular Imaging • Diagnostic Ultrasound (76506 – 76999) • Radiologic Guidance (77001 – 77032) o Fluoroscopic o CT o MRI • Mammography (77051 – 77059) • Bone & Joint Studies (77071 – 77084) • Radiation Oncology (77261 – 77799) • Nuclear Medicine (78000 – 7899) • Other Therapeutic Radiation Procedures (79005 – 7999) Table 10: Radiology Modifiers The following modifiers can be used on Radiology CPT codes. See Appendix A for modifier descriptions. Modifier -22 -26 -32 -51 -52 -53 -59 -66 -76 -77 Description Unusual Services Professional Component Mandated Services Multiple Procedures Reduced Services Discontinued procedure Distinct procedural service Surgical Team Repeat procedure by same physician Repeat procedure by another physician
Pathology & Laboratory (80000 – 89999) Like radiology, pathology & laboratory procedures are comprised of two components: technical and professional. Same modifiers apply (–TC and –26). Note: when –TC and/or –26 are not present, it is implied the physician or an employee of the physician performed both components. Just as sections listed above, Pathology & Laboratory is subdivided into subsections: • Organ or Disease-Oriented Panels (80040 – 80076) • Drug Testing (80100 – 80103) • Therapeutic Drug Assays (80150 – 80299) • Evocative & Suppression Testing (80400 – 80440) • Clinical Pathology Consultation (80500 – 80502) • Urinalysis (81000 – 81099) Page 26 of 47
• • • • • • • • • • • •
Chemistry (82000 – 84999) Hematology & Coagulation (85002 – 85999) Immunology (86000 – 86849) Transfusion Medicine (excluding apheresis & therapeutic phlebotomy) (86850 – 86999) Microbiology (87001 – 87999) Anatomic Pathology (postmortem examination) (88000 – 88099) Cytopathology (88140 – 88199) Cytogenic Studies (88230 – 88299) Surgical Pathology (88300 – 88399) Transcutaneous Procedures (88400) Other Laboratory Procedures (89049 – 89240) Reproductive Medicine Procedures (89250 – 89356)
Table 11: Pathology & Laboratory Modifiers The following modifiers can be used on Pathology & Laboratory CPT codes. See Appendix A for modifier descriptions. Modifier -22 -26 -32 -52 -53 -59 -90 -91 Description Unusual Services Professional component Mandated Services Reduced Services Discontinued procedure Distinct procedural service Reference (outside) laboratory Repeat clinical diagnostic laboratory test
Medicine (90000 – 99199) This section is not to be confused with “medication.” Medication is reported and billed with HCPCS level II codes, which are not addressed in this course. Medicine procedures and services are reported in many different settings. The Medicine section includes services and procedures such as immunizations, chiropractic, psychiatry, echocardiography, allergy testing, and physical therapy. When selecting a code from the Medicine section, make sure the insurance carrier you are billing will accept the code being billed, as some carriers may require a HCPCS level II code or E&M code be billed in lieu of a Medicine code. Medicine is subdivided as follows: • Immune Globulins (90281 – 90399) • Immunization Administration (for vaccines & toxoids) (90465 – 90474) • Vaccines & Toxoids (90476 – 90749) • Hydration, Therapeutic, Prophylactic, and Diagnostic Injections & Infusions (excluding Chemotherapy) (90760 – 90779) • Psychiatry (90801 – 90899) • Biofeedback (90901 – 90911) Page 27 of 47
• • • • • • • • • • • • • • • • • • • • • • • • • • •
Dialysis (90918 – 90999) Gastroenterology Procedures (91000 – 91299) Ophthalmology (92002 – 92499) Special Otorhinolaryngologic Services (92502 – 92700) Cardiovascular Procedures & Services (92950 – 93799) Noninvasive Vascular Diagnostic Studies (93875 – 93990) Pulmonary (94002 – 94799) Allergy & Clinical Immunology (95004 – 95199) Endocrinology (95250 – 95251) Neurology & Neuromuscular Procedures (95805 – 96020) Medical Genetics & Genetic Counseling Services (96040) Central Nervous System Assessments & Testing (96101 – 96120) Health & Behavior Assessment & Interventions (96150 – 96155) Chemotherapy Administration (96401 – 96549) Photodynamic Therapy (96567 – 96571) Special Dermatological Procedures (96900 – 96999) Physical Medicine & Rehabilitation (97001 – 97799) Medical Nutrition Therapy (97802 – 97804) Acupuncture (97810 – 97814) Osteopathic Manipulative Treatment (98925 – 98929) Chiropractic Manipulative Treatment (98940 – 98943) Education & Training for Patient Self-Management (98960 – 98962) Special Services, Procedures & Reports (99000 – 99091) Qualifying Circumstances for Anesthesia (99100 – 99140) Moderate (Conscious) Sedation (99143 – 99150) Other Services & Procedures (99170 – 99199) Home Health Procedures & Services (99500 – 99602)
