Medical Terminology & Anatomy (1-20)

 Prefix "hyper-": Excessive, above, or increased. Example: Hyperglycemia (high blood sugar).
Clinical Context: Often indicates a pathological state requiring intervention.
 Prefix "hypo-": Deficient, below, or decreased. Example: Hypothyroidism (low thyroid hormone).
Clinical Context: Can lead to various symptoms depending on the deficiency.
 Prefix "brady-": Slow. Example: Bradycardia (slow heart rate). Clinical Context: Can be benign in
athletes but may also indicate a cardiac conduction problem.
 Prefix "tachy-": Fast. Example: Tachycardia (fast heart rate). Clinical Context: Can be a normal
response to exercise or stress but may also be a sign of a cardiac arrhythmia.
 Suffix "-itis": Inflammation. Example: Dermatitis (skin inflammation). Clinical Context: Often
characterized by redness, swelling, heat, and pain.
 Suffix "-ectomy": Surgical removal. Example: Hysterectomy (removal of the uterus). Clinical
Context: A common surgical procedure for various conditions.
 Suffix "-ostomy": Creation of an opening. Example: Ileostomy (creating an opening in the ileum).
Clinical Context: Often done to divert stool or urine.
 Root "cardi/o": Heart. Example: Cardiology (study of the heart). Clinical Context: Essential for
understanding cardiovascular conditions and procedures.
 Root "gastr/o": Stomach. Example: Gastritis (inflammation of the stomach lining). Clinical
Context: Relates to digestive system disorders.
 Root "hepat/o": Liver. Example: Hepatomegaly (enlarged liver). Clinical Context: Important for
understanding liver diseases.
 Root "nephr/o" or "ren/o": Kidney. Example: Nephrectomy (removal of a kidney). Clinical
Context: Key for understanding renal function and diseases.
 Root "arthr/o": Joints. Example: Arthritis (joint inflammation). Clinical Context: A common cause of
pain and disability.
 Root "oste/o": Bone. Example: Osteomyelitis (bone infection). Clinical Context: Essential for
understanding fractures and bone diseases.
 Directional Term: "proximal": Nearer to the point of attachment or trunk. Example: The proximal
end of the femur. Clinical Context: Important for describing anatomical location.
 Directional Term: "distal": Farther from the point of attachment or trunk. Example: The distal end
of the tibia. Clinical Context: Used in conjunction with proximal for accurate anatomical description.
 Plane: "sagittal": Divides the body into left and right sections. Clinical Context: Useful for
understanding anatomical relationships.
 Plane: "transverse": Divides the body into upper (superior) and lower (inferior) sections. Clinical
Context: Also called the horizontal plane.
 Musculoskeletal: "fracture types": Examples:
o Comminuted: Bone is broken into multiple fragments.
o Greenstick: Incomplete fracture, common in children.
o Compound (open): Fracture with a break in the skin.
o Clinical Context: Accurate identification of fracture type is essential for ICD-10-CM coding.
 Cardiovascular: "arrhythmia": Irregular heartbeat. Examples:
o Atrial fibrillation: Rapid, irregular contractions of the atria.
o Ventricular tachycardia: Rapid, regular contractions of the ventricles.
o Clinical Context: Can be asymptomatic or life-threatening.
 Respiratory: "COPD": Chronic obstructive pulmonary disease. Encompasses:
o Emphysema: Destruction of alveoli.
o Chronic bronchitis: Inflammation of the bronchi.
o Clinical Context: A major cause of morbidity and mortality.
 ICD-10-CM Coding (21-40)
 ICD-10-CM Official Guidelines: These are your bible! Thoroughly understand the conventions
(NEC, NOS, Excludes1/2), general coding rules, and chapter-specific guidelines. They are
essential for accurate coding.
 Laterality: Laterality is critical. Many codes specify right (1), left (2), or bilateral (3). Avoid using
unspecified codes if laterality is documented. This is a common exam pitfall.
 Excludes1 Note: "NOT coded here." These conditions are mutually exclusive and should
never be coded together if they occur in the same patient at the same time. Example:
Cellulitis and abscess of the same site.
 Excludes2 Note: "NOT included here." These conditions are distinct, and both codes may
be used if the patient has both conditions. Example: Acute sinusitis and chronic sinusitis.
 Combination Code: A single code that represents two diagnoses or a diagnosis with a
manifestation. Example: E11.51 (Type 2 diabetes with diabetic peripheral angiopathy with
gangrene). Using combination codes simplifies coding and improves data accuracy.
 "Code Also" Instruction: Indicates that another code may be required to fully describe the
condition. Example: A code for a fracture might instruct to "code also" any associated open
wound.
 Seventh Character for Injuries: Crucial for accurate injury coding.
o A: Initial encounter
o D: Subsequent encounter
o S: Sequela (late effect)
 Example: A fracture code with a 7th character of "A" indicates the patient is being seen for the
initial treatment of the fracture.
 Neoplasm Table: Organized by site and behavior. Accurate classification of neoplasms
(malignant, benign, in situ, uncertain behavior) is essential.
 Diabetes Categories (E08-E13): These categories classify different types of diabetes. Each
category has combination codes for common complications. Accurate coding of diabetes
requires careful attention to the type of diabetes and any associated complications.
 Hypertension (I10): "Essential" or "primary" hypertension is coded I10 unless there is documented
heart or kidney involvement. In such cases, combination codes are used.
 Acute vs. Chronic: Many codes differentiate between acute (sudden onset, short duration)
and chronic (long-standing) conditions. Accurate differentiation is essential for code
selection.
 Obstetric Codes (O00-O9A): Obstetric coding requires identification of the trimester and any
complications.
 Poisoning vs. Adverse Effect: A poisoning is due to the wrong substance, the wrong dose, or
both. An adverse effect is a harmful reaction to the correct substance taken at the correct dose.
This distinction is critical for code selection.
 External Cause Codes (V00-Y99): These codes describe the circumstances of an injury. They
are used in addition to the injury code itself. Examples: Fall from ladder, motor vehicle accident,
assault.
 "Use Additional Code": Similar to "code also," this instruction indicates that another code is
required to fully describe the condition. Example: Sepsis with a documented organism requires
an additional code to identify the specific organism.
 Unspecified (NOS) Codes: Use only when no more specific information is available in the
medical record. Strive for the highest level of specificity possible.
 Z-Codes (Z00-Z99): These codes cover a wide range of situations, including status codes,
screenings, aftercare, and other factors influencing health status. They are not used for acute
diagnoses.
 Initial vs. Subsequent Encounter (Injuries): Essential for accurate injury coding.
 Initial: The patient's first visit for treatment of the injury.
 Subsequent: A follow-up visit for routine healing of the injury.
 "Code First" / "Code Underlying Condition": These instructions indicate that the underlying
condition should be sequenced before the manifestation. Example: If a patient has pneumonia
due to influenza, influenza is coded first.
 ICD-10-CM Alphabetic Index: Always begin your code search in the Alphabetic Index. Then,
verify the code in the Tabular List to ensure accuracy and completeness.

Evaluation & Management (E/M) (41-60)

 E/M Key Components (pre-2023): You correctly identify the three key components: History,
Examination, and Medical Decision Making (MDM). While these are still relevant for some E/M
services (e.g., Preventive Medicine), the 2023 guidelines significantly changed how most E/M
codes are selected.
 2023 E/M Guidelines: For most office/outpatient and hospital-based E/M services, code
selection is now based on MDM or total time spent on the date of the encounter. This is a
major shift.
 Medical Decision Making (MDM) Levels: MDM complexity is the primary factor for code
selection in most E/M encounters. The four levels are:
o Straightforward
o Low Complexity
o Moderate Complexity
o High Complexity
o MDM is assessed based on:
o Number and complexity of problems addressed
o Amount and complexity of data reviewed
o Risk of complications and/or morbidity or mortality
 Time-Based E/M: Time can be used instead of MDM to select the appropriate E/M code. The
time must be the total time spent by the physician or other qualified healthcare professional
(QHP) on the date of the encounter. This includes all time spent related to the patient's care,
even if not face-to-face. Accurate documentation of time is essential.
 Office/Outpatient E/M Codes (99202-99215): These are the most commonly used E/M codes.
Since 2021, code selection is based on MDM or time. Know the specific requirements for each
level.
 Hospital Inpatient/Observation E/M (99221-99239): Also MDM or time-based. Distinguish
between initial hospital care, subsequent hospital care, and discharge services.
Observation care is now billed using the inpatient codes.
 Emergency Department E/M (99281-99285): No distinction between new and established
patients in the ED. Typically MDM-based.
 Consultations (99242-99255): Check payer policies carefully. Medicare often disallows
consultation codes and requires them to be billed as E/M services.
 Critical Care (99291, +99292): Time-based. The time must be spent actively involved in the
patient's critical care. Can be continuous or aggregated.
 Preventive Medicine Services (99381-99397): Age-based and new/established patient status.
These codes are not MDM or time-based in the same way as other E/M services.
 Observation Care: As of 2023, observation care is billed using the inpatient E/M codes
(99221-99239). The separate observation codes (99218-99226) are no longer used.
 Nursing Facility Services (99304-99310): Also MDM or time-based. Distinguish between
initial and subsequent nursing facility care.
 Home/Residence E/M (99341-99350): MDM or time-based.
 Counseling & Coordination: While counseling is a component of MDM, the "greater than
50%" rule for time-based coding is no longer applicable with the 2023 guidelines.
 Split/Shared Visits: Rules for split/shared visits are complex and can change. Stay up-to-date
with the current CMS guidelines.
 Prolonged Services (99354-99357, 99415-99417): Add-on codes for time beyond the typical
E/M service. Medicare may use G2212 instead. These codes require meticulous documentation.
 Non-Face-to-Face Prolonged Services (99358-99359): For prolonged services outside of a face-
to-face encounter.
 Telehealth E/M (99201-99499): E/M codes can be used for telehealth services. Pay attention
to specific payer guidelines regarding modifiers, place of service codes, and eligible
services.
 Modifier -25: Significant, separately identifiable E/M service on the same day as a minor
procedure. The E/M service must be above and beyond the usual pre- and post-service care
for the procedure. Proper documentation is essential.
 Modifier -24: Unrelated E/M visit during the postoperative global period of another
procedure. The E/M service must be truly unrelated to the original procedure.
Documentation must clearly support the reason for the visit.

Anesthesia (61-80)
 Anesthesia Code Range (00100-01999): You correctly identify the range. These codes are
organized by anatomic site and procedure.
 Base Units: Each anesthesia code has a base unit value assigned by the American Society
of Anesthesiologists (ASA). These units reflect the complexity of the anesthesia service.
 Time Units: Anesthesia time is typically reported in 15-minute increments, though some
payers use actual minutes. Total anesthesia time is defined as the time from the start of
anesthesia care to the time the patient is safely placed under postoperative supervision.
 Physical Status Modifiers (P1-P6): *These modifiers reflect the patient's overall health status and
significantly impact payment. Know these definitions cold for the CPC exam.
o P1: A normal healthy patient.
o P2: A patient with mild systemic disease.
o P3: A patient with severe systemic disease.
o P4: A patient with severe systemic disease that is a constant threat to life.
o P5: A moribund patient 1 not expected to survive without the operation.
o P6: A declared brain-dead patient whose organs are being harvested for transplant.
 Anesthesia Modifiers: These modifiers describe the provider's role in the anesthesia
service.
o AA: Anesthesia services personally performed by the anesthesiologist.
o QK: Medical direction of 2-4 concurrent anesthesia procedures.
o QX: CRNA (Certified Registered Nurse Anesthetist) service with medical direction by a
physician.
o QZ: CRNA service without medical direction by a physician.
 Monitored Anesthesia Care (MAC): MAC involves the administration of sedatives or
analgesics to render a patient anxious or uncomfortable during a procedure. It can be billed
 with specific MAC codes or converted to general anesthesia if necessary. Medicare often uses G8,
G9 modifiers for MAC.
 Cardiac Anesthesia: Cardiac anesthesia procedures (e.g., CABG, valve surgery) typically have
higher base unit values due to their complexity. Transesophageal echocardiography (TEE)
may require additional codes.
 Obstetric Anesthesia (01960-01969): These codes cover anesthesia for labor analgesia and
Cesarean delivery. Time-based reporting is used.
 Anesthesia Time Calculation: Accurate documentation of anesthesia time is essential.
Document start and stop times clearly. Breaks or multiple providers complicate billing and
require careful documentation of each segment of time.
 Local/Topical Anesthesia: Local or topical anesthesia administered by the surgeon is
typically included in the surgical procedure's global package and is not separately coded as
anesthesia.
 Physical Status Payment: Payers often add additional units for higher physical status
modifiers (P3-P5). The specific number of additional units varies by payer contract.
 Epidural vs. Spinal Anesthesia: These are different types of anesthesia and have distinct code
sets. Pay close attention to the code descriptors to select the correct code.
 Field Block: *A field block performed by the surgeon is usually included in the surgical procedure.
It is not separately coded as anesthesia. However, if the field block is performed by the
anesthesia provider, it may be separately coded.
 Modifier -23 (Unusual Anesthesia): This modifier is used rarely when anesthesia is provided
for a procedure that typically does not require anesthesia due to unusual circumstances.
 Multiple Procedures: Anesthesia for multiple concurrent procedures is typically coded
using the highest base unit value procedure, plus time units for all procedures. Do not code
anesthesia separately for each procedure.
 CRNA Billing: *Payment rules for CRNA services (QX or QZ modifiers) are complex and vary
by payer. Understand the rules for shared medical direction and payment splits.
 Calculating Anesthesia Payment: (Base Units + Time Units + Modifying Units) x Conversion
Factor = Payment. Modifying units may be added for physical status or qualifying
circumstances. The conversion factor is determined by the payer.
 Qualifying Circumstances (99100-99140): These are add-on codes used to report specific
situations that increase the complexity of the anesthesia service. Examples: Extreme age (<1
or >70), total body hypothermia.
 Emergency Anesthesia (Modifier -EM or 99140): Anesthesia complicated by emergency
conditions can be reported with modifier -EM or code 99140. The emergency nature of the
service must be documented.
 Anesthesia Crosswalk: Anesthesia crosswalks (often provided by the ASA or other
resources) can be helpful for identifying appropriate anesthesia codes based on the
surgical CPT code. However, always verify the code in the CPT manual.
 Key Takeaways for Anesthesia Coding:
o Base Units are Key: Understand how base units are assigned.
o Time is Essential: Accurate documentation of anesthesia time is crucial.
o Physical Status Modifiers Impact Payment: Know the definitions of P1-P6.
o Provider Modifiers Matter: Use the correct modifier to reflect the provider's role (AA,
QK, QX, QZ).
o Know the Rules for MAC, Cardiac, and Obstetric Anesthesia: These areas have
specific coding rules.
o Understand How to Calculate Anesthesia Payment: Be familiar with the formula and
the components involved.
 o Documentation is Paramount: Thorough and accurate documentation is essential
for all anesthesia services.

Surgery (81-100)
81. Global Surgical Package: This is a critical concept. The global surgical package includes all
services related to the surgical procedure, typically encompassing:

 Preoperative visits (within a defined period)

 Intraoperative services (the procedure itself)
 Routine postoperative care (for a specified period: 0, 10, or 90 days, depending on
the procedure)
 Understanding what's included in the global package is essential to avoid
unbundling and overbilling.

82. Surgery Sections (10000-69990): You correctly list the major surgical sections. Familiarity with
the organization of these sections is crucial for efficient code lookup.
83. Separate Procedure: This designation indicates that a procedure is usually included in a
more extensive procedure performed at the same session. It can be billed separately only if
it is performed independently or for a distinctly separate reason.
84. Integumentary Codes: This section covers a wide range of procedures, from simple I&Ds to
complex skin grafts.
85. Lesion Excision Measurements: Accurate measurement of the lesion plus the margins is
essential. The size and nature (benign vs. malignant) of the lesion determine the
appropriate code.
86. Wound Repairs: Classification of wound repairs (simple, intermediate, complex) is based on
the depth of the wound and the type of closure. Layered closures are a key indicator of
complexity.
87. Fracture Treatment: *Fracture treatment codes are classified based on the type of fracture
(e.g., closed, open), the method of treatment (e.g., manipulation, reduction), and the use of
internal fixation (ORIF). Pay close attention to these details in the documentation.
88. Arthroscopy: If a diagnostic arthroscopy is performed followed by a surgical arthroscopy in
the same joint, the diagnostic arthroscopy is included in the surgical code and is not billed
separately.
89. Cardiovascular Bypass Grafts: CABG codes are differentiated based on the type of grafts
used (vein only vs. vein and artery) and the number of grafts.
90. Pacemaker Insertion: Pacemaker codes distinguish between single and dual chamber devices,
initial insertion, replacement, and upgrade procedures.
91. Digestive Endoscopies: Endoscopy codes are very specific about the procedures performed
(e.g., biopsy, polypectomy, fulguration). Careful review of the operative report is essential.
92. Hernia Repairs: Hernia repair codes are classified by type (inguinal, femoral, umbilical, incisional),
approach (open vs. laparoscopic), and status (initial vs. recurrent).
93. Cholecystectomy: Cholecystectomy codes differentiate between laparoscopic and open
approaches, and whether cholangiography is performed.
94. Urinary Cystoscopy: Cystoscopy codes include a range of procedures, from simple diagnostic
cystoscopy to more complex procedures such as biopsy, stent placement, and lithotripsy.
95. Female Genital: Hysterectomy codes are classified by approach (abdominal, vaginal,
laparoscopic) and the extent of the procedure (e.g., with or without removal of tubes and ovaries).
96. Obstetric Codes: This section covers a wide range of obstetric services, including antepartum
care, deliveries, postpartum care, and high-risk procedures such as cerclage and version.
97. Nervous System: Spinal procedure codes (laminectomy, discectomy, spinal fusion) may or may
not include instrumentation. Instrumentation codes (22840-22849) are often bundled but can be
billed separately in certain circumstances.
98. Eye Surgery: Cataract extraction codes differentiate between procedures with and without
intraocular lens (IOL) insertion.
99. Ear Procedures: Ear procedure codes distinguish between procedures such as myringotomy,
tympanostomy tube insertion, and mastoidectomy.
100. Surgical Modifiers: These are essential for accurate surgical coding.

