Make the Most of CPT® at Your Fingertips
AMA’s official guide is now more helpful than ever.
Coders always are on the lookout for tips and tools to improve job performance and efficiency. Among the very best resources is one that coders use every day (and may take for granted): The CPT® book. The CPT® book is more than just a list of codes and parenthetical instructions, and even advanced coders would benefit from re-familiarizing themselves with all it has to offer.
Be Complete, Be Current
The CPT® Professional Edition is published each year by the American Medical Association (AMA), and is available as a print publication, as a CD, or via the Internet (the electronic version may be configured for one or more users). The AMA owns the copyright to the codes, their descriptions, and guidelines for use. You may purchase AMA’s CPT® Professional Edition through AAPC and other vendors. Only the AMA CPT® Professional Edition is permitted for use in AAPC credentialing exams, and it is the only version that includes official guidelines.
Be sure you’re always using the most current version of the CPT® book. Codes and coding guidelines change every year, and if you’re using an outdated edition, your coding accuracy is guaranteed to suffer. Saving a few dollars by using last year’s edition is no bargain when you consider the inevitability of miscoded, delayed, and/or rejected claims. The Health Insurance Portability and Accountability Act (HIPAA) also requires the use of current CPT® codes, so if an auditor finds you using an outdated CPT® book, you will solicit little sympathy.
Take a Tour of CPT®
The typical busy coder references the CPT® index as needed, double-checks the code(s) and parenthetical instruction in the numerical listings, codes that portion of the claim, and quickly moves on. The wise coder knows, however, that it’s worth investing time to study the book a bit more closely. The introductory materials, for instance, aren’t just filler. These often-overlooked portions of the book are invaluable resources.
You’ve probably noticed the list of modifiers and modifier descriptors on the front inside cover, and the Place of Service (POS) code listing on the facing page, but what if you venture a few pages further?
The Introduction (pages x-xiii of the CPT® 2011 Professional Edition) summarizes the layout of the CPT® book, how the codes are listed and defined, and modifier use; and defines terminology and the various symbols used throughout the book. Sure, this is basic information. But, just as you must know how to add and subtract before you can do long division or solve algebraic equations, so too does complex coding rely on a solid understanding of fundamental concepts. You’re never too advanced to review the essentials, and it’s wise to do so with every new release. Several icons and features are new in the last decade.
Which Way Is Up?
Pages xiv-xviii of CPT® 2011 Professional Edition provide a list of medical prefixes, suffixes, and word roots, as well as anatomic illustrations demonstrating body planes and aspects (sagittal plane, anterior aspect, etc.) and a list of illustrations that appear throughout the book. For example:
Curious about brain anatomy? See Figure 18A.
Want a pictorial explanation of abdominal aortic aneurysm repair? See the illustration that accompanies code 34802 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using bifurcated prosthesis (1 docking limb).
Often, a visual representation of a concept or procedure allows the coder literally to picture the correct coding, and the CPT® book provides a great variety of resources to facilitate this.
E/M Tables Simplify Code Selection
The CPT® Professional Edition contains tables in the Evaluation and Management (E/M) Services Guidelines section listing the required key components and, when applicable, typical service time for various categories/levels of E/M services (office or other outpatient services, initial hospital care, etc.). These tables provide an at-a-glance reference to help you select an appropriate E/M service level when the key components and/or counseling/coordination of care time have been documented and determined.
Decision Tree Takes a Vacation, but Still Applies
The New vs. Established Patient Decision Tree, which previously was included in the Evaluation and Management (E/M) Services Guidelines section, does not appear in the CPT® 2011 Professional Edition. Peter A. Hollmann, MD, vice chair of the AMA CPT® Editorial Panel, announced on Nov. 10, 2010 at the CPT® and RBRVS 2011 Annual Symposium in Chicago that the omission of the New vs. Established Patient Decision Tree from CPT® 2011 does not represent a change in policy regarding how to determine whether a patient is new or established. The definition of “new” and “established” patients in the Evaluation and Management (E/M) Services Guidelines remains unchanged from 2010. Hollmann predicts the New vs. Established Patient Decision Tree will reappear in the 2012 edition of CPT®.
Be on the Lookout for Coding Tips
Also new for 2011, the AMA has included supplemental coding tips throughout CPT® Professional Edition. These tips, set apart with a green “Coding Tip” indicator, provide valuable information for appropriate code selection, and are separate from the parenthetical and section head instructions most coders already know.
For example, preceding the Other Emergency Services codes, CPT® 2011 Professional Edition includes a Coding Tip advising, “No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.” Be sure to read and observe such Coding Tips to assist you in your code choices.
The Coding Tips are concentrated in the E/M portion of CPT® for 2011, but look for these helpful hints to become more widespread in years to come.