Table 12: Medicine Modifiers The following modifiers can be used on Medicine CPT codes. See Appendix A for modifier descriptions. Modifier -22 -26 -32 -51 -52 -53 -55 -56 -57 -58 -59 -73 Description Unusual services Professional component Mandated Services Multiple procedures Reduced services Discontinued procedure Postoperative management only Preoperative management only Decision for surgery Staged or related procedure by same physician during the postoperative period Distinct procedural service Discontinued outpatient/ASC procedure prior to anesthesia Page 28 of 47
Table 12: Medicine Modifiers-continued Modifier -74 -76 -77 -78 -79 -90 Description Discontinued outpatient/ASC procedure after initiation of anesthesia Repeat procedure by the same physician Repeat procedure by another physician Return to operating room for a related procedure during the postoperative period Unrelated procedure or service by the same physician during a postoperative period Reference (outside) laboratory
STEPS TO LOOKING UP A CPT CODE
Now that you know about the CPT manual, here are the basic steps of looking up the appropriate CPT code for reporting/billing. 1. Identify the procedure or service documented in the report or medical record 2. Search for the main term in the index of the CPT manual 3. Locate the code in the main section of the CPT manual that best describes the service rendered Happy coding!
Obtain a current copy of a CPT manual (copies to borrow may available at your local library, medical school, or hospital). Find the CPT description for the following codes. Be sure to indicate any special markings (e.g. +, , ). Answers follow on next page (2007 CPT manual used – your answers may vary slightly depending upon which manual date you use) 1. 99204___________________________________________________________ 2. 99283___________________________________________________________ 3. 01490___________________________________________________________ 4. 11200___________________________________________________________ 5. 35490___________________________________________________________ 6. 59400___________________________________________________________ 7. 69990___________________________________________________________ 8. 71020___________________________________________________________ 9. 78580___________________________________________________________ Page 29 of 47
10. 80061__________________________________________________________ 11. 89260___________________________________________________________ 12. 90656___________________________________________________________ 13. 90911___________________________________________________________ 14. 97001___________________________________________________________ 15. 99510___________________________________________________________
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Answers to Exercise 1. 99204 = Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: Comprehensive History, Comprehensive Examination, Medical Decision Making of Moderate Complexity 2. 99283 = Emergency department visit for the evaluation and management of a patient, which requires these three components: Expanded Problem Focused History, Expanded Problem Focused Examination, Medical Decision Making of Moderate Complexity 3. 01490 = Anesthesia for lower leg cast application, removal, or repair 4. 11200 = Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 5. 35490 = Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery 6. 59400 = Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and or/forceps) and postpartum care 7. +69990 = Microsurgical techniques, requiring the use of operating microscope 8. 71020 = Radiologic examination, chest, two views, frontal and lateral 9. 78580 = Pulmonary perfusion imaging, particulate 10. 80061 = Lipid Panel 11. 89260 = Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis 12. 90656 = Influenza virus vaccine, split virus, preservative free, when administered to 3 years and older, for intramuscular use
13. 90911 = Biofeedback training, perineal muscles, anorectal, or urethral sphincter, including EMG and/or manometry 14. 97001 = Physical therapy evaluation 15. 99510 = Home visit for individual, family, or marriage counseling
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Adams, Wanda L, CPC, Adams' Coding and Reimbursement: A Simplified Approach, second edition. Elsevier Mosby: St. Louis, Missouri. ©1994 American Medical Association: CPT Category I Vaccine Codes. © 2008, American Medical Association. www.ama-assn.org/ama/pub/category/10902.html, accessed September 10, 2008 Beebe, Michael, et al, Current Procedural Terminology (CPT®) 2007 Professional Edition: American Medical Association ©2006 Buck, Carol J, MS, CPC, Step-By-Step Medical Coding. Elsevier Saunders: St. Louis Missouri. ©2005 Centers for Medicare & Medicaid Services, 1995 & 1997 Documentation Guidelines: http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp, accessed September 8, 2008 Medline Plus Online Medical Dictionary: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html, accessed September 8, 2008 Schreck, Bonnie G, CCS, CPC, CPC-H, CCS-P, et al, Coders' Desk Reference for Procedures 2004. Ingenix Inc/St. Anthony Publishing: Eden Prairie, MN. ©2003. Pgs 1-23
