ensure that the code selected accurately
CPT 2021
CURRENT PROCEDURAL TERMINOLOGY
 set of codes, descriptions and guidelines
intended to describe procedures and
services performed by physicians
intended to describe procedures and
services performed by physicians and
other health care professionals.
 5 digits code
 -published annually by AMA
 January 1-effective date for use of the
updated CPT code sets
Codes are used by:
 Clinics
 Hospital
 Rehabilitation Units
 Wherever health care services are
provided
CATEGORY 1 CODE - published annually
 five- digit category
 page 5-818 (every Jan 1)
CATEGORY 2 CODE- alphanumeric code
 final character F
 PAGE 819
CATEGORY 3 CODE- alphanumeric codes
 final character T
CPT SECTIONS
 E/M (evaluation and management)-
99201-99499
 Anesthesia- 00100-01999, 99100-99140
 Surgery- 10004-69990
 Radiology- 70010-79999
 Pathology and Laboratory- 80047-
89398
 Medicine- 90281-99199, 99500-99607
Categorized by:
 Sections divided into subsections
 Subsections divided into subheadings
 Subheading divided into categories
Index
 NOT a substitute for the main text of
the CPT code book.
 even if only one code is present, the
user must refer to the main text to
identifies the services performed.
Main terms:
 Procedure or services
 Organ or other anatomical site
 Condition
 Synonyms, eponyms and abbreviations
Examples:
1. Laparoscopic Cholecystectomy
a. Cholecystectomy >
Laparoscopic > 47562-47564
2. Bronchoscopy with endobronchial biopsy
a. Bronchoscopy > biopsy >
31625-31629, 31632,31633
3. Incision and drainage of Simple pilonidal
cyst
a. Incision and drainage > cyst >
skin > pilonidal > 10080, 10081
4. Reduction of the breast
a. Breast > Reduction > 19318
5. Open biopsy of the breast
a. breast> biopsy > 19100, 19101
6. Manipulation of tibial fracture
a. tibia > manipulation > 27532,
27752
7. EEG
8. ERCP
9. TURP
10. Clagget procedure
Presentation of codes in index
 Singular Code: 38115
 Multiple code: 26645, 26650
 Range of code: 22310-22328
Remember:
a. DO not code directly from the
index
b. Reference the main portion of
the CPT
Notes:
c. located through the CPT
d. "MUST read" before coding
Examples:
 Surgery of Skull base- specific notes
applicable to a group of codes.
Two types of codes:
  Stand alone- Full description indicate that a code should not be
 Indented- Dependent upon preceding reported with another code.
code for full description  Circle with line- -51 cannot be used with
Semicolons these codes.
 -indicates that you must read the full Modifier 51 exempt:
description in the preceding code.  All add on code
 Codes after the stand alone code-  codes with circle with line symbol
o (;) stopper sign, followed by the Unlisted Services
indented code definition - codes end in "-99"= "no specific code"
1. 23% body surface- debridement - processed by payers individually
2. 11000, 11001, 11001 - slow to get paid
 CPT Format Use only if no specific CPT code can be found
o symbols throughout CPT - including category III codes
o used in the CPT manual to - written report must accompany
convey information about the Written report
code. A. Indicates:
SYMBOLS: B. Nature
 Bullet- new code, new code for service/ C. Extent
procedure symbol D. Need
E. Time
 Triangle- description change, changed
F. Effort
code description
G. Equipment used
 Right and left triangle- Beginning and
ending of text change, for insertion of
Unlisted services:
transvenous implantable defibrillator
1. 1599- Unlisted procedure, excision
lead[s], without thoracotomy, use 33216
pressure ulcer
or 33217
2. 30999- unlisted procedure, none
 (+) Plus- add-on code
3. 31899- unlisted procedure, trachea,
e. always performed in addition to
bronchi
the primary service or procedure
4. 41899- unlisted procedure,
f. -NEVER reported as a
dentoalveolar structures
standalone code.