 -50: Bilateral procedure

 -51: Multiple procedures
 -58: Staged or related procedure or service by the same physician during the
postoperative period
 -59: Distinct procedural service
 -79: Unrelated procedure or service by the same physician during the postoperative
period

Medicine (141-160)
141. Medicine Section Range (90000-99999): This section covers a diverse range of services,
from immunizations and dialysis to cardiology tests and psychiatric services.
142. Immunization Admin Codes (90460-90474): These codes cover the administration of
vaccines. They are differentiated by the route of administration (injection vs. oral/nasal) and
whether counseling is provided.
143. Vaccine Product Codes (907xx): These codes report the vaccine product itself. Both the
administration code and the product code are typically reported, unless the product is provided at
no cost (e.g., state-supplied vaccines).
144. Dialysis (90935-90947): These codes cover hemodialysis, peritoneal dialysis, and other
forms of dialysis. They are often billed on a per-session basis.
145. ESRD Monthly Services (90951-90970): These codes cover the comprehensive monthly
management of end-stage renal disease (ESRD) patients. They are age-based and tiered by the
number of visits during the month.
146. Cardiology: ECG (93000, 93005, 93010): These codes cover the global service (tracing
and interpretation), the tracing only, and the interpretation only of an ECG.
147. Cardiac Stress Tests (93015-93018): Similar to ECGs, stress test codes can be billed
globally or split among supervision, tracing, and interpretation components.
148. Echo Codes (93306, etc.): Echocardiography codes cover various types of
echocardiograms, including transthoracic (TTE), transesophageal (TEE), and stress
echocardiograms. Pay close attention to the specific type of echo performed.
149. Infusions & Injections (96360-96549): These codes cover the administration of infusions
and injections. They are classified by the type of substance infused (hydration, therapeutic,
chemotherapy) and the complexity of the infusion. It's important to distinguish between IV push
and infusion.
150. Injection Codes (96372, 96374): *These are specific injection codes. 96372 is for
therapeutic IM or subcutaneous injections. 96374 is for IV push injections. Always confirm the
route of administration and the specific drug administered.
151. Chemotherapy Administration (964xx): Chemotherapy administration codes are used
for the administration of chemotherapeutic agents. These codes are more complex than routine IV
infusions due to the nature of the drugs and the required monitoring.
152. Psychiatry (90791, 90832-90837): Psychiatry codes cover a range of services, including
diagnostic evaluation and psychotherapy. Psychotherapy codes are time-based.
153. Allergy Testing (95004, 95024): Allergy testing codes are billed per allergen tested.
Percutaneous and intradermal tests have separate code ranges.
154. Physical Therapy (97110, 97112, etc.): Physical therapy codes are time-based, typically
billed in 15-minute increments. Different codes are used for different types of therapeutic exercises
and activities.
155. Chiropractic Manipulation (98940-98943): These codes are based on the number of
regions manipulated.
156. ESI or Nerve Blocks: Epidural steroid injections (ESI) and nerve blocks can be found in
both the Surgery and Medicine sections. Carefully check the code descriptions to select the correct
code.
157. Holter Monitor (93224): This code covers the global service for Holter monitoring
(application, scanning, and interpretation). Separate codes may be used for the technical and
professional components if necessary.
158. Immunization Modifiers: Some payers, especially for state-supplied vaccines, may
require specific modifiers (e.g., -SL) in addition to the administration and product codes. Always
check local payer policies.
159. Remote Monitoring: Remote patient monitoring (RPM) codes are used for the remote
monitoring of physiologic parameters. Payer coverage for these services can vary significantly.
160. Tobacco Cessation Counseling (99406-99407): These codes are used for intermediate
and intensive tobacco cessation counseling sessions.

HCPCS Level II (161-180)

161. HCPCS Code Structure: You correctly describe the alphanumeric structure. Emphasize
that these codes are separate and distinct from CPT codes.
162. Common HCPCS Sections: It's crucial to be familiar with the types of items and services
covered in each section.
163. Ambulance Services: Accurate use of origin and destination modifiers is essential for
ambulance claims. These modifiers specify the type of facility where the patient was picked up and
transported to.
164. Durable Medical Equipment (DME): DME must be medically necessary, prescribed by a
physician, and meet specific criteria for coverage.
165. Modifiers: NU, RR, UE: These modifiers are crucial for DME billing. They indicate
whether the equipment is new, rented, or used.
166. Orthotics & Prosthetics: These codes require detailed documentation of the patient's
condition, measurements, and fitting. Laterality (LT/RT) is often required.
167. Drugs (J codes): Accurate dosage calculation is essential for J codes. The billed units
must match the administered dosage. Pay close attention to the units specified in the code
descriptor (e.g., per mg, per unit).
168. Enteral/Parenteral Nutrition (B codes): Coverage for enteral and parenteral nutrition
depends on strict medical necessity criteria.
169. Medical Supplies: These codes cover a wide range of supplies. Pay close attention to the
units of measure (e.g., per each, per dozen, per 50).
170. Unlisted / Misc Codes: Use of unlisted codes requires detailed documentation to explain
the item or service being provided. This documentation is essential for obtaining payment.
171. Modifiers -GA, -GY, -GZ: These modifiers are specific to Medicare and relate to Advance
Beneficiary Notices (ABNs).

 -GA: ABN on file.

 -GY: Item or service is statutorily excluded from Medicare.
 -GZ: No ABN was obtained, and the provider expects a denial.

172. LT/RT: These modifiers are used to indicate the left or right side of the body for certain
DME items.
173. KX Modifier: This modifier is used to indicate that the requirements specified in a medical
policy have been met. It is often required for certain DME items and therapy services.
174. Ambulatory Aids: These items (canes, walkers, etc.) are coded in the E0xxx range.
175. Ostomy Supplies: These supplies are coded in the A4xxx range. There are often monthly
quantity limits for these supplies.
176. Glucose Monitoring: These supplies (test strips, lancets) are billed per quantity. Payer
coverage often includes monthly limits unless there is documented medical necessity for additional
supplies.
177. Compression Stockings: Medical necessity for compression stockings must be
documented (e.g., edema, venous stasis).
178. Diabetic Shoes: Coverage for diabetic shoes requires specific documentation of diabetic
foot conditions.
179. Temporary HCPCS (G, Q, S, T codes): These codes are used by Medicare and other
payers for temporary coverage of new technologies, services, or drugs. They are not permanent
codes.
180. HCPCS Annual Updates: It is essential to stay up-to-date with annual HCPCS code
updates. Using outdated codes can lead to claim denials.

Compliance & Modifiers/Payment (181-200)

181. Fraud vs. Abuse: Fraud involves intentional deception or misrepresentation to obtain
payment. Abuse involves unintentional or improper practices that may result in overpayment.
182. False Claims Act: This law prohibits knowingly submitting false claims to the government.
Violations can result in significant penalties, including treble damages.
183. Stark Law: This law prohibits physicians from referring patients to entities in which they
have a financial interest for designated health services.
184. Anti-Kickback Statute: This law makes it a criminal offense to offer or receive anything of
value in exchange for referrals of patients for services covered by federal health care programs.
185. HIPAA Privacy Rule: This rule protects the privacy of protected health information (PHI)
and limits its disclosure without patient authorization.
186. NCCI Edits: National Correct Coding Initiative (NCCI) edits prevent improper billing of
bundled services. Column 1/Column 2 edits identify services that should not be billed together.
Modifier -59 can be used to override some NCCI edits if the services are truly separate and
distinct.
187. Modifier -59 (Distinct Service): This modifier is used to indicate that a service is
separate and distinct from another service performed on the same day. It is often misused, so
proper documentation is essential.
 188. Modifier -52 (Reduced Services): This modifier is used when a procedure is partially
reduced at the physician's discretion.
189. Modifier -53 (Discontinued Procedure): This modifier is used when a procedure is
discontinued due to extenuating circumstances that threaten the patient's well-being.
190. Modifier -58 (Staged/Related Procedure): This modifier is used for a staged or
related procedure performed during the postoperative period of the initial procedure.
191. Modifier -78 (Unplanned Return to OR): This modifier is used when a patient returns
to the operating room during the postoperative period for a complication of the initial
procedure, and the same physician performs the reoperation.
192. Modifier -79 (Unrelated Procedure): This modifier is used when a patient undergoes
a separate and unrelated procedure during the postoperative period of another procedure.
193. Modifier -26 (Professional Component): This modifier is used to bill for the
professional component (interpretation) of a radiologic or pathologic procedure.
194. Modifier -TC (Technical Component): This modifier is used to bill for the technical
component (equipment, supplies) of a radiologic or pathologic procedure.
195. Global Period: The global period is the period of time following a surgical procedure
during which certain services are included in the global surgical package.
196. RBRVS & RVUs: The Resource-Based Relative Value Scale (RBRVS) is a system used
to determine physician payment. RVUs (Relative Value Units) are assigned to each CPT code and
reflect the work, practice expense, and malpractice associated with the service.
197. DRG (Diagnosis-Related Group): DRGs are used to classify inpatient hospital stays for
payment purposes. Patients with similar diagnoses and procedures are grouped together.
198. APC (Ambulatory Payment Classification): APCs are used to classify outpatient
procedures for payment purposes.
199. Medical Necessity: Services must be medically necessary to be covered by payers. The
diagnosis code(s) must support the medical necessity of the service(s) provided.
200. Advance Beneficiary Notice (ABN): An ABN is a notice given to a Medicare beneficiary
before a service is provided if the provider believes that Medicare may not cover the service. The
ABN allows the beneficiary to make an informed decision about whether to receive the service and
accept financial responsibility for it if Medicare denies payment.

ICD-10-CM Notes

The purpose of ICD-10-CM is to report diagnoses

7th Character indicator
A-initial encounter
D-Subsequent encounter (Routine Healing)
S- Sequela (Late effect).
Laterality
Right-1
 Left -2
Bilateral-3
Unspecified

III. Official Coding Conventions & Guidelines

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a

complex system. Mastering it requires understanding not just the codes themselves, but also the rules and
conventions that govern their use. These conventions are crucial for ensuring accurate and consistent
coding.

1. Abbreviations
 NEC (Not Elsewhere Classifiable): This doesn't mean the condition is "not classifiable" at all. It
means the specific condition documented isn't explicitly listed in the code set. NEC is used when
the documentation provides more detail than any available code.
o It often points to a need for a more specific code, but one doesn't currently exist.
Example: A very rare genetic disorder with specific manifestations not explicitly listed.
You'd use NEC and then potentially a code for the specific manifestation.
 NOS (Not Otherwise Specified): This is used when the documentation is insufficient to assign a
more specific code. It represents a lack of detail. NOS should be used sparingly, as it reflects
incomplete documentation.
o Example: "Headache, NOS." This tells us very little about the headache. More detail (e.g.,
location, type, associated symptoms) is needed for a more specific code. Using NOS often
triggers requests for more documentation from the provider.

2. Punctuation & Symbols

 Square Brackets [ ]: These have two main uses:
o Tabular List: They enclose synonyms, alternative wordings, or explanations that don't
affect the code assignment.
 Example: "S52.531A Displaced fracture of distal end of radius, left arm [Colles'
fracture]"
o Alphabetic Index: They enclose manifestation codes that must be reported as
secondary codes. This is a key point.
 Example: In the index, under "Diabetes," you might see "retinopathy [H36.0-]" in
brackets. This means if the patient has diabetic retinopathy, you must code the
diabetes first, and then the retinopathy code (H36.0-).
 Parentheses ( ): These enclose supplementary terms or nonessential modifiers. These terms
may clarify the diagnosis but don't impact the code selection.
o Example: "Acute appendicitis (with perforation)" - The presence or absence of perforation
will affect the code, but "with perforation" itself is the supplementary term.
 Colon : Used in the Tabular List when a code description is incomplete and requires additional
terms (modifiers) to complete it.
o Example: "I25.1 Atherosclerotic heart disease of native coronary artery:" This code
requires further specification, such as the number of vessels involved.
 3. Instructional Notes
These notes are critical for proper code assignment.

 Includes: Defines the scope of a code or code range. It lists conditions that are classified within
that code.
o Example: A code for "Acute bronchitis" might include "with tracheitis" or "with laryngitis" in
the "includes" note.
 Excludes1: This is a hard exclusion. It means the two conditions listed cannot be coded
together. They are mutually exclusive.
o Example: A code for a specific type of fracture might have an Excludes1 note for a code
for the same fracture with open wound. You wouldn't code both.
 Excludes2: This is a softer exclusion. It means the excluded condition is not part of the
condition being coded. However, both conditions can be coded if they are both present in
the patient.
o Example: A code for a specific type of pneumonia might have an Excludes2 note for
influenza. The patient could have both pneumonia and influenza, and you would code both
separately.
 Use additional code: This note indicates that more than one code is required to fully
describe the patient's condition. The note will specify what additional code(s) are needed.
o Example: A code for a manifestation of a disease often requires a code for the underlying
disease as well.
 Code first: This note tells you the order in which to sequence multiple codes. It specifies
which code should be listed first. This is particularly important for conditions with
manifestations or underlying causes.

4. “And” vs. “With”

 “And”: In a code description, "and" usually means "and/or." It doesn't necessarily mean
both conditions must be present.
 “With” or “In”: These terms indicate a relationship between two conditions. They imply a
causal relationship or that the second condition is a complication of the first.
o Example: "Diabetes with retinopathy" implies the retinopathy is due to the diabetes. The
documentation must support this link to use a "with" code.

5. Combination Codes

These are single codes that represent two diagnoses, a diagnosis with an associated manifestation,
or a diagnosis with a complication. They simplify coding and reduce the number of codes needed.

Example: E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene. This
single code captures the diabetes, the peripheral angiopathy, and the gangrene.

Steps to Accurate ICD-10-CM Coding

Accurate ICD-10-CM coding is a multi-step process that requires careful attention to detail and a thorough
understanding of the coding guidelines. Rushing through the steps can lead to errors, which can have
significant consequences for billing, reimbursement, and data analysis.

1. Identify the Main Term in the Alphabetic Index (Volume 2)

 Start with the Condition: Begin by identifying the main term that best describes the patient's
condition or diagnosis as documented by the provider. This is often the noun form of the disease or
condition.
o Examples: "Diabetes," "Pneumonia," "Fracture," "Arthritis."
 Look for Eponyms: Some conditions are known by eponyms (names of people). If you can't find
the condition under its common name, try looking under the eponym.
o Example: "Hodgkin's disease" might be found under "Hodgkin" or "Disease, Hodgkin."
 Consider Synonyms: Be aware of synonyms for the condition.
o Example: "High blood pressure" might be found under "Hypertension."
 External Causes and Complications: If the condition is due to an external cause (e.g., an
accident) or is a complication of a procedure or another condition, you'll need to look under
the appropriate main term for the cause or complication, not the resulting condition itself.
o Examples: "Fall" (for a fracture due to a fall), "Infection" (for a post-operative infection).
 Avoid Starting with Anatomic Sites: While the location of a condition is important, it's usually
better to start with the condition itself as the main term. Example: Instead of looking up "Knee,"
look up "Osteoarthritis" and then look for the subterm "knee."

2. Review Subterms (Indented) under the Main Term

 Specificity is Key: Once you've found the main term, carefully review the indented subterms.
These subterms provide greater detail about the condition, such as:
o Acute/Chronic: The duration of the condition.
o Location/Laterality: The specific site affected (e.g., "left knee," "upper lobe of lung").
o Type/Nature: The specific type of the condition (e.g., "type 1 diabetes," "bacterial
pneumonia").
o Etiology: The cause of the condition (e.g., "drug-induced," "post-traumatic").
o With/Without: Presence or absence of associated conditions or complications.
 Select the Most Specific Subterm: Choose the sub term that most accurately reflects the
patient's condition as documented in the medical record.

3. Verify the Code in the Tabular List (Volume 1)

 Don't Skip This Step! Never code directly from the Alphabetic Index. The Index is just a guide.
You must verify the code in the Tabular List.
 Check for Notes and Instructions: The Tabular List contains essential notes and instructions that
may affect code assignment. Pay close attention to:
o Includes/Excludes1/Excludes2 notes: As discussed previously, these notes provide
critical information about code usage.
o Code first/Use additional code notes: These notes dictate sequencing when multiple
codes are required.
 Ensure Code Validity: Confirm that the code is valid and has not been deleted or replaced.
 Expand to the Highest Specificity: ICD-10-CM codes can range from 3 to 7 characters. Always
code to the highest level of specificity documented in the record. Use placeholder "X" if needed.
4. Check for Additional Guidelines

 7th Character/Placeholder X: Many ICD-10-CM codes require a 7th character to provide

additional information, such as the episode of care (initial, subsequent, sequelae) or the type of
fracture healing. Use placeholder "X" when you don't have the information needed for the 7th
character, but the code structure requires it.
 Mandatory Second Codes: Some codes require a second code to fully describe the condition.
o Examples: External cause codes for injuries, manifestation codes for underlying diseases.
 Chapter-Specific Guidelines: Be aware of any chapter-specific coding guidelines that may apply
to the condition you are coding.

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)

HIV Coding Guidelines: B20 vs. Z21

The distinction between confirmed HIV disease and asymptomatic HIV-positive status is paramount.

 B20 (Human immunodeficiency virus [HIV] disease): This code is used only when the patient
has a confirmed diagnosis of HIV disease. This means they have developed symptomatic HIV or
AIDS-related conditions.
o Examples include opportunistic infections (like Pneumocystis carinii pneumonia or Kaposi's
sarcoma), certain cancers, or a low CD4+ T-cell count meeting the criteria for AIDS. The
key here is that B20 signifies the presence of active disease or related conditions.
 Z21 (Asymptomatic human immunodeficiency virus [HIV] infection status): This code is used
when a patient has tested positive for HIV (meaning they are infected with the virus), but they are
asymptomatic and have not developed any AIDS-defining conditions or other HIV-related
illnesses. They are HIV-positive but not currently ill from the virus. This code is crucial for tracking
HIV prevalence and for managing patients who are HIV-positive but not yet showing symptoms.
 Important Considerations:
o A patient with a history of AIDS-related conditions who is now asymptomatic but on
antiretroviral therapy would still be coded with B20. Once a patient has been diagnosed
with HIV disease (B20), they retain this code even if their symptoms resolve with
treatment.
o If a patient is newly diagnosed with HIV and is asymptomatic, the correct code is Z21.
They would only be assigned B20 if and when they develop symptoms or conditions
related to HIV disease.
o It is crucial to review the provider's documentation carefully to determine whether the
patient has HIV infection (Z21) or HIV disease (B20).