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TEST QUESTIONS Introduction to CPT Course #1220409 Directions: • Before taking this test, read the instructions on how to correctly complete the answer sheet. • Select the response that best completes each sentence or answers each question from the information presented in the module. • If you are having great difficulty answering a question, go to www.ncctinc.com and select Recertification/CE, then select Updates/Revisions to see if course content and/or a test question have been revised. If you do not have internet access, call Customer Service at 800-874-4404. 1. The purpose of medical coding is to __________. a. provide jobs to many individuals in a comfortable setting b. frustrate physicians in hopes they will quit practicing medicine c. report, track, and bill for services rendered to patients in a variety of healthcare settings d. ensure patient safety in healthcare facilities 2. Many organizations utilize medical coding in a variety of ways. Some of these organizations include __________. a. Medicare, Medicaid, World Health Organization b. Grocery stores, mortgage brokers, business owners c. Physician spousal organizations, landlords for medical office spaces, hospital maintenance workers d. Veterinarians, Mechanics, and garbage collectors 3. The six types of codes used in reporting and billing for medical services are __________. a. b. c. d. Fixed, changing, modified, collection, contract, billing Diagnostic, therapeutic, injection, imaging, office, hospital CPT, ICD9, HCPCS, NCD, Revenue, ADA Dental Codes Physician, nurse, technician, facility, transport, nutrition
4. Which one of these organizations has responsibility for maintaining the CPT manual? a. b. c. d. American Dental Association (ADA) American Medical Association (AMA) Centers for Medicare & Medicaid (CMS) World Health Organization (WHO)
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5. In what year was the first CPT manual published? a. b. c. d. 1996 1800 2000 1966
6. CPT codes are also called __________. a. b. c. d. HCPCS Level I codes HCPCS Level II codes HCPCS Level V codes Diagnosis codes
7. What is the purpose of CPT? a. To provide a uniform language that accurately describes medical, surgical, and diagnostic services b. To provide a convoluted, obscure way to randomly report medical services with the goal of swindling insurance companies and unsuspecting patients c. To track potential epidemics and provide necessary information to authorities in an attempt to thwart the spread of disease d. None of the above 8. Which of the following is an index entry describing a specific procedure? a. b. c. d. Abscess, Auditory Canal, External……………69020 Bunion Repair…………………..………………28296 – 28299 EKG see Electrocardiography Backbone see Spine
9. Modifiers change the essential definition of the CPT code. a. True b. False 10. Which modifier would be used to report Unrelated E & M Service by the Same Physician during a Postoperative Period? a. b. c. d. –76 –25 –TC –24
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11. To report a bilateral procedure performed on a patient, which one of the modifiers below would be appended to the reported CPT code? a. b. c. d. –99 –82 –50 –Bi
12. Which modifier is reported with the CPT code when a surgical team performs a surgery on a patient? a. b. c. d. –66 –50 –TC –99
13. A patient comes to the emergency room with a laceration on his arm. The ED doctor repairs the laceration and then advises the patient to see their Primary Care Physician (PCP) in 10 days to have the sutures removed. The ED physician reports CPT code 12002 (Simple repair of …extremities, 2.6cm-7.5cm). Which modifier is used on CPT code 12002 to inform the insurance that the ED doctor is not expecting the patient to return to the ED for suture removal? a. b. c. d. –80: Assistant surgeon –54: Surgical care only –79: Unrelated procedure by same physician during post-op period –99: Multiple modifiers
14. A cardiologist performs a transesophageal echocardiography (TEE) on a pediatric patient with Tetralogy of Fallot (a congenital cardiac anomaly) prior to having a cardiac catheterization procedure. The cardiologist reports CPT code 93317. After the procedure, the cardiologist performs a repeat TEE on the patient, and reports CPT code 93317. Which modifier is appended to the second 93317? a. b. c. d. –66: Surgical team –52: Reduced services –54: Surgical care only –76: Repeat procedure by same physician