Follow Citations for Supplemental Coding Advice
Throughout CPT® you will find citations to CPT® Assistant (designated by an arrow within a green circle) and Clinical Examples in Radiology (designated by an arrow within a red circle). Although not an official part of the CPT® book, advice from either of these publications provides supplemental information on, and examples of, proper code use. These citations are useful especially when differentiating among several similar codes (or modifiers). The extra legwork to find and follow the citation often pays for itself.
To give just one example: If you must report colpopexy (57280 Colpopexy, abdominal approach, 57282 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus), 27284 Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) the CPT® Assistant reference (January 1997) instructs, “during reconstructive pelvic surgery, when either a vaginal or abdominal paravaginal defect repair is performed for correction of stress urinary incontinence or cystocele formation, and in addition a separate procedure for correction of vaginal vault inversion such a sacrospinous ligament fixation (code 57282) or an abdominal colpopexy (code 57820) is performed, codes 57282 or 57280 with modifier 51 may be reported in addition to 57284.”
Lacking this information, the coder may fail to report 57282, when appropriate, in addition to 57284. This translates into 7.97 physician work relative value units (RVUs) lost, or approximately $250 at average Medicare rates.
Subscriptions to CPT® Assistant and Clinical Examples in Radiology, as well as archives of past issues, are available through the AMA.
But Wait! There’s More!
CPT® contains supplemental information in addition to that described above, including appendices with clinical examples, a summary of codes exempt from modifiers 51 Multiple procedures and 63 Procedure performed on infants less than 4 kgs, a list of separate nerves for electrodiagnostic testing (especially helpful for neurology coders), and much more. There’s also a handy list of common abbreviations on the inside back cover. In other words, there’s probably more to your CPT® book than you knew.
Take the time to page through your CPT® book and identify those resources that you find most helpful. Remember, it’s not a sacred text: You’re allowed (and encouraged) to make notes in the margins, underline and highlight pertinent information, add your own tabs for easy reference, or incorporate “cheat sheets” within its pages. If you make the most of the resources at hand, your value as a coder appreciates.
Case Study: The Fundamentals of Time
If you haven’t reviewed the Introduction recently, you might be surprised to discover a new (added in 2011) explanatory paragraph on Time, as it relates to CPT® coding. Here you’ll find essential time information. Unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary:
- Time is face-to-face time with the patient.
Note that many inpatient services, as well as subsequent observation care 99224-99226 (technically an outpatient service) define time as bedside or floor/unit time. This is one case where descriptor-specific instructions override general guidelines.
- Phrases such as “interpretation and report” in the code descriptor are not intended to indicate in all cases that report writing is part of the reported time.
- A unit of time is attained when the mid-point is passed.
As an example, critical care services (99291-99292) are time based, with 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes reporting the first hour of critical care. To report 99291, the length of service must exceed the “half-way” mark, or at least 31 minutes. Critical care lasting fewer than 31 minutes is reported using an appropriate evaluation and management (E/M) code, rather than 99291. Similarly, +99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (list separately in addition to code for primary service) reports “each additional 30 minutes” of critical care, in excess of the first hour. This means that to report +99292, at least 75 minutes of critical care must be documented (60 minutes for the first hour, plus at least 15 minutes—the “halfway mark”—to report the additional 30 minutes of critical care as reported by +99292).
- When codes are ranked in sequential typical times and the actual time is between the two typical times, the code with the typical time closest to the actual time is used.
For instance, when reporting a time-based E/M service for an established outpatient, the documented counseling/coordination of care time is 22 minutes. By CPT® standards, this would mean the proper coding is 99214 (Physicians typically spend 25 minutes face-to-face with the patient and/or family), rather than 99213 (Physicians typically spend 15 minutes face-to-face with the patient and/or family), because 22 is closer to 25 than to 15. Note that not all payers agree with this rule. For example, the Centers for Medicare & Medicaid Services (CMS) typically views the E/M reference time as the minimum time needed to report a service.
- When another service is performed concurrently with a time-based service, the time associated with the concurrent service should not be included in the time used for reporting the time-based service.
Time spent performing separately-reported services concurrent with critical care services 99291-99292 may not be counted toward critical care time.
The Evaluation and Management (E/M) Services Guidelines also have undergone revisions for 2011 to clarify better how time relates to E/M services. A summary of the additions include:
- Verification that non-face-to-face (pre- and post-encounter) time may not be included when calculating total time for an office service
- Notification that the total work of E/M services has been calculated to include non-face-to-face time
- A restatement that time shall be considered the key factor for E/M leveling, when counseling and coordination of care dominate the encounter
- A determination that counseling or coordination of care includes time spent with patients or those individual(s) (including non-family members) who have assumed responsibility for the patient
- A requirement that the extent of counseling and/or coordination of care must be documented in the medical record
- Advice to report add-on codes for prolonged E/M services
The introductory materials … aren’t just filler. These often-overlooked portions of the book are invaluable resources.
Brad Ericson, MPC, CPC, COSC, is AAPC director of publishing.
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