Acute vs. Chronic Infections and Excludes1 Notes

Differentiating between acute and chronic infections is essential for accurate coding.

 Acute Infections: These are infections that develop quickly and typically last for a shorter
duration. They often involve more severe symptoms.
 Chronic Infections: These infections persist for a longer period and may not always cause
noticeable symptoms. They can sometimes be lifelong.
 Coding Considerations:
 o The ICD-10-CM often has separate codes for acute and chronic forms of the same
infection. Example: Acute vs. chronic hepatitis.
o Carefully review the provider's documentation to determine whether the infection is acute
or chronic. Terms like "acute," "subacute," "chronic," "persistent," or "recurrent" can
provide clues.
o If the documentation doesn't explicitly state whether the infection is acute or chronic, query
the provider for clarification.
 Excludes1 Notes: These notes are particularly important in the chapter on infectious diseases.
They help prevent the coding of two conditions that cannot occur together.
o Example: A code for a specific acute infection might have an Excludes1 note for the
chronic form of the same infection. This prevents you from coding both the acute and
chronic forms simultaneously. Always check for Excludes1 notes before finalizing
your code.

Chapter 2: Neoplasms (C00-D49)

This chapter classifies neoplasms (tumors), which are abnormal growths of tissue. Accurate coding of
neoplasms is critical for cancer registries, treatment planning, and prognosis prediction.

Organization by Site (Topography) and Behavior

Neoplasms are primarily classified by two key characteristics:

 Site (Topography): This refers to the anatomical location of the neoplasm. The ICD-10-CM uses
specific anatomical terms to identify the primary site.
o Examples: Lung, breast, colon, skin.
 Behavior: This describes the nature of the neoplasm, categorized as:
o Benign: Non-cancerous; these tumors do not spread to other parts of the body.
o Malignant: Cancerous; these tumors can invade surrounding tissues and spread
(metastasize) to distant sites.
o Carcinoma in situ: Cancer cells are confined to the original location and have not spread;
often considered pre-cancerous.
o Uncertain behavior: The pathologist cannot determine if the neoplasm is benign or
malignant.
o Unspecified behavior: The behavior of the neoplasm is not documented.

Specifying Primary vs. Secondary Site(s) for Malignant Neoplasms

 Primary Site: This is the original location where the cancer began.
 Secondary Site(s) (Metastasis): These are locations where the cancer has spread from the
primary site. When coding malignant neoplasms, it's crucial to identify both the primary site and
any secondary (metastatic) sites. The ICD-10-CM has specific codes for secondary sites.
o Example: "Lung cancer with metastasis to the brain" would require separate codes for both
the primary lung cancer and the secondary brain metastasis.

Z85 Codes for Personal History of Malignancy

  Complete Eradication: Once a malignant neoplasm has been completely eradicated (cured), and
there is no evidence of current disease, a Z85 code is used to indicate a personal history of
malignancy. This is important for follow-up care and risk assessment. Example: A patient who had
breast cancer 10 years ago, successfully treated with surgery and chemotherapy, and is now
cancer-free, would have a Z85 code for personal history of breast cancer. It's important to note
that Z85 codes are not used if the cancer is still present or being treated.

Chemotherapy, Immunotherapy, and Radiation Codes (Z51.0-, Z51.1-)

 Treatment Encounters: When a patient receives chemotherapy, immunotherapy, or radiation

therapy for a neoplasm, additional codes from the Z51.- category are used to indicate these
treatments. These codes are used in addition to the neoplasm code(s).
o Z51.0: Encounter for radiotherapy
o Z51.1: Encounter for chemotherapy
o Z51.11: Encounter for antineoplastic immunotherapy
 Sequencing: The Z51.- treatment codes are typically sequenced after the neoplasm code(s).

Chapter 3: Endocrine, Nutritional, and Metabolic Diseases (E00-

E89)
This chapter covers a wide range of conditions related to hormone imbalances, nutrition, and metabolism.
Accurate coding in this chapter is essential for managing chronic conditions like diabetes and obesity.

Diabetes Mellitus: Type 1, Type 2, and Other Specified Types

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia (high blood sugar). The
ICD-10-CM classifies diabetes into several types:

 Type 1 Diabetes (E10): This type is characterized by the body's immune system attacking the
cells in the pancreas that produce insulin. It was previously known as juvenile diabetes or insulin-
dependent diabetes.
 Type 2 Diabetes (E11): This is the most common type of diabetes. It is characterized by insulin
resistance, where the body's cells don't respond properly to insulin, combined with relative insulin
deficiency. It was previously known as adult-onset diabetes or non-insulin-dependent diabetes.
 Other Specified Types of Diabetes (E08, E09, E13): These categories include other forms of
diabetes, such as diabetes due to underlying conditions (e.g., Cushing's syndrome), drug-induced
diabetes, and other less common types.

Combination Codes for Diabetes with Manifestations

One of the key aspects of diabetes coding is the use of combination codes. These are single codes that
capture both the type of diabetes and any associated complications or manifestations. This simplifies
coding and provides a more complete picture of the patient's condition.

 Examples of Manifestations:
o Diabetic retinopathy (eye disease)
o Diabetic neuropathy (nerve damage)
o Diabetic nephropathy (kidney disease)
 o Diabetic foot ulcers
o Cardiovascular complications
 Example Combination Code: E11.621 (Type 2 diabetes mellitus with diabetic foot ulcer). This
single code captures both the type 2 diabetes and the presence of a foot ulcer, which is a common
and serious complication.
 Importance of Combination Codes: Using combination codes is crucial because it provides a
more accurate representation of the patient's overall health status. It also helps in tracking the
prevalence of diabetes-related complications.

Obesity vs. Morbid Obesity Distinctions

Obesity is a condition characterized by excessive body fat accumulation that presents a risk to health. The
ICD-10-CM distinguishes between general obesity and morbid obesity:

 Obesity (E66.9): This code is used for individuals who are overweight or obese but do not meet
the criteria for morbid obesity.
 Morbid Obesity (E66.01): This code is used for individuals with a very high level of obesity,
typically defined by a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with
significant co-morbid conditions. Morbid obesity carries a significantly increased risk of serious
health problems.
 Importance of Distinction: The distinction between obesity and morbid obesity is important
because morbid obesity is associated with a greater risk of health complications and may require
more intensive interventions, such as bariatric surgery.

Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders

(F01-F99)
This chapter covers a wide range of mental health conditions, including mood disorders, anxiety disorders,
neurodevelopmental disorders, and substance-related disorders. Accurate coding in this chapter is crucial
for appropriate diagnosis, treatment planning, and tracking mental health trends.

Common Outpatient Diagnoses

In outpatient settings, mental health professionals frequently encounter and treat several common
conditions:

 Depression: This can include major depressive disorder, persistent depressive disorder
(dysthymia), and other depressive disorders. Coding should specify the severity (mild, moderate,
severe), presence of psychotic features, and any other relevant clinical features.
 Anxiety Disorders: This category encompasses various anxiety disorders, such as generalized
anxiety disorder (GAD), panic disorder, social anxiety disorder (social phobia), and specific
phobias. Coding should specify the type of anxiety disorder and any associated features.
 Bipolar Disorder: This mood disorder is characterized by alternating periods of mania (or
hypomania) and depression. Coding should specify the type of bipolar disorder (I, II, or other), the
current episode (manic, hypomanic, depressed, or mixed), and any psychotic features.

Substance Use Disorders (F10-F19)

Coding substance use disorders requires careful attention to the specific substance involved and the
pattern of use. The ICD-10-CM distinguishes between several levels of involvement:

 Use: This refers to any consumption of the substance, regardless of whether it leads to problems.
It doesn't necessarily imply problematic use.
 Abuse: This involves a pattern of substance use that leads to significant problems in the person's
life, such as difficulties at work, school, or in relationships. It does not involve dependence.
 Dependence: This is a more severe form of substance use disorder characterized by tolerance
(needing more of the substance to achieve the desired effect), withdrawal symptoms when the
substance is discontinued, and compulsive use despite negative consequences.
 Remission: This indicates a period during which the individual no longer meets the criteria for
dependence. Remission can be partial or full, and it's essential to specify the type of remission.
 Coding Considerations for Substance Use Disorders:
o Specific Substance: The codes in this section are organized by the specific substance
involved (e.g., alcohol, opioids, cocaine). It's crucial to identify the correct substance.
o Pattern of Use: The codes differentiate between use, abuse, dependence, and remission.
Accurate coding requires careful assessment of the patient's history and current use
patterns.
o Severity: For dependence, the codes often specify the severity (mild, moderate, severe).
o Complications: If the substance use has led to medical or psychiatric complications (e.g.,
liver damage, depression), these should be coded separately in addition to the substance
use disorder code.

Accurate coding of mental, behavioral, and neurodevelopmental disorders requires careful clinical
assessment and a thorough understanding of the diagnostic criteria and the ICD-10-CM coding guidelines.
Pay particular attention to the distinctions between use, abuse, dependence, and remission for substance
use disorders. Always consult the official ICD-10-CM coding manual for the most accurate and up-to-date
information.

Chapter 9: Diseases of the Circulatory System (I00-I99)

This chapter encompasses a wide range of conditions affecting the heart, blood vessels, and lymphatic
system. Accurate coding in this chapter is essential for diagnosing and managing cardiovascular diseases,
which are a leading cause of morbidity and mortality worldwide.

Hypertension

Hypertension, also known as high blood pressure, is a condition in which the force of the blood against the
artery walls is too high. The ICD-10-CM distinguishes between several types of hypertension:

 Essential (Primary) Hypertension (I10): This is the most common type of hypertension, where
the cause is unknown. It is also referred to as idiopathic hypertension.
 Hypertension with Heart Failure: When a patient has both hypertension and heart failure, it is
important to code both conditions. The codes for heart failure (I50.-) should be used in conjunction
with the appropriate hypertension code. If the documentation specifically links the heart failure to
the hypertension, code I11.0 (Hypertensive heart disease with heart failure) should also be
assigned.
  Other Types of Hypertension: The ICD-10-CM also includes codes for other types of
hypertension, such as secondary hypertension (due to an underlying condition) and malignant
hypertension.

Heart Failure

Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's needs.
The ICD-10-CM classifies heart failure based on several factors:

 Type:
o Systolic Heart Failure: The left ventricle is unable to contract forcefully enough to pump
blood effectively.
o Diastolic Heart Failure: The left ventricle is unable to relax and fill properly, reducing the
amount of blood that can be pumped.
o Combined Systolic and Diastolic Heart Failure: Both the contraction and relaxation
functions of the left ventricle are impaired.
 Severity: Heart failure can be classified as acute or chronic. Acute heart failure develops suddenly,
while chronic heart failure develops over time.

Cerebrovascular Accident (CVA)

A cerebrovascular accident (CVA), also known as a stroke, occurs when the blood supply to the brain is
interrupted. The ICD-10-CM distinguishes between several types of CVAs:

 Hemorrhagic Stroke (I60-I62): This type of stroke occurs when a blood vessel in the brain
ruptures, causing bleeding into the brain tissue.
 Ischemic Stroke (I63): This type of stroke occurs when a blood clot blocks a blood vessel in the
brain, depriving brain tissue of oxygen and nutrients.
 Sequelae/Stroke Residual Codes (I69): These codes are used to describe the long-term effects
or residual deficits that result from a stroke. They are used after the acute phase of the stroke has
resolved.

Accurate coding of circulatory system diseases requires careful attention to detail, including the specific
type of hypertension, the type and severity of heart failure, and the type of CVA. Remember to use
combination codes when appropriate and to code any long-term effects of a stroke using the appropriate
sequelae codes. Always consult the official ICD-10-CM coding manual for the most accurate and up-to-date
information.

Diseases of the Respiratory System (J00–J99)

The ICD-10 code range J00-J99 encompasses a wide variety of diseases affecting the respiratory system.
Here's a breakdown of some key categories and examples:

Acute Upper Respiratory Infections (J00-J06)

 Common cold (J00): This is a viral infection of the upper respiratory tract, causing symptoms like
runny nose, sore throat, and cough.
 Acute sinusitis (J01): Inflammation of the sinuses, often caused by viral or bacterial infection.
  Pharyngitis (J02): Inflammation of the pharynx (throat), commonly known as strep throat when
caused by Streptococcus bacteria.
 Laryngitis (J04): Inflammation of the larynx (voice box), often causing hoarseness or loss of voice.

Influenza and Pneumonia (J09-J18)

 Influenza (J09-J11): A viral infection causing fever, chills, cough, and body aches.
 Pneumonia (J12-J18): An infection of the lungs, which can be caused by bacteria, viruses, or
fungi. The ICD-10 code specifies the causative organism if known, such as J15.0 for pneumonia
due to Klebsiella.

Other Acute Lower Respiratory Infections (J20-J22)

 Acute bronchitis (J20): Inflammation of the bronchi (airways in the lungs), often causing a cough
with mucus production.
 Acute exacerbation of asthma (J45.901): A worsening of asthma symptoms, such as wheezing,
shortness of breath, and chest tightness.

Other Diseases of Upper Respiratory Tract (J30-J39)

 Allergic rhinitis (J30): Inflammation of the nasal passages due to allergies, causing symptoms
like sneezing, runny nose, and itchy eyes.
 Chronic sinusitis (J32): Long-term inflammation of the sinuses.
 Nasal polyps (J33): Benign growths in the nasal passages, which can cause congestion and
difficulty breathing.

Chronic Lower Respiratory Diseases (J40-J47)

 Chronic obstructive pulmonary disease (COPD) (J44): A group of lung diseases that block
airflow to the lungs, including chronic bronchitis and emphysema. COPD is often coded with an
additional code for acute exacerbation if present.
 Asthma (J45): A chronic condition that causes inflammation and narrowing of the airways, leading
to wheezing, shortness of breath, and chest tightness. Asthma is classified based on severity (mild
intermittent, mild persistent, etc.) and may have an additional code for acute exacerbation.
 Bronchiectasis (J47): A condition where the bronchial tubes are abnormally widened, leading to
mucus buildup and recurrent infections.

Lung Diseases Due to External Agents (J60-J70)

 Pneumoconiosis (J60-J65): A group of lung diseases caused by inhaling dust, such as coal dust
(J60), asbestos (J61), or silica (J62).
 Hypersensitivity pneumonitis (J67): An inflammatory lung disease caused by inhaling organic
dusts, such as mold or animal proteins.

Other Respiratory Diseases

 Pulmonary embolism (I26): A blood clot that blocks an artery in the lungs.
 Pleurisy (J90-J94): Inflammation of the lining of the lungs (pleura).
  Respiratory failure (J96): A condition where the lungs cannot adequately provide oxygen to the
body or remove carbon dioxide.

Important Notes:

 Combination codes: Some respiratory conditions have combination codes that include both
the underlying disease and an acute exacerbation, such as COPD with acute exacerbation
(J44.1).
 Specificity: ICD-10 codes can be very specific, so it's important to identify the exact
condition and any contributing factors, such as the causative organism in pneumonia.
 Coding guidelines: Accurate coding requires following official ICD-10 guidelines and updates.

This information provides a general overview of respiratory diseases and their ICD-10 codes. For more
detailed information and specific coding questions, please consult the official ICD-10-CM code book or a
qualified medical coder.

Diseases of the Digestive System (K00–K95)

The ICD-10 code range K00-K95 covers a wide range of diseases affecting the digestive system, from the
oral cavity to the anus. Here's a breakdown of some key categories and examples:

Diseases of Oral Cavity, Salivary Glands, and Jaws (K00-K14)

 Dental caries (K02): Tooth decay caused by bacteria.

 Gingivitis and periodontitis (K05): Inflammation of the gums and supporting structures of the
teeth.
 Oral mucositis (K12): Inflammation of the mucous lining of the mouth, often caused by
chemotherapy or radiation therapy.

Diseases of Esophagus, Stomach, and Duodenum (K20-K31)

 Esophagitis (K20): Inflammation of the esophagus, often caused by acid reflux.

 Gastroesophageal reflux disease (GERD) (K21): A chronic condition where stomach acid flows
back into the esophagus, causing heartburn and other symptoms.
 Gastric ulcers (K25): Sores in the lining of the stomach.
 Duodenal ulcers (K26): Sores in the lining of the duodenum (the first part of the small intestine).
 Gastritis (K29): Inflammation of the stomach lining.

Diseases of Appendix (K35-K38)

 Appendicitis (K35): Inflammation of the appendix, a small pouch attached to the large intestine.

Hernia (K40-K46)

 Inguinal hernia (K40): A protrusion of abdominal contents through the inguinal canal in the groin.
 Hiatal hernia (K44): A protrusion of the stomach through the diaphragm, the muscle that
separates the chest from the abdomen.
Noninfective Enteritis and Colitis (K50-K52)

 Crohn's disease (K50): A chronic inflammatory bowel disease that can affect any part of the
digestive tract.
 Ulcerative colitis (K51): A chronic inflammatory bowel disease that affects the large intestine.

Other Diseases of Intestines (K55-K64)

 Diverticulosis (K57): A condition where small pouches bulge outward through the wall of the
colon.
 Irritable bowel syndrome (IBS) (K58): A common disorder that affects the large intestine, causing
abdominal pain, bloating, and changes in bowel habits.
 Intestinal obstruction (K56): A blockage in the small or large intestine.

Diseases of Peritoneum and Retroperitoneum (K65-K68)

 Peritonitis (K65): Inflammation of the peritoneum, the lining of the abdominal cavity.

Diseases of Liver (K70-K77)

 Alcoholic liver disease (K70): Liver damage caused by excessive alcohol consumption.
 Nonalcoholic fatty liver disease (NAFLD) (K76): A condition where fat builds up in the liver, not
caused by alcohol.
 Hepatitis (K70-K77): Inflammation of the liver, which can be caused by viruses, alcohol, or other
factors.