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15. A two year old in apparent distress was brought to the doctor’s office. She had a fall and is not using her arms. After a thorough examination and X-rays of both arms, the physician diagnoses the problem as bilateral nursemaid’s elbow (elbow dislocation). The physician snaps the elbows back in place and the patient is sent home. The physician reports an office visit E&M code 99214 and CPT code 24640 (reduction of nursemaid’s elbow) for both elbows. Which modifiers are required on the claim? a. b. c. d. 92214–25: E&M on same day as procedure; 24640-50: Bilateral procedure 92214–57: Decision for surgery; 24640-P1: A normal healthy patient 92214–58: Staged or related procedures; 24640-99: Multiple modifiers No modifiers are required on either code
16. Which appendix lists codes with the symbol (+)? a. b. c. d. Appendix C: Clinical Examples Appendix D: Summary of CPT Add-on Codes Appendix E: Summary of CPT Codes Exempt From Modifier 51 Appendix F: Summary of CPT Codes Exempt From Modifier 63
17. Which appendix lists codes with the symbol ( )? a. b. c. d. 18. Appendix B: Summary of Additions, Deletions, and Revisions Appendix C: Clinical Examples Appendix D: Summary of CPT Add-on Codes Appendix E: Summary of CPT Codes Exempt From Modifier 51
Which appendix lists codes with the symbol ( )? a. b. c. d. Appendix K: Products Pending FDA Approval Appendix A: Modifiers Appendix D: Summary of CPT Add-on Codes Appendix G: Summary of CPT Codes That Include Moderate (Conscious) Sedation
Which symbol below is used to identify FDA approval pending? a. b. c. d.
20. Which symbol below is used to identify a new code? a. b. c. d.
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21. An unlisted code can be used __________. a. when the insurance carrier denies the claim b. when a more appropriate code that describes the service rendered can not be found c. when you do not want to charge the patient d. at the physician’s request 22. E&M stands for __________. a. b. c. d. Exact & Moderate Evaluation & Medical billing Evaluation & Management Employment & Management
23. What is the code range for E&M services? a. b. c. d. 99201 – 99499 00100 – 01999 70000 – 79999 90000 – 99199
24. E&M codes were first established in __________, revised in __________, and revised again in __________. a. b. c. d. 1966, 1972, 2000 1999, 2000, 2004 1992, 1995, 1997 1992, 1997, 2000
25. Which guidelines does Medicare allow providers to use for E&M billing? a. b. c. d. 1995 guidelines 1995 or 1997 guidelines 1997 guidelines 1992, 1995 or 1997 guidelines
26. A patient can once again be considered a “New” patient if they have NOT been seen by the provider or one of their colleagues in the same specialty in the same office for at least 3 years. a. True b. False
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27. Discharge Service is a __________. a. service rendered to a patient who has been discharged from the military b. service rendered to a patient who has any discharge from one or more of their orifices (mouth, nose, etc) c. patient who is fired (or “discharged”) from the practice for chronically not showing for appointments d. service rendered to a patient on the last day being confined to a facility; a patient who is being discharged from the facility on that day 28. Non-critical care services rendered to neonates are classified into which of the following three weight classes? a. Low Birth Weight 1500gm – 2500gm Normal Birth Weight 2500gm – 3500gm High Birth Weight Baby >3500gm Very Low Birth Weight <1500gm Low or Moderate Birth Weight 1500gm – 3000gm Very High Birth Weight >3000gm Very Low Birth Weight <1500gm Low Birth Weight 1500gm – 2500gm Normal Birth Weight >2500gm Normal Birth Weight >2500gm Near Normal Birth Weight 2000gm – 2500gm Low Birth Weight <2000gm
29. Anesthesia services listed in the CPT manual are generally subdivided by anatomical site, with the exception of __________. a. b. c. d. codes with a P-Status oncology procedures, mammography, and E&M local anesthesia and topical anesthesia radiological procedures, burn treatments, and obstetrics
30. An expectant mother sees her OB/GYN for 12 visits prior to delivery. On the day of delivery, the OB/GYN is called to the hospital to deliver the baby. It is a normal, spontaneous, vaginal delivery (NSVD) with episiotomy. The patient returns to the OB/GYN six weeks later for a routine postpartum visit. Which of the following surgical CPT codes should be used to report this service? a. b. c. d. 59409 – Vaginal delivery only (with or without episiotomy and/or forceps) 59426 – Antepartum care only, 7 or more visits 59430 – Postpartum care only (separate procedure) 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care Page 38 of 47
31. A cardiologist is called to the operating room to repair a cardiac wound on a patient who is on cardiopulmonary bypass (heart-lung machine). Once in the OR, he performs a cardiac wound repair. Which of the following surgical CPT codes should be used to report this service? a. b. c. d. 33300 – Repair of cardiac wound; without bypass 33005 – Repair of cardiac wound; with cardiopulmonary bypass 33310 – Exploratory cardiotomy without bypass 33315 – Exploratory cardiotomy with cardiopulmonary bypass
