Procedural coding introduction

The CPT manual

Procedural coding changes the written descriptions of procedures and services delivered in a healthcare facility into numeric or alphanumeric codes. These codes are used for a variety of purposes. They can be used to track the services that are being provided to patients and on claims sent for payment from insurance companies. There are three procedure code sets used for these purposes:

• International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
• Current Procedural Terminology (CPT)
• Healthcare Common Procedure Coding System (HCPCS)

Medical assistants most often work in an outpatient setting. This chapter focuses on the CPT and HCPCS code sets. Because ICD-10-PCS is used for inpatient coding, and medical assistants most often work in an outpatient setting, we will not review ICD-10-PCS coding in this chapter. The medical biller is responsible for maintaining accurate medical records and for processing insurance claims. This can be done efficiently by using the CPT and HCPCS codes. These codes identify procedures and services commonly used in an outpatient healthcare facility.

The Current Procedural Terminology (CPT) system was developed and is maintained by the American Medical Association (AMA). It is updated each year and released on October 1 to become effective on January 1. The CPT coding manual consists of descriptive terms and identifying codes for reporting professional and technical services. CPT codes convert written descriptions of procedures and services into numeric codes. They establish a standard system that accurately describes medical and surgical services.

Code categories in the CPT manual

There are three different categories of codes in the CPT. Category I codes are used most frequently and are required for insurance claim submission. Category II and Category III codes are used for data collection.

Category I codes

Category I codes are in the Tabular List of the CPT manual and arranged by sections. For example, codes beginning with 7 (e.g., 70100—radiologic examination of the mandible, partial, with less than four views) are in the Radiology section of the manual. Each code has a description of the service or procedure performed. These are five-digit numeric codes.

Category II codes

Category II codes are a set of supplemental tracking codes that healthcare facilities use for performance measurement. Category II codes are optional. They cannot be used as a substitute for Category I codes, and they are not used as part of the insurance billing process. When these codes are used, it can reduce the need for abstracting information from the health record. These codes describe clinical components that may be typically included in Evaluation and Management services, or clinical services. In a Category II code, the fifth digit is the letter F. If a patient was seen by the provider for asthma, a Category I code of 99213 could be used for the visit. In addition, a Category II code of 2015F Asthma impairment assessed (Asthma) could be used.

Category II codes are described and listed in their own section, which is located after the Medicine section and before the appendices. Category II codes are reviewed by the Performance Measures Advisory Group. This group is composed of members from various medical organizations and government agencies.

Category III codes

Category III codes are temporary codes used for emerging and new technology, services, and procedures that have not been officially added to the Tabular List. The fifth digit in a Category III code is the letter T. Category III codes may be used in billing and reporting under the following conditions:

• No code in the Tabular List correctly describes the technology, service, or procedure performed.
• No Category I code matches the documentation.

In most publishers’ editions of the CPT manual, Category III codes are also listed in their own section, after the Medicine section and before the appendices.

Format of the CPT coding manual

• Comprehensive instructions for using the manual, including the steps for coding
• Tabular List, which includes the following six sections:
• Evaluation and Management
• Anesthesia
• Surgery
• Radiology
• Pathology and Laboratory
• Medicine
• Coding Guidelines, Conventions, and Notes
• Appendices (16; A–P)
• The Alphabetic Index

Organization of the CPT manual

The CPT coding manual is separated into the Alphabetic Index and the Tabular List. These will be discussed in the following sections.

The alphabetic Index

CPT coding starts with the Alphabetic Index. It is found in the back of the CPT manual and is an alphabetic listing of main terms. These terms represent the type of surgery, the anatomic site, or eponym. Much like the Alphabetic Index in the ICD-10-CM manual, the Alphabetic Index in the CPT gives a code, codes, or a code range that must be verified in the Tabular List of the CPT manual.

The tabular list

The Tabular List is divided into six sections, with codes listed in numeric order in each section. As in the ICD-10-CM, the codes in the Tabular List include definitions, guidelines, and notes. These enable the coder to select the most specific code based on the procedural statement and service descriptions documented in the health record. The six sections of the Tabular List and their CPT code ranges are as follows:

• Evaluation and Management (99201–99499)
• Anesthesia (00100–01999, 99100–99140)
• Surgery (10021–69990)
• Radiology, including nuclear medicine and diagnostic ultrasound (70010–79999)
• Pathology and Laboratory (80047–89398)
• Medicine (90281–99199, 99500–99607)

Sections are subdivided into subsections, subsections are subdivided into subheadings, and subheadings can be subdivided into categories. Each level of a section provides more specificity about the procedure or service performed and the anatomic site or organ system involved. Each section and subsection provides coding guidelines and, if needed, a reference to the CPT Assistant. In most instances, all four levels are found, although this is not a hard-and-fast rule.

In the CPT manual, the subsection is listed below the section and indented. The subsection usually describes an anatomic site or an organ system, as in the following examples:

• Anatomic site: Heart, femur, or skull
• Organ system: Digestive, integumentary, or cardiovascular

A subheading is listed below the subsection; it generally refers to a specific procedure or service, but it can also indicate a more specific anatomic site:

• Procedures: Esophagoscopy, incision and drainage, or cardiac catheterization
• Specific anatomic site: Mitral valve, distal femur, or occipital bone

Category is the lowest level of code description.

Format of tabular list

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