Disorders of Gallbladder, Biliary Tract, and Pancreas (K80-K87)

 Cholelithiasis (K80): Gallstones, which are hard deposits that can form in the gallbladder.
 Cholecystitis (K81): Inflammation of the gallbladder, often caused by gallstones.
 Pancreatitis (K85): Inflammation of the pancreas, a gland that produces digestive enzymes and
hormones.

Other Diseases of the Digestive System (K90-K95)

 Celiac disease (K90): An autoimmune disorder that damages the small intestine when gluten is
ingested.
 Malabsorption (K90): A condition where the small intestine cannot absorb nutrients from food.

Important Notes:

 Specificity: ICD-10 codes can be very specific, so it's important to identify the exact condition and
any contributing factors, such as whether an ulcer is acute or chronic, and whether it has
hemorrhage or perforation.
 Cholelithiasis vs. cholecystitis: It's crucial to distinguish between cholelithiasis (gallstones) and
cholecystitis (inflammation of the gallbladder), as they have different ICD-10 codes.
 Obstruction: The presence of obstruction in conditions like cholecystitis or intestinal obstruction
should be noted, as it can affect the ICD-10 code.
 Coding guidelines: Accurate coding requires following official ICD-10 guidelines and updates.
 Diseases of the Musculoskeletal System (M00–M99)
The ICD-10 code range M00-M99 encompasses a vast array of conditions affecting the bones, joints,
muscles, ligaments, and tendons. Here's a breakdown of some key categories and examples:

Infectious Arthropathies (M00-M06)

 Pyogenic arthritis (M00): Infection of a joint, often caused by bacteria.

 Septic arthritis (M00): Similar to pyogenic arthritis, but specifically referring to infection caused by
bacteria.
 Reactive arthropathies (M02): Joint inflammation triggered by an infection elsewhere in the body.

Inflammatory Arthropathies (M05-M14)

 Rheumatoid arthritis (M05-M06): A chronic autoimmune disease that causes inflammation of the
joints.
 Seropositive rheumatoid arthritis (M05): Rheumatoid arthritis with the presence of certain
antibodies in the blood.
 Seronegative rheumatoid arthritis (M06): Rheumatoid arthritis without those specific antibodies.
 Psoriatic arthritis (M07): A form of arthritis associated with psoriasis, a skin condition.
 Ankylosing spondylitis (M45): A chronic inflammatory disease that primarily affects the spine.

Osteoarthritis (M15-M19)

 Osteoarthritis (M15-M19): A degenerative joint disease characterized by the breakdown of

cartilage. It's important to note that osteoarthritis is coded by site, so there are specific codes for
osteoarthritis of the knee, hip, hand, etc.

Other Joint Disorders (M20-M25)

 Internal derangement of knee (M23): Problems with the ligaments or cartilage in the knee.
 Other disorders of joint (M25): This is a catch-all for other specified joint problems.

Diseases of Bone (M80-M90)

 Osteoporosis (M80-M82): A condition characterized by decreased bone density and increased

risk of fractures. Crucially, the ICD-10 code specifies with or without current pathological fracture.
 Osteomalacia (M83): Softening of the bones due to vitamin D deficiency.
 Osteomyelitis (M86): Infection of the bone.

Acquired Deformities of Limbs (M20-M21)

 Hallux valgus (M20.1): Bunion, a deformity of the big toe joint.

 Hammer toe (M20.4): Deformity of the toe where it bends abnormally.

Disorders of Spine (M40-M54)

  Scoliosis (M40-M41): Curvature of the spine.
 Kyphosis (M40): Excessive outward curvature of the spine (hunchback).
 Lordosis (M40): Excessive inward curvature of the spine (swayback).
 Intervertebral disc disorders (M50-M51): Problems with the discs that cushion the vertebrae,
such as disc displacement or degeneration. These are coded by location (cervical, thoracic,
lumbar, etc.).
 Spondylosis (M47): Degenerative changes in the spine.

Diseases of Soft Tissue (M60-M79)

 Myositis (M60): Inflammation of the muscles.

 Tendonitis (M75-M79): Inflammation of a tendon.
 Bursitis (M70-M71): Inflammation of a bursa (a fluid-filled sac that cushions joints).

Other Disorders of the Musculoskeletal System (M95-M99)

 Fracture, not otherwise classified (M84): This is used when a fracture is present but the specific
type isn't specified.
 Nonunion of fracture (M84.0): When a broken bone fails to heal properly.

Important Notes:

 Specificity: Musculoskeletal ICD-10 codes are often very specific, requiring information on the
exact location, laterality (left or right), and any associated conditions.
 Arthritis: It's critical to differentiate between the various types of arthritis (osteoarthritis,
rheumatoid arthritis, etc.) as they have distinct codes. Furthermore, osteoarthritis is coded by site.
 Osteoporosis: The code for osteoporosis must specify whether a current pathological fracture is
present.
 Disc disorders: Intervertebral disc disorders are classified by location (cervical, thoracic, lumbar,
etc.).
 Coding guidelines: Accurate coding necessitates adherence to official ICD-10 guidelines and
updates.

Injury, Poisoning, and Certain Other Consequences of External

Causes (S00–T88)
The ICD-10 code range S00-T88 covers a broad spectrum of injuries, poisonings, and other adverse
effects due to external causes. Accurate coding in this section is crucial for tracking injury statistics and
ensuring appropriate treatment. Here's a breakdown of key categories and coding considerations:

Fractures (S00-T14)

Fracture coding is complex and requires detailed information to select the correct code. Key elements
include:
  Open vs. Closed: An open fracture (compound fracture) involves a break in the skin, while a
closed fracture (simple fracture) does not.
 Displaced vs. Nondisplaced: A displaced fracture means the bone fragments are not aligned,
while a nondisplaced fracture means they are still in alignment.
 Anatomical Location: The specific bone and part of the bone affected must be identified (e.g.,
distal radius, femoral shaft, tibial plateau).
 Laterality: Whether the fracture is on the left, right, or bilateral (both sides) must be documented.
 Episode of Care: The code must indicate whether this is the initial encounter (first time the patient
is seen for the fracture), a subsequent encounter (follow-up visit for healing), or a sequela
(complication from the fracture).
 Healing Status: The code should reflect the healing process:
o Routine healing: The fracture is healing as expected.
o Delayed healing: The fracture is taking longer than usual to heal.
o Nonunion: The fracture is not healing at all.
o Malunion: The fracture has healed in a misaligned position.

Dislocations (S00-T14)

Similar to fractures, dislocation codes specify the joint involved, laterality, and episode of care.

Injuries to Nerves and Blood Vessels (S00-T14)

These codes identify the specific nerve or blood vessel injured and the nature of the injury (e.g., laceration,
contusion).

Injuries to Muscles and Tendons (S00-T14)

These codes specify the muscle or tendon injured and the type of injury (e.g., strain, tear).

Open Wounds (S00-T14)

These codes classify open wounds (e.g., lacerations, punctures) by location and depth.

Burns (T20-T32)

Burn coding requires specifying:

 Depth:
o First-degree: Affects only the outer layer of skin (redness, pain).
o Second-degree: Affects deeper layers of skin (blisters).
o Third-degree: Full-thickness burn, damaging all layers of skin (may appear white or
charred).
 Extent: The percentage of Total Body Surface Area (TBSA) affected by the burn must be
documented. The "rule of nines" is often used for estimating TBSA in adults.
 Site: The anatomical location of the burn(s) should be specified.

Poisoning (T36-T65)
Poisoning codes identify the substance involved and the intent:

 Accidental: The poisoning was unintentional.

 Intentional self-harm: The poisoning was a deliberate attempt to cause harm.
 Assault: The poisoning was inflicted by another person.
 Undetermined: The intent of the poisoning is unknown.

Adverse Effects (T36-T65)

Adverse effects are reactions to medications or other substances that occur when the substance is used
correctly. It's crucial to distinguish adverse effects from poisoning:

 Adverse Effect: The substance was taken as prescribed or directed, but an unintended side effect
occurred.
 Poisoning: The substance was taken in an excessive amount, or with harmful intent.

Other Injuries (T15-T19, T66-T88)

This category includes a variety of other injuries, such as:

 Foreign body in orifice (T15-T19): Object lodged in an opening like the eye, ear, or nose.
 Effects of radiation (T66): Injuries caused by exposure to radiation.
 Thermal and chemical burns (T20-T32): Burns caused by heat or chemicals.
 Frostbite (T33-T35): Injury caused by freezing temperatures.
 Complications of trauma (T80-T88): Problems that arise after an injury, such as infections or
nonunion of fractures.

Important Notes:

 Specificity: Injury codes are highly specific. Accurate coding requires detailed documentation of
the injury.
 External Cause Codes: In addition to the injury code, it's often necessary to use an external
cause code (V00-Y99) to identify how the injury occurred (e.g., fall, car accident).
 Coding guidelines: Accurate coding requires adherence to the official ICD-10 guidelines and
updates.

External Cause codes (V00-Y99)

are crucial for providing a complete picture of how an injury or condition occurred. They add valuable
context to the primary diagnosis code (the "what" of the injury) by specifying the "how," "where," and
sometimes "who" involved in the event.

Here's a breakdown of the importance and use of External Cause codes:

Purpose of External Cause Codes:

 Mechanism of Injury: These codes describe the event that caused the injury (e.g., fall, collision,
cut, strike).
  Intent: They clarify whether the injury was accidental, intentional (self-harm, assault), or of
undetermined intent.
 Place of Occurrence: They indicate where the event happened (e.g., home, street, school,
workplace).
 Activity: They may specify what the person was doing at the time of the injury (e.g., walking,
playing sports, working).
 Involved Party: In some cases, they identify other parties involved in the event (e.g., driver in a
car accident).

Why are External Cause Codes Important?

 Data Analysis: They are essential for tracking injury trends and identifying high-risk activities or
locations. This information is used for public health initiatives, safety programs, and research.
 Workers' Compensation: These codes are often required for workers' compensation claims to
determine the circumstances of a workplace injury.
 Legal Purposes: They can be relevant in legal cases involving injuries.
 Public Health Surveillance: External cause codes help track and monitor the incidence of injuries
related to specific causes, such as motor vehicle crashes, falls, or assaults.
 Billing and Reimbursement (Sometimes): While not always required by all payers for routine
medical claims, they can be necessary in specific situations, particularly those involving potential
third-party liability (e.g., auto accidents).

Structure of External Cause Codes:

The V00-Y99 range is organized into categories that cover various types of external causes, such as:

 Transport accidents (V00-V99): Car accidents, motorcycle crashes, pedestrian accidents, etc.
 Falls (W00-W19): Falls from height, falls on the same level, etc.
 Exposure to environmental factors (W20-W49): Exposure to heat, cold, natural forces, etc.
 Contact with sharp or blunt objects (W50-W99): Cuts, punctures, blows, etc.
 Assault (X00-X19): Physical violence.
 Intentional self-harm (X60-X84): Suicide attempts.
 Activities (Y93): Codes to specify the activity the person was engaged in at the time of the injury.
 Place of occurrence (Y92): Codes to specify where the event occurred.

Key Considerations:

 Not Always Required: While highly recommended, external cause codes may not be mandatory
for all healthcare claims. However, their use is becoming more common, especially with the
increasing focus on data analysis and injury prevention.
 Coding Guidelines: Accurate assignment of external cause codes requires careful review of the
medical record and adherence to official ICD-10 coding guidelines.
 Hierarchy: When multiple external causes are present, there are rules for prioritizing which code to
use. Typically, the code that most accurately describes the event leading to the injury is selected.

Factors Influencing Health Status & Contact with Health Services (Z00-Z99). These "Z codes" are used for
situations other than a current illness or injury. They describe encounters with healthcare for reasons like:
  Routine Examinations: These are check-ups, screenings, and preventive care visits. Examples
include:
o Z00.00: General adult medical exam without abnormal findings
o Z00.129: Encounter for health check-up without abnormal findings
o Z01.419: Gynecological exam without abnormal findings
 Immunizations: Codes for visits solely for vaccinations.
o Z23: Encounter for immunization
 Status Codes: These describe a patient's ongoing condition or situation. Examples include:
o Z94: Transplanted organ and tissue status
o Z98.89: Other specified condition status
 Other Circumstances: This is a broad category for situations not classified elsewhere, such as:
o Z38.00: Liveborn infant, single birth, born in hospital
o Z71.3: Encounter for health education and advice

Why are Z codes important?

 Tracking Preventive Care: They help track and measure the utilization of preventive services like
screenings and immunizations.
 Documenting Health Status: They provide a record of a patient's ongoing conditions, such as
having a transplanted organ.
 Coding Encounters for Specific Purposes: They allow for clear coding of visits that are not
primarily for treating a disease or injury.

Key Considerations:

 Not Primary Diagnosis: Z codes are not used as a primary diagnosis. They are supplemental
codes that explain the reason for the healthcare encounter.
 Specific Coding: It's important to select the most specific Z code that accurately describes the
reason for the visit.
 Coding Guidelines: Accurate use of Z codes requires following the official ICD-10 coding
guidelines.

ICD-10-CM Special Considerations & Documentation

Requirements Study Guide
1. Laterality and Specificity

 ICD-10-CM requires documentation of right, left, or bilateral for applicable conditions (e.g.,
fractures, joint disorders, ocular diseases).
 If the documentation does not specify laterality:
o Query the provider for clarification.
o If no additional information is available, assign the unspecified code.
 Some codes inherently include laterality (e.g., H25.11 - Age-related nuclear cataract, right eye).

2. Acute vs. Chronic Conditions

  Certain conditions require distinct codes based on duration:
o Acute conditions: Sudden onset, short duration (e.g., J96.00 - Acute respiratory failure).
o Chronic conditions: Long-standing or recurring (e.g., J96.10 - Chronic respiratory failure).
o Acute on chronic conditions: A worsening of a chronic issue (e.g., J96.20 - Acute and
chronic respiratory failure).
 Always follow coding guidelines to determine whether a single combination code is available or if
separate codes are needed.

3. Sequencing of Diagnoses

 The first-listed diagnosis is the primary reason for the encounter.

 If guidelines state “code first underlying condition,” prioritize that condition before reporting
manifestations.
 Coexisting conditions that impact care should also be reported (e.g., hypertension with chronic
kidney disease).
 Some conditions require a “Use additional code” instruction to fully describe the clinical picture.

4. Pregnancy & Obstetrics (Chapter O00–O9A)

 If a patient is pregnant, postpartum, or in labor, always begin coding from Chapter 15 (O00–O9A).
 Assign a 7th character if it specifies fetal involvement.
 Examples:
o O24.415 – Gestational diabetes in pregnancy, insulin-controlled.
o O36.4XX0 – Maternal care for intrauterine death, unspecified trimester.

5. Poisoning, Adverse Effects, & Underdosing

 Poisoning: Incorrect drug, wrong dosage, overdose, or contamination.

o Example: T40.1X1A – Heroin poisoning, accidental (unintentional), initial encounter.
 Adverse Effect: Properly administered drug, but patient experiences a side effect.
o Example: T88.7XXA – Unspecified adverse effect of drug or medication.
 Underdosing: Patient took less than prescribed, leading to worsening condition.
o Example: T36.95XA – Underdosing of unspecified systemic antibiotic, initial encounter.
o Assign Z91.12 (Patient’s intentional underdosing) or Z91.13 (Patient’s unintentional
underdosing) as additional codes if relevant.

6. Manifestation & Etiology Codes

 Some conditions require two codes: one for the underlying etiology and another for the
manifestation (secondary effect).
 In the Alphabetic Index, manifestation codes appear in brackets ([ ]).
 Example: Type 2 Diabetes with Mild Nonproliferative Diabetic Retinopathy:
o E11.321 – Type 2 diabetes with mild nonproliferative diabetic retinopathy.
o H35.00 – Unspecified nonproliferative diabetic retinopathy (if additional detail needed).
 Combination codes exist for many conditions, reducing the need for separate manifestation coding.

Key Takeaways for Coders:

  Always prioritize specificity. If documentation lacks detail, query the provider.
 Follow sequencing rules. First-listed diagnosis should reflect the primary reason for care.
 Use combination codes when available. They simplify coding and ensure accuracy.
 Pay attention to 7th characters. These often indicate severity, episode of care, or fetal
involvement.
 Understand cause-and-effect relationships. Use the proper sequencing when coding
complications or manifestations.

 Unspecified Codes

 Always review documentation for more specific details before resorting to an unspecified code.
 If specificity is truly unavailable, ensure there's proper documentation to justify its use.

 Excludes1 Confusion

 Excludes1 notes mean do not code together—check the ICD-10-CM guidelines carefully.
 If both conditions are documented, ensure there's no exception (e.g., underlying vs. separate
condition).

 Not Using 7th Characters

 The 7th character provides critical details on the stage of care (e.g., initial, subsequent, sequela).
 Double-check the coding guidelines for trauma, fractures, and pregnancy-related codes.

 Missed Combination Codes

 Some conditions require a single combination code instead of two separate ones (e.g.,
hypertension with CKD).
 Use the ICD-10-CM Index and Tabular List to verify if a combination code exists.

 Failure to Update Codes Annually

 CMS and AMA update codes every October—always verify the latest coding changes.
 Use official coding resources like the ICD-10-CM Guidelines, CPT® Manual, and HCPCS Level II
updates.

Tab Key Guidelines

 Use color-coded tabs for guidelines, tables, and key sections to quickly locate information.
 Pay special attention to the Official Guidelines for Coding and Reporting in ICD-10-CM—they
are frequently tested.

Practice with Real Clinical Scenarios

 Simulate exam conditions by setting a timer and coding full case scenarios from operative or
office notes.
 Practice abstracting key details from reports (e.g., main diagnosis, procedures, and modifiers).
Memorize High-Frequency Codes

 Besides common ICD-10-CM codes, memorize frequently used CPT® codes (e.g., 99213 for a
common office visit).
 Learn modifier usage (e.g., -25 for separate E/M service, -59 for distinct procedural service).

Use “Code Also” Notes

 Ensure secondary conditions are coded when applicable, but only if documentation supports it.
 Pay attention to “Excludes1” vs. “Excludes2” notes—some conditions should not be coded
together.

Map the Documentation Terms

 Understand how provider terminology maps to codes.