32. A medical assistant is asked by the physician to draw blood from a 35 year old patient for diagnostic lab tests. The medical assistant performs one venipuncture and successfully draws the blood as requested. Which of the following surgical CPT codes should be used to report the medical assistant’s service? a. 61020 – Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir without injection b. 36415 – Collection of venous blood by venipuncture c. 36410 – Venipuncture, age 3 years or older, necessitating physician’s skill for diagnostic or therapeutic purposes d. 36561 – Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older 33. A 45-year-old patient comes is brought to the emergency room after a motor vehicle accident. The emergency physician stabilizes the patient and determines the patient’s right eye is so badly damaged it may need to be removed. An ophthalmologist examines the patient and agrees the eye must be immediately removed. The patient is taken to the operating room where the ophthalmologist performs an enucleation of the patient’s eye, but does not implant an artificial eye at that time. Which of the following surgical CPT codes should be used to report the ophthalmologist’s service? a. b. c. d. 65091 – Evisceration of ocular contents; without implant 65093 – Evisceration of ocular contents; with implant 65101 – Enucleation of eye; without implant 65103 – Enucleation of eye; with implant; muscles not attached
34. A patient is sent by their PCP to a local podiatrist for an office consultation because of chronic, infected toenails of bilateral great-toes. After a detailed examination, the podiatrist decides to completely remove both toenails at that visit. The patient is prepped in the usual manner and the procedure is started. The right nail is avulsed without any problem. The podiatrist begins the left nail avulsion but halfway through the procedure he stops because the patient says it is too painful. The podiatrist administers additional digital block anesthesia. After a few minutes, the patient is ready to continue the procedure. The podiatrist finishes the procedure on the left toe without complication. The wounds are dressed, and the patient is asked to come back in 5 days for postoperative wound check. Which of the following CPT code combinations and modifiers should be used to report the podiatrist’s services? Page 39 of 47
99243-25,-57 – Office consultation with detailed history, detailed exam, medical decision making low complexity 11730 – Avulsion of nail plate, partial or complete, simple or single nail 11732 – Avulsion of nail plate, partial or complete, each additional nail 99214-25 – Office visit for an established patient with detailed history, detailed exam, medical decision making moderate complexity 11730-50 – Avulsion of nail plate, partial or complete, simple or single nail 99221-25 – Initial hospital care with detailed history, detailed examination, medical decision making low complexity 01462-P1 – Anesthesia for all closed procedures on lower leg, ankle, and foot 11752-47,-50 – Excision of nail and nail matrix, partial or complete, for permanent removal; with amputation of tuft of distal phalanx 99253-25,-57,-74 – Inpatient consultation with detailed history, detailed exam, medical decision making low complexity 11730-54,-57 - Avulsion of nail plate, partial or complete, simple or single nail 11732-54,-57,-74 – Avulsion of nail plate, partial or complete, each additional nail
35. Which of the following is NOT a radiological imaging procedure? a. b. c. d. X-ray CT Fluoroscopy Anesthesia
36. Radiology includes technical procedures such as __________. a. b. c. d. Hemodialysis Radiation Oncology for cancer treatment Open spine surgery Photodynamic Therapy
37. What are the two components of radiology CPT codes? a. b. c. d. Radiation and Ultrasound Diagnostic and Therapeutic Technical and Professional With Contrast and Without Contrast
38. A patient presents to their PCP with shortness of breath, coughing, and fever. After an examination of the patient, the doctor orders an in-office frontal & lateral chest x-ray. The radiographer performs the chest x-ray and the physician reads it. What is the appropriate radiology CPT code to report for the x-ray? a. 71010-99,-TC,-26 – Radiologic examination, chest; single view, frontal b. 71020 – Radiologic examination, chest, two views, frontal and lateral c. 71030-26 – Radiologic examination, chest, complete, minimum of four views d. 71035-TC – Radiologic examination, chest, special views (e.g. Later decubitus, Bucky studies) Page 40 of 47