5. 44979-unlisted laparoscopy
g. Mother code, (+) baby code
procedure, appendix
h. -always performed in addition to
6. 47379- unlisted laparoscopy
the primary service or procedure
procedure, liver
i. NEVER reported as a
7. 50549- unlisted laparoscopy
standalone code
procedure, renal
j. Do not report modifier 50,
Modifier 63- Procedure Performed on Infants
bilateral procedures, in
Less than 4 kg
conjunction with add on codes.
Category III codes
k. -All add-on codes in the CPT
- New technology
code set are exempts from the
- Temporary Codes
multiple procedure concept
o used up to 5 years
(modifier 51)
- Identify emerging technology, services,
Parenthetical Notes
and procedures
- Instructions, typically included as
- Located after the medicine section
parenthetical notes with selected codes,
- Alphanumeric characters (0042T)
Category I codes (00100-99607) have been:
- -approved by AMAs
o Food and Drug Administration
o Proven clinical effectiveness
- Category III codes have not ben
approved by FDA and may not have
proven clinical effectiveness.
Five character codes
- 0042T, cerebral perfusion analysis using
contract administration
- Category III codes may or may not
receive a category I code in the future
- Supplemental tracking codes
- Provide additional data
A. Appendix A- modifiers
B. Appendix B- Additions, deletions,
revisions
C. Appendix C- clinical examples of
E/M
D. Appendix D- add on codes
E. Appendix E- -51 exempt codes
F. Appendix F- -63 exempt codes
G. Appendix G- Moderate (conscious)
sedations, removed January 2017
H. Appendix H: Alphabetical clinical
topics - deleted
I. Appendix I: Genetic testing code
modifiers - deleted
J. Appendix J: Nerve conduction
studies
K. Appendix K: Pending FDA approval
L. Appendix L: Vascular families
M. Appendix M: Renumbered CPT
codes - crosswalk
N. Appendix N: Resequenced CPT
codes
O. Appendix O: Multianalyte assays
with algorithmic analyses
P. Appendix P: Telemedicine services
MODIFIERS
- two character suffixes (alpha and/or
numeric) that are attached to a procedure
code.
- they provide a way to indicate that the
service or procedure has been altered by
some specific circumstance, but has not
been changed in definition or code.
- modifiers are intended to communicate
specific information about a certain
service or procedure that is not already
contained in the code definition itself
Modifiers may be used to indicate to the
recipient of a report that:
 A service or procedure had both a
professional and technical component
 A service or procedure was performed
by more than one physician or other
healthcare professional and/or in more
than one location
 A service or procedure was increased or
reduced
 Only a part of a service was performed
 An adjunctice service was performed
 A bilateral procedure was performed
 A service or procedure was provided
more than once.
 Unusual events occurred
Two types of modifiers:
1. Payment modifiers
• Can affect the reimbursement
○ 50 - Bilateral procedure
○ 51 - Reduced services
○ 52 - Multiple procedures
2. Informational modifiers
 More specific information about the
procedure
 Level II HCPCS/National on the inside
cover of the book
○ LT - Left side
○ RT - Right side
○ F1 - Left hand, second digit
Example: how to add the modifiers
31622-LT = done on the left side
31622-50 = done bilaterally
• Procedure code needs to come first
• Modifiers are suffixes
Example: multiple modifiers
31622-50-LT
• Payment modifier (-50)
• Informational modifier (-LT)
• Just an example!
30903-74-RT
• -74 = discontinued
• -RT = right side
Modifiers example:
1. 31622- LT (on the left side)
2. 31622- 50 (bilateral)
3. 30903- 74- RT (discontinued procedure)
24- Unrelated evaluation and management
services by the Same physician or other
qualified health care professional during a post
operative period
1. 45 days post op from total hip
replacement- E&M code- 24 and patient
fell injuring her arm - CPT radiology
code.
25- Significant, separately identifiable
evaluation and management service by the same
physician or other qualified healthcare
professional on the same day of the procedure or
other services
1. Patient presents with a laceration to right
arm sustained during an accident on the
play ground- E&M code- 25 Patient was
given a flu vaccine during the same
encounter- Flu vaccine- Medicine CPT
code.