Example:
o "Diabetic nephropathy" = E11.21 (Type 2 DM with nephropathy)
o "HTN with CKD" = I12.9 (Hypertensive CKD, unspecified stage)
 Look out for implied relationships (e.g., “due to,” “secondary to”).

Time Management

 The CPC exam is 5 hours and 40 minutes, so pace yourself:

o E/M and anesthesia questions → typically quicker
o ICD-10-CM & procedure-based coding → may take longer
 Use process of elimination on multiple-choice questions.

Putting It All Together

1. Medical Necessity & Diagnosis Coding

 The diagnosis must justify the procedure—always ensure codes support medical necessity.
 Use Local Coverage Determinations (LCDs) when applicable.

2. Documentation is Key

 If documentation is incomplete or unclear, never assume—query the provider if necessary.

 Ensure specificity, especially for laterality (left/right), acute vs. chronic conditions, and
complications.

3. Cross-Referencing

 The CPC exam tests ICD-10-CM, CPT®, and HCPCS—use all references in conjunction.
 Regularly review CMS guidelines, CPT® Assistant, and AHA Coding Clinic for updates.

4. Avoid Overcoding

 Only report conditions that impact patient care during that visit.
  Be cautious with coding symptoms separately when a definitive diagnosis is documented.

Introduction to Evaluation & Management (E/M)

1. Definition

 E/M codes (CPT® 99202–99499) represent provider cognitive work: evaluating, diagnosing, and
managing patient care.
 Key components (historically):
o History (HPI, ROS, PFSH)
o Exam (Organ systems/body areas)
o Medical Decision Making (MDM)

2. Impact on Healthcare

 E/M accounts for a significant portion of provider reimbursement—especially in primary care,

internal medicine, and emergency medicine.
 Medical necessity is crucial: payers audit E/M claims to ensure the selected level matches the
complexity of the case.

3. Exam Relevance

 10–15% of CPC exam = E/M coding.

 You must analyze clinical documentation to assign the correct E/M level.
 Key areas tested:
o Office visits (99202–99215)
o Hospital inpatient (99221–99239)
o Consultations (99242–99255)
o ER visits (99281–99285)
o Nursing facility (99304–99318)

II. E/M Guidelines: An Evolving Landscape

1. Background

 Before 2021:
o Coders followed 1995/1997 Documentation Guidelines, requiring detailed history,
exam, and MDM.
 2021 Update:
o Office/Outpatient E/M codes (99202–99215) were simplified—E/M level now based on
Time or MDM only.

2. What Changed in 2023?

 2023 Expansion: The MDM/Time-based model now applies to more E/M categories:
o Hospital inpatient/observation (99221–99239)
 o Emergency department (99281–99285)
o Nursing facility (99304–99318)
o Home/residential care (99341–99350)
 Key changes:
o History & Exam are no longer factors for code selection—they are still required but
must be clinically relevant.
o Providers select the E/M code based on:
 Total Time spent on the encounter OR
 Medical Decision Making (MDM)

3. Why It Matters?

 Coders must apply the latest 2023 E/M guidelines for accurate coding.
 CPC Exam Focus:
o Differentiating Time-based vs. MDM-based coding
o Coding multi-problem cases, prolonged services, and critical care
o Recognizing E/M audit risks (e.g., upcoding, downcoding)

Final Study Tips for CPC Exam

✅ Memorize the 2023 MDM table—focus on the 3 elements:

 # of Diagnoses/Problems Addressed
 Data Complexity (Labs, Imaging, HIE, etc.)
 Risk of Complications/Morbidity

✅ Know the thresholds for Time-based coding (e.g., 99214 = 30–39 min, 99215 = 40–54 min).

E/M Guidelines: Pre-2021 vs. 2023+ Comparison Chart

Category Pre-2021 Guidelines (Legacy) 2023+ Guidelines (Current)
MDM OR Total Time (History/Exam still
Code Selection 3 Key Components: History, Exam, &
documented but not required for level
Based On MDM
selection)
Required & impacted E/M level Required clinically, but does not impact E/M
History & Exam
selection level
Medical Decision Included 3 elements (Problems Still includes 3 elements, but guidelines
Making (MDM) Addressed, Data Reviewed, Risk) clarify data points and complexity
Time-Based Used only when >50% of visit was Now a primary option—Total Time includes
Coding counseling/coordination of care all physician/NP/PA time on encounter date
2021: Office/Outpatient (99202-99215)
E/M Code
updated
Categories All E/M services followed old guidelines
2023: Expanded to Inpatient, ED, Consults,
Affected
Nursing Facility, Home/Residential
1995 vs. 1997 Differed in how body areas/organ No longer relevant for code level
 Category Pre-2021 Guidelines (Legacy) 2023+ Guidelines (Current)
Exam Guidelines systems were counted selection
Prolonged Separate codes for different settings Simplified prolonged service codes based
Services (99354-99357, 99417) on time spent

💡 Key Takeaways:
✅ History & Exam are still documented but no longer impact E/M level selection.
✅ MDM and Time are the only two drivers of E/M code selection.
✅ Time-based coding now includes all provider time on the date of the encounter (not just face-to-
face time).
✅ Critical care, hospital, nursing facility, and home visits follow 2023+ guidelines..

Comparison: Pre-2021 vs. 2023+ Guidelines

Category Pre-2021 E/M Guidelines 2023+ E/M Guidelines

Key Components History, Exam, MDM MDM or Total Time
Number of Diagnoses, Data,
MDM Elements Number & Complexity of Problems, Data, Risk
Risk
Exam
1995 vs. 1997 Guidelines No mandatory physical exam level
Requirements
Total time includes provider time for all visit-related
Time Consideration Only for prolonged services
tasks

2023+ E/M Guidelines: MDM or Time-Based Coding Study Guide

A. MDM-Based Coding

1. Three Elements of MDM

 Element 1: Number and Complexity of Problems Addressed

 Element 2: Amount and/or Complexity of Data to be Reviewed and Analyzed
 Element 3: Risk of Complications and/or Morbidity or Mortality

2. MDM Levels

Each level requires meeting or exceeding 2 out of the 3 MDM elements:

 Straightforward: 1 self-limited or minor problem, minimal data, minimal risk.

 Low: 2+ self-limited problems, 1 stable chronic illness, or 1 acute uncomplicated illness/injury;
limited data; low risk.
 Moderate: 1 or more chronic illnesses with exacerbation, 2+ stable chronic illnesses, or an acute
illness with systemic symptoms; moderate data; moderate risk (e.g., prescription drug
management).
  High: 1 or more chronic illnesses with severe exacerbation, life-threatening conditions, advanced
progression, or acute injuries posing a threat to life; extensive data; high risk (e.g., decision for
hospitalization, DNR discussion).

3. What Counts Toward MDM?

 Problems Addressed: Must be actively evaluated or managed during the encounter.

 Data Reviewed: Labs, imaging, old records, discussions with other clinicians, unique documents.
 Risk: Based on interventions, management options, potential morbidity (e.g., new Rx with high risk
of side effects, complex procedures).

B. Time-Based Coding

1. Total Time on the Date of the Encounter

Includes all the provider’s time spent on the patient's care that day, including:

 Face-to-face and non-face-to-face time

 Chart review, counseling, care coordination, documentation
 Excludes staff time or separately billable services

2. Typical Time Ranges

Each E/M code has an associated time range (e.g., 99213: 20-29 minutes for office visits).

 Exceeding the upper limit may require prolonged services coding.

3. Prolonged Services

When total time exceeds the maximum threshold for the highest-level E/M code:

 Use add-on prolonged service codes (e.g., 99354–99357, 99415–99417).

 Specific rules vary based on setting (office, outpatient, inpatient).

 Office or Other Outpatient Services (99202–99215):

 New Patient: 99202–99205

 Established Patient: 99211–99215
 These codes now focus on either Time or Medical Decision Making (MDM), as per the 2021
guidelines.
 99211 does not require a face-to-face encounter, as long as it is medically necessary and under
supervision.
 Hospital Inpatient/Observation Services (99221–99239):

 These codes were merged in 2023 into combined Inpatient/Observation codes (e.g., 99221–
99223 for initial hospital care).
 Level selection is determined by MDM or Time for admission, subsequent visits, and discharge.

 Emergency Department Services (99281–99285):

 No distinction between new or established patients since the ED is “new” to everyone.

 After 2023, these codes are selected by MDM only; Time is not typically used for ED E/M
levels.

 Consultations (99242–99245 / 99252–99255):

 These can be office or inpatient services.

 Documentation must show a request for opinion from a qualified practitioner, advice from the
consulting provider, and a written report back to the requesting provider.
 Note: Medicare no longer reimburses for many consultation codes.

 Nursing Facility Services (99304–99318):

 Initial visits: 99304–99306.

 Subsequent visits: 99307–99310.
 Discharge: 99315–99316.
 In 2023, these codes allow selection based on MDM or Time for initial and subsequent visits.

 Home/Residence Services (99341–99350):

 For services provided in the patient’s residence, such as private homes or assisted living.
 In 2023, these codes align with the new MDM or Time guidelines.

 Preventive Medicine Services (99381–99397):

 These are typically for well visits, based on age and whether the patient is new or established.
 Usually not selected by Time or MDM, but instead based on a comprehensive preventive
evaluation.
 May be coded with additional services, like screenings or procedures.

 Special E/M Services:

 Prolonged Services (99354–99357; 99415–99417; G2212 for Medicare)

 Care Plan Oversight (99374–99380)
 Transitional Care Management (99495–99496)
 Chronic Care Management (99490, 99439, etc.)
 These codes are often used in scenario expansions on the CPC exam, testing when an E/M code
alone is insufficient.
Quick Tips for E/M Coding Success

✅ Understand MDM elements—two of three elements must meet/exceed a level.

✅ Use time-based coding if total provider time is well-documented and exceeds minimums.
✅ Pay attention to risk factors like prescription drug management and decision-making complexity.
✅ Review payer-specific rules for prolonged services coding.

Key Documentation Requirements and Tips

 Medical Necessity: This is paramount. A high level of service doesn't justify the code if the
patient's condition doesn't warrant it. Auditors scrutinize this closely. The documentation must
clearly support the medical necessity of the services provided.
 Signature & Credentials: A missing signature is a red flag. It's essential to have the rendering
provider's signature and credentials (e.g., MD, DO, NP, PA) clearly documented. Electronic
signatures are acceptable if they meet specific requirements.
 Chief Complaint & Relevant History: While the 2023 E/M guidelines de-emphasized history and
exam for code selection (for most visit types), they are still crucial for patient care and medical
necessity. The history should be relevant to the chief complaint and guide the examination and
medical decision-making.
 Time Tracking: If time is used to determine the E/M level, meticulous documentation is key. The
total time spent by the provider on the encounter (including both face-to-face time and time spent
on related activities like reviewing records or preparing to see the patient) must be documented. A
brief description of the activities is also recommended.
 Cloning & Templates: Cloning and overuse of templates are major audit risks. Documentation
must be individualized to each patient encounter. Auditors are trained to spot generic or copied
text. Templates can be helpful for reminders of what to document, but they should not be used to
create identical notes for different patients.

Common Pitfalls and Audit Risks

 Incorrect Use of Consultation Codes: True consultation codes (99241-99245) are rarely used
now, especially by Medicare. Most payers treat these as regular E/M visits. The key is that a
consultation requires a request from another provider and a written report back to that provider.
 Failing to Update to 2023 E/M Guidelines: This is a critical error. Using the old "3 of 3 key
components" method for history and exam for office/outpatient visits is incorrect. Code selection for
these visits is now based on Medical Decision Making (MDM) or time.
 Misapplication of Time: Only the provider's time spent on medically necessary activities on the
date of the encounter counts towards time-based coding. Including staff time, time spent on tasks
performed on a different day, or double-counting time (e.g., also billing a prolonged service code
when time has already been factored into the E/M level) is improper.
 Over-Leveling MDM: MDM complexity must be supported by the documentation. Simply stating
"moderate" or "high" complexity is insufficient. The documentation must detail the number and
complexity of problems addressed, the data reviewed, and the risk of complications.
 99211 Abuse: 99211 represents a minimal level of service. It should only be used when the
service provided truly reflects minimal physician work. Routine vital sign checks or simple
 medication refills typically do not justify a 99211 unless there is some other minimal but medically
necessary service provided.
 Preventive vs. Problem-Oriented: It's essential to correctly distinguish between preventive and
problem-oriented visits. A preventive visit (e.g., 99381-99397) is for routine health maintenance,
while a problem-oriented visit (e.g., 99212-99215) addresses a specific medical issue. If both types
of services are provided on the same day, the appropriate modifier (usually -25) must be used to
indicate that a separately identifiable E/M service was performed.

Office Visit, New Patient, Time-Based

 Patient: New, with multiple chronic conditions (hypertension, type 2 diabetes).

 Time Spent: 35 minutes (mostly counseling on diet and medications).
 Code Selection:
o 99203 (30–44 minutes) might align based on time.
o If the MDM is moderate complexity, it could be 99203 or 99204 depending on the exact
complexity and time.
o MDM complexity (moderate) and time spent both play a role in confirming the appropriate
code.

Established Patient with Low MDM

 Patient: Established, stable hypothyroidism.

 MDM: Low complexity (minimal data review, no prescription changes).
 Time Spent: 15 minutes.
 Code Selection:
o Likely 99213 as it aligns with the low MDM and the short time spent.
o Since the patient is stable, the low MDM and time indicate this level of service.

Inpatient Encounter, High MDM

 Patient: Acute CHF exacerbation with multiple comorbidities, elevated BNP, risk of respiratory
failure.
 MDM: High complexity (life-threatening condition, multiple data points, high-risk management).
 Code Selection:
o For initial care on the first day, 99223 may apply (representing a higher-level initial
inpatient code).
o For subsequent days, 99233 could be more appropriate depending on the exact level of
care provided.
o The high MDM corresponds to the need for intensive management and a higher-level
code.

Emergency Department

 Patient: Chest pain with EKG changes, possible acute coronary syndrome.
 MDM: Likely high complexity (life-threatening condition).
 Time Spent: Not the deciding factor in the ED; MDM is key.
 Code Selection:
o 99285 is most likely due to the high complexity and urgent nature of the scenario.
 o Time is not typically used in ED E/M coding; instead, MDM (e.g., risk of life-threatening
conditions and the level of management required) is the main factor.

Nursing Facility, Subsequent Visit

 Patient: Alzheimer’s disease, stable, requiring routine monthly evaluation.

 MDM: Likely low or straightforward (no new issues).
 Code Selection:
o Given the stable condition and the lack of new problems, the appropriate code might be
99307 or 99308.
o These codes apply to low-complexity or routine follow-up visits.

Key Takeaways:

 Time is important for certain E/M codes, especially for new patient office visits and home services,
but MDM often plays a more significant role in inpatient, emergency department, and follow-up
visits.
 Always check for the level of MDM (e.g., minimal, low, moderate, or high) and the complexity of
care required to ensure accurate code assignment.

MDM, time-based coding,

1. Understand the New Grid

 Familiarize yourself with the MDM grid in your CPT® book (2023+ guidelines). This grid helps
categorize problems, data review, and risk. Understanding how to navigate and apply this grid will
help you determine the appropriate E/M codes more easily.

2. Careful with Time Thresholds

 Time ranges: Make sure you know the specific time thresholds for each code level in the
office/outpatient setting.
 Prolonged services: For add-on codes like 99417 and G2212 (for Medicare), be sure you identify
the correct one, as using the wrong code can result in errors.

3. Check Payer Policies

 While the CPC exam follows the CPT® standard guidelines, remember that real-world payers
(e.g., Medicare) may have different policies.
 For the CPC exam, always rely on AMA/CPT® E/M guidelines unless otherwise instructed.

4. Practice Real-World Scenarios

 Vignettes: Work through sample notes or scenarios, highlighting the key elements related to MDM
and time.
 Identify any red herrings (extra info that doesn't affect MDM) and focus only on the relevant details
for coding.
5. Modifier 25

 Modifier 25 is crucial when a significant, separately identifiable E/M service is provided on the
same day as a procedure (either minor or major).
 Be prepared for questions that ask whether to use Modifier 25 to indicate a separately identifiable
service.

6. Keep it Simple

 Time-based coding: If the question clearly states the total time spent (e.g., 35 minutes,
predominantly counseling), this is a clear indicator that you should use time as your coding
determinant.
 MDM-based coding: If the question provides a breakdown of problems, data review, and risk,
you will use MDM for coding.
 The exam will often clarify whether you should use time or MDM, so always carefully read the
question.

To familiarize yourself with the MDM grid in your CPT® book (2023+ guidelines), it's important to
understand the three key components that the grid helps categorize: problems, data review, and risk.
This grid is used to determine the complexity of medical decision making (MDM) and, therefore, the
appropriate E/M code. Here's a breakdown of each component:

1. Problems

 Categories of Problems:
o Self-limited or minor problems: These are simple, not requiring significant medical
intervention.
o Established, stable chronic illness: Conditions that are controlled and don’t require new
or additional treatment.
o Chronic illness with exacerbation, progression, or side effects of treatment: This
involves managing conditions that have worsened or are causing complications.
o Acute illness or injury: This may involve conditions that are more severe or require
immediate treatment.
o Chronic illness with severe exacerbation: This is high-risk and involves severe
progression of a chronic illness.
o Severe life-threatening conditions: Conditions that are critical and require intensive
intervention.

2. Data Review

1. Categories of Data:
1. Minimal: Limited or no data review needed.
2. Limited: Requires review of a minimal number of documents or tests.
3. Moderate: Requires review of several documents, tests, or management strategies.
4. Extensive: Involves review of multiple complex records or data sets, such as lab results,
diagnostic tests, and medical records.

3. Risk
 1. Categories of Risk:
1. Minimal risk: Situations with no significant risk, such as routine preventive visits.
2. Low risk: Risk related to conditions like stable chronic illness or minor injuries.
3. Moderate risk: Involves managing more complex conditions that may have significant
complications (e.g., chronic illnesses with exacerbations, certain infections).
4. High risk: Life-threatening conditions, acute diseases, or those requiring invasive
treatment options.