39. A female patient comes to her OB/GYN with complaints of lower pelvic pain. The OB/GYN determines an MRI of the patient’s pelvic cavity if needed. He requests this be done without contrast, then additional images with contrast. The MRIs are performed as requested, and a Radiologist reads the films, writes the report, and send the report to the OB/GYN. Which radiology CPT code and modifier combination(s) that would be reported for the radiologist’s service? a. 72195-26 – Magnetic resonance imaging, pelvis; without contrast material 72196-26 – Magnetic resonance imaging, pelvis; with contrast material b. 72195-26 – Magnetic resonance imaging, pelvis; without contrast material 72197-26 – Magnetic resonance imaging, pelvis; without contrast material, followed by contrast material and further sequences c. 72197-26 – Magnetic resonance imaging, pelvis; without contrast material, followed by contrast material and further sequences d. 72198 – Magnetic resonance angiography, pelvis, with or without contrast material 40. A 5-year-old patient is brought to the ED with complaints of abdominal pain. The ED physician performs an examination and determines that a single view abdomen x-ray would help him determine the final diagnosis. The child is brought to the radiology suite and a single view anteroposterior x-ray is performed. The radiologist reads the x-ray and determines the patient has constipation of the large intestine with fecal impaction. What is the appropriate code for the radiologist’s service? a. b. c. d. 74270-26 – Radiologic examination, colon; barium enema, with or without KUB 74260-26 – Duodenography, hypotonic 74000-26 – Radiologic examination, abdomen; single anteroposterior view 74022-26 – Radiologic examination, abdomen, complete acute abdomen series, including supine, erect and/or decubitus views, and single view chest
41. A 50-year-old female patient sees her PCP for a regularly scheduled yearly exam. The PCP requests she get a mammography to screen for problems as it is recommended for her age. The patient goes to the mammography center where the technician performs a 2-view mammography study of each breast, as prescribed by the PCP. What is the appropriate radiology CPT code and modifier to report for the technician’s service? a. 77057-TC – Screening mammography, bilateral (2-view film study of each breast b. 77056-TC – Mammography; bilateral c. 77055-TC-50 – Mammography; unilateral d. 71035-TC – Radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies) Page 41 of 47
42. What is the code range within the Pathology & Laboratory section of the CPT manual identifying Surgical Pathology? a. b. c. d. 80100 – 80103 86000 – 86849 88300 – 88399 80500 – 80502
43. A 60-year-old man visits his doctor for his annual exam. His doctor orders a total serum cholesterol, triglycerides, and direct measurement of HDL cholesterol. What is the CPT code of the panel that needs to be ordered? a. b. c. d. 80053 - Comprehensive Metabolic Panel 80061 – Lipid Panel 80048 – Basic Metabolic Panel 82465 – Total serum cholesterol + 84478 – Triglycerides
44. A medical assistant performs a manual urine dipstick test at the request of a physician. Which CPT code listed below best describes the service rendered by the medical assistant? a. b. c. d. 81025 – Urine pregnancy test, by visual color comparison method 81005 – Urinalysis; qualitative or semiquantitative, except immunoassay 81000 – Urinalysis by dipstick, non-automated, with microscopy 81002 – Urinalysis by dipstick, non-automated, without microscopy
45. A 35-year-old male presents to his PCP with fever, night sweats, and sudden loss of weight. The doctor suspects HIV infection and orders an HIV test. The lab performs a single assay HIV-1 test, which has abnormal results. The pathologist requests the clinical laboratory scientist perform an HIV confirmatory test using a Western Blot method. Which code below should be reported for the confirmatory test ? a. b. c. d. 86701 – HIV-1 86702 – HIV-2 86703 – HIV-1 & HIV-2, single assay 86689 – HTLV or HIV antibody, confirmatory test (e.g., Western Blot)
46. A young couple goes to a reproduction specialist after several unsuccessful attempts of getting pregnant. The doctor orders a semen analysis to include an analysis for sperm presence and sperm motility. What is the appropriate CPT code for the semen analysis? a. b. c. d. 89321 – Semen analysis, presence and/or motility of sperm 89325 – Sperm antibodies 89329 – Sperm evaluation; hamster penetration test 89335 – Cytopreservation, reproductive tissue, testicular