57-Decision for Surgery
1. Patient who presented to clinic for
evaluation and management of chronic
knee OA decides to undergo elective
TKA.
22 Increase procedural services- it may be
identified by adding modifier 22 to the
procedure code when the work required to
provide a service a substantially greater than
typically required
 documentation must support the substantial
additional work and the reason for the
additional work
- increased intensity
- time
- technical difficulty of procedure
- severity of patient's condition
- physical and mental effort required
Documentation should include:
 Type of influencing circumstances
 Size of an unusually large tumor
 Dimension of the unusual incision or
excision
 Degree of difficulty
 Length of time
Examples of word that help document unusual
circumstances and justify:
 Increase risk due to
 severe respiratory distress
 Difficulty
 hemorrhage
 Blood loss of over 600cc
 Complications
 Unusual findings
- Patient who is undergoing cholecystectomy
who had a blood loss of over 600 cc and
had an extensice surgery time due to
establish hemostasis
50 Bilateral procedures
- used when a bilateral surgery is
performed and that is identical in nature
- modifier 50 = paired organs
- Used when a bilateral surgery is
performed and that is identical in nature
1. Patient undergoes bilateral open carpal tunnel
release- 64721-50
2. Patient undergoes bilateral complete
mastectomy- 19303-50
- DO NOT use with procedures identified
with "unilateral or bilateral" as per code
description
- 58600
- 54860-54861
- 58925
Excision of prostate
1. Physician excised the right side of the
prostate and established hemostasis,
then attention was turned to the left side
of the prostate. Physician now excised
 the left side. Procedure was done.
Patient transferred to PACU
(no need to place side)
Paired organs are:
- adrenal glands
- breasts
- ears
- eyes
- kidneys
- lungs
- ovaries
- testicles
LT/RT left and right
- apply to codes which identify
procedures which can be performed on
paired organs
- The LT, RT modifiers should be used
whenever a procedure is performed only
one side
example
1. pt undergoes left lumpectomy- 19301
2. Pt undergoes open txm of tibial shaft fracture,
27758
51 Multiple Procedures
- when multiple procedure, other than
E/M physical medicine and
rehabilitation services or provision of
supplies (e.g vaccines) are performed at
the same session by the same individual,
the primary procedure or service may be
reported as listed. Additional procedure
may be identified by appending MOD
51
- DO NOT use with add on codes and
E/M codes
- Documentation must support each code
independently, outlining the medical
necessity for each procedure,
Example:
1. Laparoscopic cholecystectomy due to
cholelithiasis was also performed during
laparoscopic bariatric surgery 47562
43644
52 Reduced services
- under certain circumstances, a service or
procedure is partially reduced or
eliminated at the discretion of the
physician or other qualified healthcare
professional. The service provided can
be identified by adding Mod52,
signifying that the service is reduced.
- This provides a means of reporting
reduced services without disturbing the
identification of the basic service.
- Documentation should clearly explain
why or how a procedure was not
completed.
