Using the CPT alphabetic index and tabular list
Using the alphabetic index
Procedural coding starts with identifying the main term and then locating it in the alphabetic index. Although the alphabetic index is a comprehensive, alphabetic listing of all main terms, there are no code descriptions next to each entry.
The alphabetic index is used as a guide to search for one or more codes or code ranges. The index is similar to that found in the back of any textbook; it is an alphabetic list of main and modifying terms found in the tabular list of the coding manual. In a typical index, the term or concept listed in the index is followed by the page numbers on which detailed information is presented in the body of the book. The alphabetic index in the CPT coding manual is used in the same way, except that it provides codes or code ranges rather than page numbers. As discussed earlier, the tabular list is divided into sections, and the procedures and services are listed in numeric order by the Category I code.
The alphabetic index is organized by main terms and modifying terms that are indented below the main term. Modifying terms further describe and add information needed to narrow the search for an appropriate procedure or service code. A main term can be a procedure, such as an excision. Each modifying term could provide further information:
- Anatomic location
- Organ excised
- Type of instrument used
- Special technique
- Other procedures performed at the same time (e.g., obtaining biopsy tissue for examination)
Modifying terms affect the selection of appropriate codes; therefore, it is important to review the list of modifying terms when selecting a code or code range.
Searching the alphabetic index
Begin the search of the alphabetic index by using one of the four primary classifications (or types) of main and modifying terms:
- Procedure or service (e.g., examination, excision, scope, revision, repair, drainage)
- Organ or anatomic site (e.g., clavicle, mandible, humerus, liver, colon, uterus)
- Condition, illness, or injury (e.g., cholelithiasis, ulcer, fracture, pregnancy, fever)
- Eponym, synonym, abbreviation, or acronym (e.g., Naffziger operation, MRI [magnetic resonance imaging], TURP [transurethral resection of the prostate])
Sometimes searching for a main term may not yield any results. When a main term cannot be found, search by another primary classification in the alphabetic index. Let’s search the following procedural statement: Removal of Skin Tags on Neck. Begin by identifying the main terms that closely match the four primary classifications in the alphabetic index:
- Procedure or service: Removal
- Organ or anatomic site: Neck skin
- Condition, illness, or injury: Skin tag
- Eponym: None in this case
Once all possible main terms have been abstracted, the coder can quickly search through the alphabetic index for the code or code range that matches the procedural statement.
Using see and see also in the alphabetic index
The see statement in the alphabetic index points to another location in the alphabetic index to find the code or code range. The see also statement points to additional codes or code ranges in the alphabetic index that may be useful to the code found in the original search.
Single codes and code ranges
In the alphabetic index, a procedure or service may list a single code or a range of possible codes that may match the documentation. Remember that the alphabetic index is an index; it is designed as a guide to the most suitable codes that match the documentation. At this point, the search is only for the closest match or matches to the procedural statement.
Some medical procedures and diagnostic tests can be quite complex. There may be a single code or a code range that may include one main term but has several modifying terms for the main term. For example, the code for Acromioplasty has a range of codes: 23415-23420. The same main term, Acromioplasty, with a modifying term, partial, has a single code: 23130. The code range is shown with a hyphen to indicate that all codes within that range could be appropriate.
In some cases, a single code and a range of codes are listed for the same service or procedure. For example, Craterization, femur, lists both the single code 27360 and the code range 27070-27071. Once a single code or code range has been found in the alphabetic index, the next step is to look up each of those in the tabular list. Select the code or codes that most closely match the documentation.
Steps for using the CPT alphabetic index
- Abstract the procedural statement from the medical documentation, and determine the main or modifying terms.
- Select the most appropriate main term to begin searching in the Alphabetic Index.
- Once the main term has been located, select one or more modifying terms, if needed, to narrow the search.
- If no main or modifying term produces an appropriate code or code range, repeat steps 2 and 3 using a different main term.
- Find the code or code ranges that include all or most of the description of the procedure or service found in the medical record.
Using the tabular list
Once the code or code ranges have been selected from the alphabetic index, the next stop is the tabular list. This is where the procedural coding decision takes place. In the tabular list, the conventions, symbols, guidelines, notes, and even the punctuation all play a part in choosing the most accurate code possible.
In the tabular list, look up each code or code range found numerically in the alphabetic index. Read the description of each code thoroughly to ensure that the main terms abstracted from the procedural statement in the medical documentation are all included in the code description, with nothing substantial omitted or added. Read the section guidelines and notes to determine whether additional codes should be used, add-on codes or modifiers are required, or use of the code is contraindicated.
Use of the semicolon
A semicolon (;) at the end of a main description indicates that modifying terms and descriptions follow. Every indented description below a stand-alone code is related to that stand-alone code. To get the full description for an indented code, you use the description of the stand-alone code up to the semicolon and then include the description of the indented code. Let’s look at excision of the spleen as an example. In the CPT manual you will see the following entry:
The description for code 38100 is a splenectomy, total. The description for code 38101 is splenectomy, partial. The description for code 38102 is splenectomy, total, en bloc for extensive disease, in conjunction with other procedure. If you were to use 38102, you would also have to have the code for the other procedure. You could not use just 38102.
Steps for using the CPT tabular list
Except for the special considerations required for coding from the E/M and Anesthesia sections, the following steps apply to all sections of the CPT manual:
- Look up the code or code range from the alphabetic index. Search in the tabular list numerically.
- Compare the description of the code with the procedural statement from the documentation. Verify that all or most of the health record documentation matches the code description and that there is no additional element or information in the code description that is not found in the documentation.
- Read the guidelines and notes for the section, subsection, and code to ensure that there are no contraindications to the use of the code.
- Evaluate the conventions, especially add-on codes (+) and exemption from modifier -51.
- Determine whether any special circumstances require the use of a modifier or whether a special report is required.
- Record the CPT code selected in the health record documentation next to the procedure or service performed and in the appropriate block of the insurance claim form.