MDM Grid Example:

The MDM grid typically assigns a level of complexity (low, moderate, or high) based on the combination
of these categories. For example:

 Low Complexity MDM: If the patient has self-limited problems (e.g., minor illness), limited data
review, and low risk (e.g., stable chronic illness), the MDM is low complexity.
 Moderate Complexity MDM: If the patient has chronic illness with exacerbation, moderate
data review (e.g., lab tests), and moderate risk (e.g., complications from chronic conditions), the
MDM is moderate complexity.
 High Complexity MDM: If the patient has life-threatening conditions, extensive data review,
and high risk (e.g., severe infection or acute coronary syndrome), the MDM is high complexity.

1. E/M: A Cornerstone of Outpatient Coding

 Mastering E/M is critical because it represents a significant portion of the CPC exam and coding
practices in outpatient settings. Accurate E/M coding ensures that the provider’s work and clinical
complexity are correctly captured for reimbursement purposes.
 Since E/M services are frequently billed, this area will likely appear in multiple scenarios on the
exam. Make sure you understand the coding guidelines for office visits, hospital inpatient
services, ED services, and other facility-based encounters.

2. Consistency with Documentation

 Ensure that documentation matches the E/M code selected. The documentation should include:
o The patient’s condition (diagnosis).
o The complexity of the visit (MDM level).
o Time spent with the patient (if applicable for time-based coding).
 For example, if a provider documents a complex case of diabetes with complications, the MDM
may be higher, and the code should reflect the complexity level (e.g., 99204 instead of 99202).

Introduction to Anesthesia Coding for the CPC Exam:

Anesthesia coding can be challenging, but understanding the key components and guidelines will help you
navigate the related questions on the CPC exam. Here’s a breakdown of what to focus on:

1. Purpose & Scope

  Anesthesia coding refers to reporting services provided by anesthesiologists or Certified
Registered Nurse Anesthetists (CRNAs) who administer anesthesia during surgical or other
procedures.
 CPT® codes for anesthesia range from 00100 to 01999 and cover various services related to
anesthesia administration. In addition to the CPT® codes, you also need to be familiar with
modifiers and time-based billing rules.

2. Key Components of Anesthesia Coding

 Base Units:
o Each anesthesia code has a base unit assigned by the American Society of
Anesthesiologists (ASA).
o The base unit reflects the complexity and skill level required for the anesthesia service
(i.e., how difficult or risky the procedure is).
o Base units are the starting point for calculating anesthesia reimbursement.
 Time Units:
o Anesthesia time is calculated from patient prep for anesthesia (i.e., induction) to the
point at which the patient is safely handed over to post-anesthesia care.
o Time is typically billed in 15-minute increments, though some payers may use 1-minute
increments.
o For the CPC exam, make sure you’re comfortable with time calculations and applying
them to anesthesia codes.
 Modifiers:
o Modifier 47: Indicates anesthesia was administered by the surgeon.
o Modifier 26: Used when a service is rendered by someone other than the supervising
anesthesiologist.
o Physical Status Modifiers: Indicate the patient's physical condition and risk level (e.g., P1
for a normal, healthy patient, P5 for a moribund patient).
o Be familiar with other modifiers for personal performance (e.g., AA for anesthesia
services performed personally by the anesthesiologist), medically directed services, and
medically supervised services.

3. Exam Relevance

 Anesthesia coding accounts for 4-6% of the CPC exam.

 You might encounter questions on:
o Anesthesia time calculations: Make sure you understand how to calculate and apply
time units.
o Physical status modifiers: Understand how different levels of physical status (e.g., P1,
P2) affect coding and reimbursement.
o MAC (Monitored Anesthesia Care): Learn how to code for MAC anesthesia, which
doesn’t involve general anesthesia but requires monitoring of the patient’s vital signs
during the procedure.
4. Global “Packaging” Concept:

 Global packaging is important in anesthesia coding because it encompasses all the services
provided before, during, and immediately after anesthesia administration, excluding the post-
anesthesia care unit (PACU) or follow-up services.
 Unlike surgical CPT® codes, which may be billed separately for each part of the procedure,
anesthesia services are generally packaged into a single code, reflecting the total time and
service complexity.
 Example: If an anesthesia code is used, it includes the time spent preparing the patient,
administering anesthesia, and monitoring during the procedure.

Anesthesia Code Range & Organization for the CPC Exam:

Understanding the organization of anesthesia codes in the CPT® manual is crucial for answering
questions related to anesthesia on the CPC exam. Here’s a detailed breakdown:

1. CPT® Anesthesia Section: 00100–01999

The Anesthesia section of the CPT® manual covers a wide range of codes that are primarily organized by
anatomic site and then by procedure type. Here’s how the codes are grouped:

 Head procedures: 00100–00222

 Neck procedures: 00300–00352
 Thorax (chest) procedures: 00400–00474
 Intrathoracic (heart, lungs): 00500–00580
 Spine and spinal cord: 00600–00670
 Upper abdomen: 00700–00797
 Lower abdomen: 00800–00882
 Perineum procedures: 00902–00952
 Pelvis (except hip): 01000–01190
 Upper leg (except knee): 01200–01274
 Knee and popliteal area: 01320–01444
 Lower leg (below knee): 01462–01522
 Shoulder and axilla: 01610–01682
 Upper arm and elbow: 01710–01782
 Forearm, wrist, hand: 01810–01860
 Radiological procedures, burn excisions, etc.: 01916–01936
 Obstetric anesthesia, other procedures: 01951–01999

Each of these codes corresponds to specific regions or types of surgery and covers the anesthesia
services provided for those procedures. It's important to familiarize yourself with these categories for the
exam, as some questions might require you to know which codes apply to certain procedures based on the
anatomical region.
2. Qualifying Circumstances (CPT® 99100–99140)

 These are add-on codes for unusual anesthesia situations that may require extra resources or
consideration.
 These codes are never used alone—they must always be reported in addition to a primary
anesthesia service code.
 Examples of qualifying circumstances include:
o Extreme age (e.g., infant, elderly patient).
o Emergency conditions.
o Field avoidance (e.g., anesthesia required in non-standard settings).

Note for the CPC Exam: Pay close attention to these codes and ensure you know they are not
standalone codes.

3. Not to Be Confused With

 Moderate Sedation (Conscious Sedation) codes (99151–99157) fall under the Medicine section
of the CPT® manual, not the Anesthesia section.
o These codes are for conscious sedation (a lesser form of sedation) and are often
confused with anesthesia codes.
o Make sure you recognize that these codes are separate from the anesthesia codes and
apply to less intensive sedation.
 Local Infiltration or Topical Anesthesia:
o This type of anesthesia is often used by surgeons and is usually bundled into the surgical
CPT® code.
o It is not separately coded unless explicitly indicated.

Best Practices for Anesthesia Coding on the CPC Exam:

 Review the anesthesia code ranges: Familiarize yourself with the various anatomic regions and
the corresponding anesthesia codes.
 Understand the qualifying circumstances: Know when these codes are used in conjunction with
primary anesthesia services.
 Avoid confusion with other sedation codes: Remember that moderate sedation (99151–
99157) falls under the Medicine section, not anesthesia, and should not be confused with general
anesthesia codes.
 Local anesthesia bundling: Recognize that local anesthesia by surgeons is typically bundled
into the surgical procedure code.

Types of Anesthesia for CPC Exam Preparation:

Understanding the different types of anesthesia is crucial for proper coding, as it helps identify the correct
procedure and the associated anesthesia codes. Here's a breakdown of the key anesthesia types and their
characteristics:
1. General Anesthesia

 Description: The patient is fully unconscious and requires airway management.

 Methods:
o Intravenous (IV): Drugs administered through an IV line.
o Inhalational: Drugs administered via gas or vapor.
 Coding: General anesthesia codes are used for these procedures and fall under the Anesthesia
section (CPT® 00100–01999). These codes often involve higher complexity due to the full loss of
consciousness and airway management requirements.

2. Regional Anesthesia

 Description: Anesthesia is injected or infused around major nerve bundles to block sensation in a
region of the body.
 Common Examples:
o Spinal anesthesia (used for lower body procedures).
o Epidural anesthesia (often used during labor and delivery).
o Peripheral nerve blocks (such as for a limb surgery).
 Coding: Regional anesthesia is also reported under the Anesthesia section (CPT® 00100–
01999), but the specific code will vary based on the anatomic area involved.

3. Monitored Anesthesia Care (MAC)

 Description:
o The anesthesiologist or CRNA provides sedation (usually intravenous), but the patient
maintains protective reflexes.
o The sedation level can range from minimal to deep.
o Conversion: If the situation becomes more complex, MAC can be converted to general
anesthesia if necessary.
 Coding: MAC is coded differently from general anesthesia, usually with specific MAC codes. The
anesthesia provider’s time and effort are documented to determine the proper code.

4. Moderate (Conscious) Sedation

 Description:
o The patient responds purposefully to verbal commands.
o Protective reflexes (such as the ability to breathe on their own) remain intact.
 Code Range: This sedation type is not coded under the Anesthesia section, but instead under
the Medicine section (CPT® 99151–99157) for conscious sedation.
  Important Note: If this level of sedation is provided in place of deeper anesthesia, specific codes
for moderate sedation apply, unless they are bundled into the main procedure.

5. Local/Topical Anesthesia

 Description: Anesthesia administered locally, often to a small area (e.g., numbing a spot on the
skin).
 Who Administers: Usually performed by the surgeon or proceduralist, not the anesthesiologist.
 Coding: This anesthesia type is typically bundled into the surgical procedure code and is not
separately billable using anesthesia codes.
 Common Use: Local anesthesia is commonly used for minor procedures or diagnostic exams.

Key Takeaways for CPC Exam:

 General anesthesia involves full unconsciousness and airway management.

 Regional anesthesia blocks sensation in a region of the body and may be applied through
different methods (spinal, epidural, nerve block).
 MAC is a form of monitored sedation but can be intensified into general anesthesia if necessary.
 Moderate sedation is a lighter form where the patient remains responsive and is coded under the
Medicine section.
 Local anesthesia is typically bundled into the procedure and not billed separately under
anesthesia codes. Make sure to be clear on how each type of anesthesia is used and reported in
relation to specific surgical and procedural settings to ensure accurate coding on the CPC exam.

Anesthesia Service Components & Payment Calculation

Anesthesia coding and payment follow a distinct formula that includes several components beyond the
basic service provided. The payment calculation for anesthesia services is made using the following
components:

Base Units (B): Each anesthesia CPT code has assigned base units. These units reflect
the inherent complexity and risk of the procedure being performed. More complex
procedures (like open-heart surgery) will have higher base unit values than less complex
ones. The base unit value is specific to the CPT code.

Description: Base units represent the inherent complexity of the anesthesia procedure.
They vary based on the procedure performed.

 Example: A complex procedure, such as open heart surgery, will have higher base units
compared to a simpler procedure, like a minor hand surgery.
 CPT® Codes: Each anesthesia CPT® code has its own assigned base units.
2. Time Units (T)

Time Units (T): Anesthesia time is a critical component of the calculation. It's measured
from the moment the anesthesiologist begins preparing the patient for anesthesia in the
operating room (or equivalent location) until the patient is safely turned over to post-
anesthesia care.

 Unit Calculation: The way time units are calculated can vary depending on the
payer. The most common method is to use 15-minute increments (or part thereof)
as one unit. So, 1-14 minutes is 1 unit, 15-29 minutes is 2 units, and so on.
However, always check with the specific payer as some may use different
increments or even actual minutes.

 Description: Time units account for the time spent administering anesthesia, starting from the
preparation of the patient until they are transferred to post-anesthesia care.
 Time Measurement:
o Typically calculated at 1 unit per 15 minutes, but some payers may use different time
increments.
o For example, 1–14 minutes is counted as 1 unit, while 15–29 minutes is counted as 2
units.
o Some payers may allow actual minutes for time reporting instead of increments.
 Time Period: Time starts when the anesthesia provider begins preparing the patient and ends
when the patient is transferred to post-anesthesia care.

3. Modifier Adjustment (Medically Directed, Supervised, etc.)

Modifier Adjustment: Modifier adjustments come into play when anesthesia services are
provided by a physician and a CRNA (Certified Registered Nurse Anesthetist). The
payment may be split depending on whether the anesthesiologist personally performed
the service or medically directed the CRNA. Specific modifiers are used to denote these
different scenarios. This is separate from the Physical Status Modifiers (discussed
below).

 Description: If the anesthesia service is medically directed (e.g., the anesthesiologist supervises
CRNAs), the reimbursement may be adjusted according to specific guidelines.
 Medically Directed: This occurs when one anesthesiologist supervises more than one CRNA.
 Medically Supervised: Refers to an anesthesiologist overseeing multiple anesthesia providers,
and this can affect the calculation.

4. Conversion Factor (CF)

Conversion Factor (CF): The conversion factor is a dollar amount set by Medicare and
individual payers. It’s a multiplier that converts the relative value units (RVUs) of the
anesthesia service into actual dollars. The conversion factor can vary geographically
and by payer. This is the final step in the calculation that determines the actual payment
amount.

 Description: The Conversion Factor is a dollar multiplier set by Medicare or individual payers.
 Purpose: It converts the sum of base units, time units, and any modifiers into an actual payment
amount.
 Formula: The final payment is calculated by the following formula:
o (Base Units + Time Units + Other Modifying Units) × Conversion Factor = Payment
 Example: If the sum of the units is 20, and the conversion factor is $40, the payment would be
$800.

 Other Modifying Units

Other Modifying Units: These units can be added to the base and time units in certain
situations. The most common example is the use of Physical Status Modifiers (P1-P6),
which are discussed below. "Qualifying circumstances" codes (99100-99140) can also
add units in specific, rare situations (like extreme age or hypothermia).

Anesthesia Payment Formula:

The formula you provided is accurate:

(Base Units + Time Units + Other Modifying Units) x Conversion Factor = Payment

 Physical Status Modifiers (P1–P6): These modifiers are used to reflect the patient’s physical
condition before anesthesia. They can influence the payment amount.
o P1: Normal healthy patient.
o P2: Patient with mild systemic disease.
o P3: Patient with severe systemic disease.
o P4: Patient with severe systemic disease that poses a constant threat to life.
o P5: Moribund patient who is not expected to survive without the operation.
o P6: Brain-dead patient whose organs are being removed for donation.
 Qualifying Circumstances (CPT® 99100–99140): These add-on codes reflect unusual
anesthesia situations (e.g., extreme age, emergency procedures).
 Effect on Payment: These modifiers can add extra units to the base and time units, potentially
increasing the payment.

Key Points about Physical Status Modifiers:

 Impact on Payment: Some payers provide additional reimbursement for higher physical status
modifiers (particularly P3-P5) because these patients require more complex care and may be at
higher risk.
  Documentation is Crucial: The anesthesia provider must document the patient's physical status
in the medical record to support the use of these modifiers. It cannot be assumed or based on the
surgical procedure alone.

Important Considerations for Anesthesia Coding and Billing:

 Accurate Timekeeping: Precise recording of anesthesia time is essential for proper

reimbursement.
 Modifier Selection: Choosing the correct physical status modifier and any other applicable
modifiers is crucial.
 Payer Policies: Always check with individual payers for their specific rules and guidelines
regarding anesthesia billing, including how they calculate time units and reimburse for physical
status modifiers.
 Medical Direction: If CRNAs are involved, understanding the rules for medical direction and the
appropriate use of modifiers is critical.

Anesthesia Modifiers (AA, QK, QX, QZ, etc.)

Modifiers are used in anesthesia coding to indicate specific circumstances or conditions that impact the
administration of anesthesia services. These can affect reimbursement rates and help ensure that the
correct level of service is reimbursed. Below are common HCPCS Level II modifiers and other relevant
modifiers used in anesthesia coding:

1. HCPCS Level II Modifiers

 AA: Anesthesia services personally performed by an anesthesiologist.

o Indicates that the anesthesiologist performed the entire anesthesia service without
delegation.
 AD: Medical supervision by a physician of more than four concurrent anesthesia procedures.
o This modifier is used when the anesthesiologist supervises more than four cases
simultaneously, which is considered medical supervision rather than medical direction.
 QK: Medical direction of two, three, or four concurrent anesthesia procedures by an
anesthesiologist.
o Used when the anesthesiologist is directing two to four concurrent anesthesia services,
meeting all medical direction criteria.
 QX: CRNA service with medical direction by a physician (anesthesiologist).
o Applied when a Certified Registered Nurse Anesthetist (CRNA) provides anesthesia
services under the direction of an anesthesiologist.
 QZ: CRNA service without medical direction by a physician (anesthesiologist).
o Used when a CRNA provides anesthesia services independently without medical
direction from an anesthesiologist.
2. Other Common Modifiers

 QS: Monitored Anesthesia Care (MAC).

o Informational modifier used for situations where the anesthesia provider administers
sedation and monitors the patient. This may be used in conjunction with another modifier
like AA or QX to indicate who is providing the MAC.
 23 (CPT modifier): Unusual Anesthesia.
o This modifier is rarely used in routine anesthesia coding, but it may be applied to surgery
codes to indicate that anesthesia for the procedure was unusually complicated.

3. Medical Direction vs. Medical Supervision

 Medical Direction:
o An anesthesiologist directs 2 to 4 concurrent anesthesia cases. The anesthesiologist is
responsible for performing the pre-anesthetic exam, monitoring the patient throughout the
procedure, and being available to provide additional support if necessary.
o Reimbursement: Payment is typically split between the CRNA and the anesthesiologist.
 Medical Supervision:
o When the anesthesiologist supervises more than 4 concurrent anesthesia cases or fails
to meet the requirements for medical direction (such as performing all aspects of the
anesthesia care).
o Reimbursement: Lower compared to medical direction, as the anesthesiologist is less
involved in each individual case.

Medical Direction vs. Medical Supervision: This distinction is critical for proper coding and
reimbursement.

 Medical Direction: The anesthesiologist is actively involved in the care of 2-4 concurrent
anesthesia cases. They must meet specific criteria, such as performing the pre-anesthetic
evaluation, being present during all critical periods of the anesthetic, and being immediately
available for any complications. Payment is typically split between the CRNA and the
anesthesiologist when medical direction is provided.
 Medical Supervision: The anesthesiologist is overseeing more than four concurrent anesthesia
cases or does not meet all the criteria for medical direction. Reimbursement for medical
supervision is typically lower than for medical direction.