- Example is a bilateral procedure code
where only one side was performed
2. Hemorrhoidectomy0 46255-52 (only
internal hemorrhoid excision was
performed)
3. Tonsillectomy 42820-42836
4. Patient undergoes left breast
lumpectomy- 19301-LT
5. Patient undergoes bilateral breast
lumpectomy- 19301-
53 discontinued procedures
- under certain circumstances, the
physician may elect to terminate a
surgical or diagnostic procedure
- due to extenuating circumstances or
those that threaten the well being of the
patient, it may be necessary to indicate
that a surgical or diagnostic procedure
was started but discontinued
Example:
1. Patient was admitted for
cholecystectomy, had an A-fib with
RVR, procedure was aborted. Patient
was transferred to ICU
58 staged or related procedure
- it may be necessary to indicate that the
performance of a procedure or service
during postoperative period was:
- Planned or anticipated (staged)
- More extensive than the original
procedure; or
- for therapy following a surgical
procedure
73 discontinued OP procedure
53 vs 73
73 discontinued outpatient procedure prior to
Anesthesia administration
- due to extenuating circumstances or
those that threaten the well being of the
patient , the physician may cancel a
surgical or diagnostic procedure
subsequent to the patients surgical
preparation (including sedation when
provided, and being taken to the room
where the procedure is to be performed),
but prior to administration of anesthesia
(local, regional block (s) or general)
Take note before appending modifier 73;
patient should be:
- Brought inside the operating room
- Prepped and draped in OR
74 discontinued outpatient procedure after
anesthesia administration
- due to extenuating circumstances or
those that threaten the well being of the
patient, the physician may terminate a
surgical or diagnostic procedure, after
the administration of anesthesia (local
regional blocks, general or after the
procedure was started (incision made,
intubation started, scope inserted, etc)
78 unplanned return to the operating room
- It may be necessary to indicate that
another procedure was performed during
the post operative period of the initial
procedure (unplanned procedure
following the initial procedure)
- When this procedure is related to the
first, and required the use of an
operating room,it may be reported with
modifier 78 to the related procedure
- professional/physician coding
o DC proc- 53
- Facility coding
o DC proc- 73/74
What modifier should be used for hospital OP
discontinued prior to anesthesia administration?
-73
59 Distinct procedural services
- under certain circumstances, it may be
necessary to indicate that a procedure or
services was distinct or independent
from the other non- E/M services
performed on the same day. It is used to
identify procedures/ servies, other than
E/M services, that are not normally
reported together, but are appropriate
under the circumstances.
Examples:
1. Patient undergoes excision of malignant
lesion in left forearm. Laceration in the right
buttock is closed by intermediate repair
- excision of malignant lesion L forearm
-intermediate repair buttocks- 59
- 51- physician coding
- 59- facility coding
XE - SEPARATE ENCOUNTER
- A service that is distinct because it
occurred during a separate encounter.
- This modifier should only be used to
described separate encounters on the
same date of service
Ex:
07/01/2021
- 8am – lap chole
- 1pm – discharged home
- 7pm – fracture = ED
- ED = ORIF
- 8pm = ORIF
- 11pm = discharge home
= Lap chole, ORIF-XE
XS- SEPARATE STRUCTURE
- A service that is distinct because it was
performed on a separate organ /
structure
 Removal of deep hardware R and L
ankle
o 20680, 20680-XS
 Removal of deep hardware R hand
and L ankle
o 20680, 20680-XS
 Injection into tendon sheath R
shoulder and R ankle
o 20550, 20550-XS
 Injection to tendon sheath bilateral
shoulder & R ankle
o 20550-50, 20550-XS
XP- SEPARATE PRACTITIONER
- A service that is distinct because it was
performed by a different practitioner
1. Patient went it for a bilateral
mastectomy with Dr. A followed by a
bilateral reconstruction of breast with
Dr. B
 bilateral mastectomy – DR. A
 bilateral reconstruction of breast – DR.
B
o 19303-50, 19342-50-XP
XU- UNUSUAL NON-OVERLAPPING
SERVICE
- The use of a service that is distinct
because it does not overlap usual
components of the main service
- Patient presented with bladder tumor for
bladder biopsy. Biopsy was done as per
pathology result, it revealed carcinoma
of the bladder.
 Bladder biopsy =
 Excised the bladder tumor = -XU
- CPT assistant
- X Modifier- Medicare

Key point on using modifiers:

- when two or more modifier are used, the
payment modifiers should be listed first,
followed by all other modifiers.
- the documentation within the medical
record should be present to support the
use of each modifier
- incorrect use of modifiers prevents the
provider or the facility from receiving
full reimbursements for the service
performed
- When two or more modifiers are used,
the payment modifier should be listed
first, followed by all other modifiers.
- The documentation within the medical
record should be present to support the
use of each modifier
- Incorrect use of modifiers prevents the
provider or the facility from receiving
full reimbursements for the service
performed.