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47. Medication (e.g. Tylenol) administered to the patient is reported with CPT codes from the Medicine section. a. True b. False 48. A 5-year-old goes for a pre-Kindergarten checkup. After a comprehensive checkup, the physician asks the medical assistant to give the child a diphtheria/tetanus/acellular pertussis (DtaP) vaccination, an intramuscular vaccine. Select the code combination to report the services rendered. a. 99392 – Preventative medicine exam for established patient age 1-4 years 90467 – Immunization administration younger than age 8, with physician counseling, for intranasal or oral immunization administration 90700 – DTaP for patient younger than 7 years, intramuscular use 99411 – Preventative medicine counseling in a group setting, 30 minutes 90473 – Immunization administration by intranasal or oral route 90701 – Diphtheria, tetanus, and whole cell pertussis (DTP), intramuscular use 99429-22 – Unlisted preventative medicine service 99393 – Preventative medicine exam for established patient age 5-11 years 90471 – Immunization administration; percutaneous, intradermal, subcutaneous, or intramuscular administration 90700 – DTaP for patient younger than 7 years, intramuscular use
49. An adult female patient sees a psychiatrist twice per month to help her deal with depression & anxiety. The psychiatrist performs insight oriented and behavior supportive psychotherapy for 30 minutes each session. After a medical evaluation today, he wrote a prescription for Celexa 10mg. What is the appropriate psychotherapy code to report for the psychiatrist’s service today? a. 90805 – Individual psychotherapy; insight oriented, behavior modifying and/or supportive; in an office or outpatient facility, approx 23-30 minutes face-to-face with the patient; with medical evaluation and management service b. 90807 – Individual psychotherapy; insight oriented, behavior modifying and/or supportive; in an office or outpatient facility, approx 45-50 minutes face-to-face with the patient; with medical evaluation and management service c. 90809 – Individual psychotherapy; insight oriented, behavior modifying and/or supportive ;in an office or outpatient facility, approx 75-80 minutes face-to-face with the patient; with medical evaluation and management service d. 99214 – Office visit for an established patient with detailed history, detailed exam, medical decision making moderate complexity Page 43 of 47
50. An adult patient is injured and referred by her physician to a physical therapist for rehabilitation therapy. On the patient’s first visit, the physical therapist performs an evaluation and determines she needs to have mechanical traction, ultrasound therapy, and massage therapy. The physical therapist begins the therapy and the patient is given 15 minutes of traction, 15 minutes of ultrasound, and 30 minutes of massage. The total time spent with the patient (including evaluation and therapy procedures) is 80 minutes. What are the appropriate codes used to report today’s physical therapist’s services? a. 97001 – Physical therapy evaluation (x1) 97012 – Application of mechanical traction (x1) 97035 – Application of ultrasound, each 15 minutes (x2) 97124 – Therapeutic massage, each 15 minutes (x3) 97001 – Physical therapy evaluation (x1) 97012 – Application of mechanical traction (x1) 97035 – Application of ultrasound, each 15 minutes (x1) 97124 – Therapeutic massage, each 15 minutes (x2) 97002 – Physical therapy re-evaluation (x1) 97012 – Application of mechanical traction (x1) 97035 – Application of ultrasound, each 15 minutes (x1) 97124 – Therapeutic massage, each 15 minutes (x3) 97002 – Physical therapy re-evaluation (x1) 99354 – Prolonged physician service in outpatient setting; face-to-face first hour 97012 – Application of mechanical traction (x1) 97035 – Application of ultrasound, each 15 minutes (x2) 97124 – Therapeutic massage, each 15 minutes (x2)
51. The patient in question #50 is sent to a chiropractor for 5 visits. The chiropractor manipulates the patient’s cervical, thoracic, and lumbar spine, as well as manipulating her right scapula, clavicle, and arm. What code(s) should the chiropractor use to report these services? a. 98942 – Chiropractic manipulative treatment; spinal, 5 regions b. 98927 – Osteopathic manipulative treatment, 5 or 6 body regions c. 98925 – Osteopathic manipulative treatment, 1 or 2 body regions 98926-59 – Osteopathic manipulative treatment, 3 or 4 body regions 98927-59 – Osteopathic manipulative treatment, 5 or 6 body regions d. 98941 – Chiropractic manipulative treatment; spinal, 3 or 4 regions 98943 – Chiropractic manipulative treatment, extraspinal, one or more regions