Additional Guidelines & Special Circumstances

1. Obstetric Anesthesia

 Vaginal Delivery (CPT 01960, 01967) or Cesarean Section (CPT 01961, 01968, 01969):
Anesthesia is provided for labor and delivery procedures.
  Epidural Anesthesia: For prolonged labor, anesthesia may be administered for several hours, and
there are special time-tracking rules.
 Combined Codes: There are combined codes for situations like neuraxial labor analgesia that
convert into cesarean sections (e.g., CPT 01967).

2. Cardiac Anesthesia

 Higher Base Units: For complex surgeries such as open-heart surgery, higher base units are
typically assigned due to the increased complexity of the procedure.
 Transesophageal Echocardiography (TEE): An anesthesiologist may perform a TEE during
cardiac surgery. If documented, this may be billed separately, depending on payer rules.

3. Pediatric Anesthesia

 Qualifying Circumstances: For pediatric patients, especially those under 1 year old or over 70,
special circumstances may apply (e.g., CPT 99100).
 Higher Risk: Pediatric anesthesia carries higher risks, including smaller airways, which can
complicate anesthesia administration.

4. MAC (Monitored Anesthesia Care)

 Overview: Anesthesia providers monitor the patient's vital signs and sedation levels during the
procedure. The goal is to provide sedation while being ready to convert to general anesthesia if
necessary.
 Common Procedures: Often used for superficial surgeries or endoscopies, and for patients
with comorbidities.
 Modifiers: QS, G8 (Medicare), or other MAC-specific modifiers are used to indicate that the
anesthesia was monitored care.

5. Emergency Modifier (Modifier -EM or CPT 99140)

 Definition: Some payers use 99140 to indicate that anesthesia was complicated due to
emergency conditions. This typically aligns with the American Society of Anesthesiologists
(ASA) classification of an emergency.
 Emergency Criteria: A situation where immediate intervention is required to prevent life or limb
from being compromised.

6. Conscious Sedation vs. Anesthesia

  Moderate (Conscious) Sedation:
o CPT 99151–99157: Used when sedation is provided in a manner that keeps the patient
responsive, but with reduced awareness of the procedure.
o Anesthesia Codes vs. Sedation Codes: If an independent anesthesia provider
administers the sedation, it is typically billed under anesthesia codes rather than
sedation codes.
o Surgeon-Provided Sedation: Surgeons who provide moderate sedation during a
procedure might be allowed to use CPT 99151–99153 for billing.

Anesthesia Modifiers
 HCPCS Level II Modifiers:
o AA: Anesthesia services performed by the anesthesiologist.
o AD: Medical supervision by a physician of more than 4 concurrent anesthesia cases.
o QK: Medical direction of 2-4 concurrent anesthesia cases by an anesthesiologist.
o QX: CRNA service with medical direction by a physician.
o QZ: CRNA service without medical direction by a physician.
 Other Modifiers:
o QS: Monitored anesthesia care (MAC).
o 23: Unusual anesthesia (sometimes used in surgery codes).
 Medical Direction vs. Supervision:
o Medical Direction: An anesthesiologist directs 2-4 concurrent cases with specific criteria.
o Medical Supervision: An anesthesiologist oversees more than 4 cases or doesn’t meet
the criteria for direction.

Special Anesthesia Guidelines

 Obstetric Anesthesia: Special codes for vaginal delivery, cesarean sections, and combined
procedures.
 Cardiac Anesthesia: Higher base units and possible separate billing for TEE.
 Pediatric Anesthesia: Qualifying codes for patients under 1 or over 70 years.
 MAC (Monitored Anesthesia Care): Used in minor surgeries and monitored for emergency
conversion to general anesthesia.
 Emergency Modifier (99140): Used for emergency situations based on ASA classification.
 Conscious Sedation vs. Anesthesia: Sedation codes (99151–99157) differ from anesthesia
codes.

Time Reporting Nuances

Start and Stop Times: Accurate documentation of start and stop times is essential. This
is the foundation for calculating anesthesia time. The start time is when the anesthesia
provider begins preparing the patient for induction, and the end time is when the patient
is safely handed off to post-anesthesia care. If there are breaks in anesthesia (patient
wakes up and then is re-sedated), each segment should be timed separately, but the
total time is added together for the overall anesthesia time for the procedure.
  Start and Stop Times: Accurate documentation is key, including any breaks in anesthesia for
additional time reporting.

Units vs. Minutes: Payer rules vary. Some payers require time to be reported in minutes, while others use
15-minute increments (or other increments) to calculate units. The CPC exam generally uses the 1 unit =
15 minutes standard unless otherwise specified in the question. Always confirm payer requirements.

 Units vs. Minutes: Some payers want time in minutes; others in 15-minute increments.

Relief Situations: If one anesthesia professional relieves another, each provider reports their own time
using the appropriate modifiers. The documentation must clearly show the change of providers and the
time each was responsible for the patient.

 Relief Situations: Report each provider's time separately if there’s a relief situation.

Split Billing (Medical Direction): In medical direction scenarios, both the anesthesiologist and the CRNA
report the same total anesthesia time. However, the payment is split between them according to Medicare
or payer policy (often 50/50 or 60/40). Each provider uses the appropriate modifier to indicate their role (QX
for the CRNA, QK for the anesthesiologist).

 Split Billing: Time is split between CRNA and anesthesiologist when there’s medical direction.

Example Scenarios

 Inguinal Hernia Repair: Base units + time units, possibly including additional units for physical
status.

Inguinal Hernia Repair: The example correctly outlines the components: base units (from
the code), time units (based on duration), physical status modifier (P2), and the conversion
factor. The modifiers (AA or QX/QK) depend on who performed the service.

 Cesarean Delivery: Combine labor analgesia and delivery codes, including emergent conditions.

Cesarean Delivery with Epidural: This example highlights the use of multiple codes (01967 and 01969),
the physical status modifier (P3), and the potential use of the emergency modifier (99140) if applicable.
Accurate timekeeping from the start of the epidural to delivery and immediate postpartum care is essential.

 MAC for Cataract Surgery: Shorter duration and lower complexity, reported with QS and AA if
performed by an MD.

MAC for Cataract Surgery: This example demonstrates the use of the MAC modifier (QS) plus a modifier
indicating who performed the MAC (AA in this case). It also shows how to calculate total units based on
base units and time units.

 Bilateral Knee Replacement: Total time reported, P4 for higher complexity.

Bilateral Knee Replacement: For bilateral procedures, the anesthesia time is typically reported as a
single service unless the payer has specific rules to the contrary. The total time is documented. The
example also correctly points out the impact of the patient's physical status (P4) on complexity and
potential reimbursement.

 Multiple Concurrent Cases: CRNAs use QX, and the anesthesiologist uses QK.

Multiple Concurrent Cases: This scenario highlights the correct use of modifiers (QX for the CRNAs, QK
for the anesthesiologist) when the anesthesiologist is medically directing multiple concurrent cases.

Common Pitfalls & Audit Triggers

 Improper Time Calculation: Avoid rounding errors or overlapping time.

 Wrong Modifier Usage: Correct modifiers must be used for different anesthesia situations.
 Missing Physical Status Modifiers: Ensure P3–P5 are added when applicable.
 Wrong Code for Anesthesia: Use anesthesia-specific codes (00100–01999) instead of surgical
codes.
 Qualifying Circumstances: Use codes like 99100–99140 appropriately.
 Confusing MAC with Moderate Sedation: Understand the difference between anesthesia and
sedation codes.

Global Surgical Package: Know what’s included in the global period (pre-op, intra-op, and post-op
care) and when modifiers like -24, -25, -57, and -78 apply.

Parenthetical Notes & Guidelines: Always check these to avoid unbundling errors.

Common Surgical Procedures: Pay attention to coding differences between open vs. laparoscopic
procedures, biopsies vs. excisions, and repairs (simple, intermediate, complex).

Global Surgical Package is a huge area for both CPC exam questions and real-world coding accuracy.

The Global Surgical Package

 Definition: The Global Surgical Package (or global period, or global concept) is a fundamental
principle in surgical coding. It bundles together all the services that are typically and routinely
provided as part of a surgical procedure into a single payment. This prevents "unbundling,"
where each component of the surgery is billed separately, which would inflate costs.

 Typical Components: The global package includes the following:

 Preoperative Visits: This includes E/M encounters after the decision for surgery has been made.
Typically, this starts on the day before the surgery or the day of the surgery if the patient is
admitted directly for the procedure. It does not include the initial evaluation visit that led to the
decision for surgery.
 Intraoperative Services: This is the surgical procedure itself, including all the work performed by
the surgeon during the operation.
 Complications Following Surgery: Routine and uncomplicated postoperative care related to the
surgical procedure is included. This covers typical complications that are expected to occur in
 some patients. It does not include care for significant complications that require additional
procedures or hospitalizations.
 Postoperative Visits: Follow-up visits with the surgeon during the global period that are directly
related to the surgical procedure and its recovery are included. The length of the global period
varies depending on the type of surgery (see below).
 Supplies: Typical supplies used during the surgery, such as instruments, drapes, gloves, sutures,
and dressings, are included in the global package. This does not include costly implants,
prosthetics, or other specialized supplies.
 Typical Pain Management: Local anesthesia, digital blocks, or topical anesthesia administered by
the surgeon are included. This does not include regional or general anesthesia provided by
an anesthesiologist.

Key Exam Focus Areas:

 Global Period Lengths:

o 0-day (minor procedures, e.g., simple lesion removals)
o 10-day (minor surgeries, e.g., simple repairs)
o 90-day (major surgeries, e.g., joint replacements, hysterectomies)
 Modifiers to Know:
o -24 (Unrelated E/M during post-op period)
o -25 (Significant, separate E/M on the same day as a minor procedure)
o -57 (Decision for surgery, major procedure)
o -58 (Staged or related procedure during post-op)
o -78 (Unplanned return to OR for a related procedure)
o -79 (Unrelated procedure during post-op period)
 Common Pitfalls:
o Billing separate E/M for routine post-op care (included in global period)
o Failing to use -57 for the decision-for-surgery visit
o Incorrectly unbundling pain management

Important Nuances and Considerations:

 Global Period Length: The global period is defined by CMS and varies depending on the
complexity of the surgical procedure. Common global periods are 0 days, 10 days, and 90 days.
Minor procedures typically have shorter global periods, while major procedures have longer
ones. Check the specific code in the CPT book or the CMS website to confirm the global period.
 Complications: As mentioned above, the global package only includes uncomplicated
postoperative care. If a significant complication occurs that requires a return to the operating
room, a new procedure, or admission to the hospital, these services can often be billed
separately. Appropriate modifiers must be used to indicate that the service is related to a
complication.
 Separate Procedures: Some procedures are specifically designated as "separate procedures" in
the CPT code descriptions. These procedures can sometimes be billed separately even if they are
performed during the global period of another procedure, if they are unrelated to the primary
procedure. Careful review of the CPT code description is necessary.
 E/M Services During the Global Period: E/M services provided during the global period for a
problem unrelated to the surgery can be billed separately. Appropriate modifiers (e.g., -24) must
be used to indicate that the E/M service is unrelated to the surgical procedure.
  Bundling vs. Unbundling: The global surgical package is designed to prevent unbundling.
Unbundling is the practice of billing separately for services that are included in the global package.
Unbundling is considered fraud and can result in significant penalties.
 Documentation: Thorough documentation is essential to support separate billing for services
provided during the global period. The documentation must clearly explain why the service was
necessary and how it is distinct from the routine postoperative care included in the global package.
 Payer Policies: Always check with individual payers for their specific policies regarding the global
surgical package. Payer policies may vary.

By understanding the components of the global surgical package and the associated rules, providers and
coders can ensure accurate billing and avoid costly errors.

 Know When the Global Period Starts & Ends:

 Begins one day before (for major surgeries requiring pre-op visits).
 Ends after the designated period (0, 10, or 90 days).

 Identify What’s Included vs. Excluded:

 Included: Pre-op, intra-op, routine post-op, surgical supplies, typical pain management.
 Excluded: Unrelated services, separate procedures, decision-for-surgery visits.

 Modifiers That Break the Global Period (Must-Know!):

 -24 → Unrelated E/M during post-op period.

 -25 → Significant, separate E/M on the same day as a minor procedure.
 -57 → Decision for surgery on the same day or day before a major surgery.
 -58 → Staged/related procedure during post-op.
 -78 → Return to OR for related complications.
 -79 → Unrelated procedure during post-op.

 CPT & CMS Guidelines Differ Slightly:

 CMS rules (Medicare) are strict on bundling and modifier use.

 CPT guidelines provide general principles but may differ from payers’ interpretations.

 Global Period Identification:

 Always check the Medicare Physician Fee Schedule (MPFS) for global period status (0, 10, or 90
days).
 Some payers follow CMS rules, but others may vary slightly.
 Commonly Tested Scenarios:
 Unrelated Office Visit During Post-Op Period:
o Modifier -24 is needed if the E/M is for a different condition.
 E/M Visit on the Same Day as a Minor Procedure:
 o Modifier -25 is required if the E/M is significant and separately identifiable.
 Return to OR for a Related Complication:
o Modifier -78 applies if the patient requires a second surgery due to a complication within
the global period.
 Unrelated Procedure During the Global Period:
o Modifier -79 applies when a new procedure is performed for a different condition.
Overview of the Surgery Section (10000-69999)
The Surgery section of CPT® is organized by body system and includes procedures related to each
system. Below is a structured breakdown to aid in studying for the CPC exam.

A. Integumentary System (10000-19999)

1. Key Procedural Groups
 Skin, Subcutaneous, Accessory Structures
 Incision and Drainage: (10040–10180)
 Debridement: (11000 series) - Based on depth and total area treated.
 Biopsies and Excision of Lesions: (11100–11446, 11600–11646) - Differentiate benign vs.
malignant, measure excised diameter (lesion + margins), and note anatomical location.
 Repairs (Closure): (12001–13160) - Simple, Intermediate, Complex.
 Skin Grafts and Flaps: (15002–15777) - Includes adjacent tissue transfer (14000 series).
 Mohs Surgery: (17311–17315) - Involves histologic mapping.
 Breast Procedures: (19000–19499) - Includes biopsies (e.g., 19081–19083 for image-guided),
mastectomy (19300–19307), and reconstruction (19316–19380).
This is a good overview of the Integumentary System subsection of the CPT Surgery section. Let's break
down the key procedural groups and special notes with some added detail and context:
A. Integumentary System (10000-19999)
This subsection covers procedures involving the skin, subcutaneous tissue, and accessory structures (hair,
nails, and mammary glands/breast).
1. Key Procedural Groups:
1. Skin, Subcutaneous, and Accessory Structures: This is a broad category encompassing many
procedures, including incisions, excisions, repairs, grafts, and more.
2. Incision and Drainage (10040-10180): These codes are for draining abscesses, hematomas,
cysts, and other fluid collections. The code selection is based on the location and complexity of the
drainage.
 3. Debridement (11000 series): Debridement involves the removal of necrotic or infected tissue.
Coding depends on the depth of the debridement (skin, subcutaneous tissue, muscle, bone) and
the surface area involved. Accurate documentation of both depth and area is essential.
4. Biopsies and Excisions of Lesions (11100-11446, 11600-11646, etc.): This is a very common
group of procedures. Key coding elements include:
1. Benign vs. Malignant: It's crucial to distinguish between benign and malignant lesions, as
they have different code ranges. Pathology reports are generally required to confirm the
diagnosis.
2. Excised Diameter: Measure the greatest diameter of the excised lesion plus the narrowest
margin taken. This is a common source of coding errors. Document the measurements
clearly in the operative report.
3. Anatomical Location: The specific location of the lesion is also a factor in code selection.
5. Repairs (Closure): Simple, Intermediate, Complex (12001-13160): Wound closure is classified
by complexity (simple, intermediate, complex) and the length of the repair. Careful documentation
of the wound closure type and length is required.
6. Skin Grafts, Flaps (15002-15777): These procedures involve transferring skin from one area of
the body to another. Coding is complex and depends on the type of graft or flap, the size of the
defect, and the donor site.
7. Mohs Surgery (17311-17315): Mohs surgery is a specialized technique for treating certain types
of skin cancer. It involves the sequential removal and microscopic examination of tissue layers until
the cancer is completely removed.
8. Breast Procedures (19000-19499): Although the breast is part of the integumentary system, it has
its own subcategory. This section includes procedures such as biopsies, lumpectomies,
mastectomies, and breast reconstruction.
2. Special Notes:
1. Lesion Excision: The points mentioned above (benign vs. malignant, excised diameter,
anatomical location) are essential for accurate coding. Double-check your measurements and
documentation.
2. Repair/Closure: Understanding the definitions of simple, intermediate, and complex closure is
critical. Don't just assume a closure is "simple."
3. Adjacent Tissue Transfer (14000 series): When adjacent tissue transfer (flaps, rearrangements)
is performed, do not separately report simple closure codes for the secondary defect created by
the flap. The closure is included in the adjacent tissue transfer code.
4. Debridement: Accurate documentation of both the depth of the debridement and the total surface
area debrided is necessary. Don't just say "debrided"; specify the extent.
5. Breast Procedures: This subsection has a wide range of procedures. Pay attention to details such
as whether the biopsy is image-guided (19081-19083) and the type of mastectomy (19300-19307).
 Breast reconstruction procedures (19316-19380) are also complex and require careful code
selection.
General Tips for Integumentary System Coding:
1. Anatomical Knowledge: A strong understanding of skin anatomy is crucial.
2. Measurement Accuracy: Accurate measurement of lesions, wounds, and grafts is essential.
3. Documentation Detail: Detailed documentation is key to supporting the codes you select.
4. Code Descriptions: Always read the CPT code descriptions carefully.
5. Payer Policies: Be aware of payer-specific policies regarding integumentary procedures.
By paying close attention to these details, you can improve your accuracy and efficiency when coding
procedures from the Integumentary System subsection.