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52. A 3-year-old female is brought to the local emergency room after she told her mother that while at daycare, an older boy put an unidentified object into her vagina and anus The physician performs an extensive examination and thorough interview. The physician needs to perform an anogenital examination with colposcopic magnification, but the child refuses. The mother agrees to allow the child to be given sedation by the emergency physician for the exam. The child is adequately sedated for a total of 45 minutes, and a colposcopic exam is performed of the anus and vagina. What codes are appropriate to bill for the emergency room physician’s service? a. 99236-25 – Observation or inpatient hospital care, including discharge on the same date, with comprehensive history, comprehensive examination, and high complexity medical decision making 99148 – Moderate sedation service provided by a physician other than the health care professional performing the diagnostic or therapeutic service, younger than 5 years of age, first 30 minutes +99150 – Moderate sedation service…each additional 15 minutes 57420 – Colposcopy of the entire vagina, with cervix 99223-25 – Inpatient hospital care, per day, with comprehensive history, comprehensive examination, and high complexity medical decision making +99145 – Moderate sedation service provided by the same physician performing the diagnostic or therapeutic service, younger than 5 years of age, each additional 15 minutes (x3) 57452 – Colposcopy of the cervix including upper/adjacent vagina 46600-59 – Anoscopy, diagnostic, with or without collection of specimens 99285-25 – Emergency department visit with comprehensive history, comprehensive exam, and high complexity medical decision making 99143 – Moderate sedation service provided by the same physician performing the diagnostic or therapeutic service, younger than 5 years of age, first 30 minutes +99145 – Moderate sedation service…each additional 15 minutes 99170 – Anogenital examination with colposcopic magnification in childhood for suspected trauma 99288 – Physician direction of emergency medical systems emergency care, advanced life support 99291-25 – Critical care evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 58999 – Unlisted procedure, female genital system (nonobstetrical) 46600-59 – Anoscopy, diagnostic, with or without collection of specimens
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53. An 82-year-old male is brought to the local emergency room with complaints of chest pain and shortness of breath. The ED doctor examines the patient and transfers him to the cardiac unit. In the cardiac unit, a cardiologist performs a comprehensive history and admits the patient for overnight observation. The patient is monitored by telemetry and hourly vitals are taken. The next morning after another exam by the physician, the patient is discharged home. What codes are used to report these events? a. Day 1: 99217 – Observation care discharge Day 2: 99215 – Office or other outpatient visit with comprehensive history, comprehensive examination, and high complexity medical decision making Day 1: nothing is to be reported Day 2: 99236 – Observation or inpatient hospital care including discharge on the same date, with comprehensive history, comprehensive examination, and high complexity medical decision making Day 1: 99220 – Initial observation care, per day, with comprehensive history, comprehensive exam Day 2: 99217 – Observation care discharge Day 1: 99220 – Initial observation care, per day, with comprehensive history, comprehensive exam Day 2: 99220 – Initial observation care, per day, with comprehensive history, comprehensive exam
54. Which of the following symbols identifies Add-on codes? a. + b. ⌧ c. d. 55. Which of the following is an Add-on code? a. b. c. d. 99211 22630 +22632 80048
56. A patient who is injured on a ski slope is airlifted to the nearest medical center. What POS is used to report the air ambulance? a. b. c. d. 41 42 21 22 Page 46 of 47
57. As a convenience to the community, the health department establishes an outreach mobile clinic. The modified RV is equipped so a physician (or other qualified healthcare provider) can see patients with acute illnesses such as sore throat, headache, earache, etc. at any location. The doctor who takes the mobile clinic on Mondays likes to park the RV at the local supermarket parking lot to see patients. What is the POS code reported when the physician sees patients in the mobile clinic in the supermarket parking lot? a. b. c. d. 02 20 15 41
58. Which code or codes are to be reported when 80 minutes of critical care is rendered to a patient? a. 99291 – Critical Care first 30-74 minutes; +99292 – Critical Care each additional 30 minutes b. 99285 – Emergency Department Visit (comprehensive history, comprehensive examination, medical decision making of high complexity) c. 99255 – Inpatient Consultation (comprehensive history, comprehensive examination, medical decision making of high complexity) d. 99220 – Initial observation care (comprehensive history, comprehensive examination, medical decision making of high complexity) 59. A CMS 1500 form is a standard insurance billing form. a. True b. False
*End of Test
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