B. Musculoskeletal System (20000-29999)

 Fractures and Dislocations: (Closed, Open, Percutaneous)
 Arthrocentesis, Aspiration, and Injection
 Tendon Repairs and Transfers
 Arthrodesis and Joint Replacement Procedures
 Osteotomy and Bone Graft Procedures
B. Musculoskeletal System (20000-29999)
This subsection covers procedures involving bones, joints, muscles, tendons, and ligaments. It's a complex
section with many nuances, so accurate coding requires a strong understanding of anatomy and surgical
techniques.
1. Major Categories:
 Incision: This category includes procedures like fasciotomies (incisions into fascia to relieve
pressure) and osteotomies (cutting of bone).
 Excision: This covers biopsies, tumor removals, and other procedures involving the removal of
tissue.
 Fracture and Dislocation Treatment: This is a large and complex area. Accurate coding depends
on several factors (discussed below).
 Arthroscopy: These procedures involve the use of a small scope inserted into a joint to visualize
and treat internal structures.
 Arthroplasty: This category includes joint replacement procedures, such as shoulder (23470-
23474), knee (27447), hip, and other joints.
  Tendon/Ligament/Muscle Repairs: These procedures involve repairing tears or other damage to
these structures.
2. Fracture and Dislocation Coding:
Fracture and dislocation coding is particularly complex and requires careful attention to detail. Key factors
include:
1. Open vs. Closed Treatment: "Open" treatment means the surgeon made an incision to directly
visualize the fracture site. "Closed" treatment means the fracture was reduced (realigned) without a
surgical incision.
2. Manipulation (Reduction) vs. No Manipulation: "Manipulation" refers to the act of realigning the
fractured bone. If the fracture is not displaced or minimally displaced, manipulation may not be
necessary.
3. Internal Fixation (ORIF) vs. External Fixation: Internal fixation involves using hardware (plates,
screws, rods) to stabilize the fracture. External fixation uses a device outside the body to hold the
bones in place.
4. Percutaneous Fixation: This involves placing fixation devices (like pins) through small incisions
without fully opening the fracture site. Percutaneous fixation often has different codes than open or
closed treatment.
5. Specific Bone and Location: Fracture codes are very specific to the bone and the precise
location of the fracture.
6. Displacement: Whether the fracture fragments are displaced (out of alignment) is a crucial factor
in code selection.
7. Comminution: If the bone is broken into multiple pieces (comminuted), this can also affect the
code.
3. Arthroscopy:
1. Diagnostic vs. Surgical: If a surgical arthroscopy is performed during the same session as a
diagnostic arthroscopy, the diagnostic arthroscopy is included in the surgical code and is not billed
separately.
2. Multiple Procedures in the Same Joint: Bundling rules apply to arthroscopic procedures. Some
procedures are considered included in others unless they are performed on a separate structure or
compartment within the joint. Carefully review the code descriptions and any NCCI edits.
4. Additional Points:
 Casting and Strapping: Casting and strapping are typically included in the fracture treatment
codes. They are not usually billed separately. Check payer guidelines for exceptions.
 Hardware Removal: If hardware (plates, screws, etc.) is removed during the global period of the
original surgery, it is usually included in the original procedure and not billed separately. If the
hardware removal is performed after the global period or is unrelated to the original surgery, it may
be billed separately. Documentation must clearly support the reason for the hardware removal.
General Tips for Musculoskeletal Coding:
 Anatomical Knowledge: A thorough understanding of musculoskeletal anatomy is essential.
 Surgical Technique: Understanding the surgical approach and techniques used is critical for
accurate coding.
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the fracture or dislocation, the type of treatment provided, and any other relevant
information.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies.
The Musculoskeletal System section is one of the most challenging in the CPT manual. Careful study,
practice, and attention to detail are essential for accurate coding.

C. Respiratory System (30000-32999)

 Nasal Procedures (e.g., septoplasty, turbinectomy)
 Laryngoscopy and Bronchoscopy
 Thoracotomy and Lung Resection Procedures
C. Respiratory System (30000-32999)
This subsection covers procedures involving the nose, sinuses, larynx, trachea, bronchi, and lungs.
1. Nasal/Sinus Procedures:
 Endoscopic Sinus Surgeries (31231-31298): These are common procedures. Key coding
considerations include:
o Unilateral vs. Bilateral: Some codes are inherently unilateral (one side), and you'll need the
-50 modifier to indicate a bilateral procedure. Other codes are inherently bilateral, so the -
50 modifier is not needed. Carefully read the code description.
o Specific Sinuses Involved: The codes often specify which sinuses are involved (maxillary,
ethmoid, frontal, sphenoid). Accurate identification of the sinuses treated is essential.
o Extent of Procedure: The codes may describe the extent of the procedure (e.g., limited,
complete).
 Septoplasty/Septorhinoplasty: These procedures correct deformities of the nasal septum and/or
the external nose. Coding depends on the complexity of the procedure:
o Septoplasty: Correction of the nasal septum.
 o Septorhinoplasty: Septoplasty plus work on the external nose (e.g., bony work, tip work,
cartilage grafting). Septorhinoplasty codes are more comprehensive and include the
septoplasty.
2. Larynx/Trachea:
1. Laryngoscopy (31505-31579): These procedures involve visualizing the larynx with a scope. Key
distinctions include:
o Direct vs. Indirect: A direct laryngoscopy involves inserting the scope directly into the
larynx. An indirect laryngoscopy uses a mirror to visualize the larynx.
o With or Without Operating Microscope: Some procedures are performed with the aid of an
operating microscope, which may have a separate code.
2. Tracheostomy (31600-31610): This procedure creates an opening in the trachea. Coding
distinctions include:
o Emergency vs. Planned: Emergency tracheostomies are often performed in critical
situations and may have a different code than planned tracheostomies.
3. Bronchoscopies (31615-31660):
 Diagnostic vs. Therapeutic: Bronchoscopies can be diagnostic (to visualize the airways) or
therapeutic (to perform procedures like biopsies, brushings, washings, or stent placement).
 Multiple Procedures: When multiple procedures are performed during the same bronchoscopy
session, some are bundled together. For example, a biopsy and brushing from the same site are
often bundled. Carefully review the code descriptions and any NCCI edits.
4. Thoracotomy/Thoracoscopy (32035-32674):
 Open vs. VATS: Thoracotomies are open surgical procedures on the chest. VATS (video-assisted
thoracoscopic surgery) are minimally invasive procedures using a scope and small incisions. VATS
procedures typically have different codes than open procedures.
 Pulmonary Resections: These procedures involve removing part or all of a lung. Specific codes
exist for lobectomy (removal of a lobe), pneumonectomy (removal of an entire lung), and other
types of resections. Accurate identification of the specific resection performed is essential.
General Tips for Respiratory System Coding:
 Anatomical Knowledge: A solid understanding of respiratory anatomy is crucial.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved and the extent of the procedure.
 Documentation Detail: Detailed documentation is essential to support the codes you select. The
operative report should clearly describe the procedure performed, including any complications or
unusual findings.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
  Payer Policies: Check with individual payers for their specific policies.
The Respiratory System subsection can be complex, particularly with endoscopic procedures and the
distinction between open and minimally invasive approaches. Thorough study, practice, and attention to
detail are essential for accurate coding.

D. Cardiovascular System (33000-39999)

 Pacemaker and Defibrillator Insertion
 CABG (Coronary Artery Bypass Graft)
 Aneurysm Repairs
 Vascular Access Procedures (e.g., 36555–36577)
D. Cardiovascular System (33000-39999)
This subsection covers procedures involving the heart, pericardium, major blood vessels, and the lymphatic
system (though the lymphatic system is often considered separately).
1. Heart and Pericardium:
 Pericardial Procedures: These include pericardiocentesis (33010-33011), which is draining fluid
from the pericardial sac, and pericardial window (33025), which involves creating an opening in the
pericardium.
 Open Heart Surgeries: This is a complex area with many different procedures. Key examples
include:
o Valve Replacements (33400-33496): These codes specify the valve being replaced (aortic,
mitral, tricuspid, pulmonary) and the approach (open or minimally invasive).
o Coronary Artery Bypass Graft (CABG) (33510-33536): CABG procedures involve grafting
blood vessels to bypass blocked coronary arteries. Coding depends on the number of
grafts and whether arterial grafts are used in addition to vein grafts. It's crucial to
distinguish between vein-only grafts (33510-33530) and procedures that also utilize
arterial grafts (33533-33536).
2. Pacemaker and ICD Procedures:
 Insertion, Replacement, Removal (33206-33249): These codes cover a range of procedures
related to pacemakers and implantable cardioverter-defibrillators (ICDs). Key coding distinctions
include:
o Single vs. Dual Leads: Pacemakers and ICDs can have single or dual leads (wires that
connect the device to the heart).
o Initial Insertion vs. Generator Change: A generator change is a replacement of the pulse
generator, while the leads remain in place. This is different from an initial insertion.
 o Specific Device Type: Codes often specify the type of device (pacemaker, ICD,
biventricular device).
 Lead Repositioning or Repair (33215, 33218, etc.): These codes are used when the leads of a
pacemaker or ICD need to be repositioned or repaired.
3. Vascular Procedures:
 Endarterectomy (35301-35390): This procedure involves removing plaque from the inside of an
artery. Coding depends on the artery involved (carotid, femoral, etc.).
 Bypass Grafts (35500-35683): Bypass grafts are used to reroute blood flow around a blocked
artery. Coding requires identifying the source and target vessels (e.g., femoral-popliteal, aorto-
iliac).
 Angioplasties, Atherectomies, Stents: These procedures are often performed via an
endovascular approach (through a catheter inserted into a blood vessel). Coding typically involves
a combination of codes:
o Interventional Radiology Codes: These codes (often in the 70000 range) describe the
imaging guidance and catheter placement.
o Surgical Codes: These codes (often in the 30000 range for percutaneous vascular
procedures) describe the angioplasty, atherectomy, or stent placement itself.
o Selective Catheter Placement: Accurate coding of selective catheter placement is crucial.
4. Central Venous Access:
 Insertion of CV Catheter (36555-36569): These codes cover the insertion of central venous
catheters. Key coding distinctions include:
o Tunneled vs. Non-tunneled: Tunneled catheters are inserted under the skin and have a
cuff that helps to secure them. Non-tunneled catheters are inserted directly into a vein.
o With or Without Subcutaneous Port or Pump: Some catheters have a subcutaneous port or
pump attached.
o Age-Based Differences (<5 years vs. 5+): There are separate codes for children under 5
years old and those 5 years and older.
 Removal, Repair, or Replacement: Codes also exist for removing, repairing, or replacing central
venous catheters.
General Tips for Cardiovascular Coding:
 Anatomical Knowledge: A thorough understanding of cardiovascular anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific vessels involved, the type of device used, and the approach (open, minimally invasive,
endovascular).
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings.
  Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits, particularly with endovascular
procedures.
 Payer Policies: Check with individual payers for their specific policies.
The Cardiovascular System subsection can be complex, particularly with the combination of surgical and
interventional radiology codes used for many procedures. Thorough study, practice, and attention to detail
are essential for accurate coding.

E. Digestive System (40000-49999)

 Esophagoscopy, Gastroscopy, and Colonoscopy
 Hernia Repairs
 Appendectomy and Colectomy Procedures
Digestive System (40000-49999)
This subsection covers procedures involving the esophagus, stomach, intestines, appendix, gallbladder,
liver, pancreas, and rectum.
1. Esophagoscopy, Gastroscopy, Colonoscopy:
 Extent of Scope: A key factor in coding these endoscopic procedures is the extent of the
examination. Codes are often differentiated by how far the scope is advanced (e.g., esophagus
only, esophagus + stomach + duodenum, colon to splenic flexure vs. colon to cecum). Accurate
documentation of the furthest extent of the scope is crucial.
 Biopsy, Polypectomy, Ablation: These procedures, when performed during an endoscopy, have
distinct codes. It's important to note that some codes combine polyp removal and biopsy. Carefully
review the code descriptions.
 Multiple Procedures: If multiple procedures are performed during the same endoscopic session
(e.g., biopsy + polypectomy + ablation), bundling rules may apply. Carefully review the code
descriptions and any NCCI edits.
2. Appendectomy (44950-44979):
 Open vs. Laparoscopic: Appendectomies can be performed either open (traditional incision) or
laparoscopically (minimally invasive). Laparoscopic appendectomies (44970) typically have a
separate code.
 Bundling: If an appendectomy is performed as part of a more extensive procedure, it may be
bundled into the primary procedure code unless it is documented as a significantly separate
procedure or due to incidental pathology. Clear documentation is essential to support separate
billing.
3. Hernia Repairs (49491-49659):
  Classification: Hernia repairs are classified by several factors:
o Type: Inguinal, femoral, incisional, umbilical, etc.
o Patient Age: There are often separate codes for pediatric patients and adults.
o Initial vs. Recurrent: A recurrent hernia repair is a repair of a hernia that has previously
been repaired.
o Open vs. Laparoscopic: Hernia repairs can be performed either open or laparoscopically.
 Specific Code Selection: Careful attention to all of these classifying factors is needed to select
the correct code.
4. Cholecystectomy (Gallbladder Removal):
 Laparoscopic vs. Open: Cholecystectomies can be performed laparoscopically (47562-47564) or
open (47600, 47605).
 Cholangiography: A cholangiography (imaging of the bile ducts) is often performed during a
cholecystectomy. Some cholecystectomy codes include the cholangiography; others may allow it to
be billed separately if it is not included in the primary code description. Check the code description
and payer guidelines.
5. Bowel Resections:
 Partial Colectomy: These procedures involve removing a portion of the colon. Codes are
differentiated by the approach (open or laparoscopic) and the extent of the resection.
 Anastomosis or Stoma: Anastomosis (reconnecting the bowel) and stoma formation (creating an
opening to the outside of the body) may be included in the bowel resection code or may be billed
separately depending on the specific procedure. Carefully review the code descriptions.
General Tips for Digestive System Coding:
 Anatomical Knowledge: A solid understanding of digestive anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
extent of the procedure, the specific structures involved, and the approach (open, laparoscopic,
endoscopic).
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies.
The Digestive System subsection contains a wide range of procedures, and many involve complex coding
considerations. Thorough study, practice, and attention to detail are essential for accurate coding.
 F. Urinary System (50000-59999)
 Nephrectomy and Kidney Transplant Procedures
 Cystoscopy and Ureteroscopy
 Lithotripsy (Kidney Stone Procedures)
Urinary System (50000-59999)
This subsection covers procedures involving the kidneys, ureters, bladder, and urethra.
1. Kidneys, Ureters, Bladder, Urethra:
 Nephrectomy (50220-50240): This procedure involves removing a kidney. Key coding distinctions
include:
o Partial vs. Total: A partial nephrectomy removes only part of the kidney, while a total
nephrectomy removes the entire kidney.
o Open vs. Laparoscopic: Nephrectomies can be performed either open or laparoscopically.
 Ureteroscopy (52320-52356): This procedure involves inserting a scope into the ureter. Common
procedures performed during ureteroscopy include:
o Stone Removal: Removing kidney stones from the ureter.
o Lithotripsy: Breaking up kidney stones using lasers or other methods.
o Stent Placement: Placing a stent in the ureter to maintain patency.
 Cystoscopy (52000-52015 range): This procedure involves inserting a scope into the bladder.
Cystoscopy codes often serve as the base procedure for a variety of add-on procedures, such as:
o Biopsy: Removing tissue for examination.
o Fulguration: Destroying tissue with an electric current.
o Urethral Dilation: Widening the urethra.
2. Lithotripsy:
 ESWL vs. Percutaneous: Lithotripsy, the breaking up of kidney stones, can be performed in
different ways:
o ESWL (Extracorporeal Shock Wave Lithotripsy): Uses shock waves to break up the stones
from outside the body.
o Percutaneous Lithotripsy: Involves inserting a probe through the skin into the kidney to
break up and remove the stones.
 Imaging Guidance: Some lithotripsy codes include imaging guidance (fluoroscopy), while others
may require separate coding for imaging. Carefully review the code descriptions.
3. Prostate Procedures:
  Transurethral Resection of the Prostate (TURP) (52601): This procedure involves removing
excess prostate tissue to relieve urinary obstruction.
 Holmium Laser Enucleation of the Prostate (HoLEP): HoLEP is a newer technique for treating
benign prostatic hyperplasia (BPH). If a distinct code exists for HoLEP, it should be used instead of
the TURP code. Check the CPT manual for the most current coding.
General Tips for Urinary System Coding:
 Anatomical Knowledge: A solid understanding of urinary anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved, the approach (open, laparoscopic, endoscopic), and any additional
procedures performed.
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits, particularly with endoscopic
procedures.
 Payer Policies: Check with individual payers for their specific policies.
The Urinary System subsection can be complex, especially with the various endoscopic procedures and
the distinctions between different approaches (open, laparoscopic, percutaneous). Thorough study,
practice, and attention to detail are essential for accurate coding.

G. Male/Female Genital System (54000-55999, 56405-58999)

3. Vasectomy and Prostatectomy
4. Hysterectomy and Oophorectomy
5. Obstetric Delivery Codes
Male Genital System (55000-55899)
This subsection covers procedures involving the male reproductive organs, including the scrotum, testes,
penis, and prostate (although the prostate is sometimes considered separately with the urinary system).
1. Scrotum and Testes:
 Common Procedures: This category includes procedures such as:
o Orchiectomy: Removal of a testicle.
o Vasectomy: Severing the vas deferens to achieve male sterilization.
o Hydrocelectomy: Repair of a hydrocele (fluid collection around the testicle).
  Code Location: As you noted, some related procedures might be found in the 50000 range
(Urinary System) if they involve structures shared with the urinary tract. Pay close attention to the
code descriptions and index to ensure you are using the most appropriate code.
2. Penile Procedures:
 Circumcision (54150-54163): Key coding considerations include:
o Age: There are separate codes for newborn circumcisions and circumcisions performed on
older children or adults.
o Anesthesia: The type of anesthesia used (local vs. regional) may also be a factor in code
selection.
 Penile Implants/Prostheses: Codes exist for the insertion of penile implants or prostheses, often
used to treat erectile dysfunction. These procedures can be complex, so careful review of the code
descriptions is essential.
3. Vasectomy (55250):
 Commonly Tested: Vasectomy is indeed a commonly tested procedure on the CPC exam. Make
sure you understand the procedure itself and the associated coding rules.
 Bundling: Many payers include the postoperative semen analysis in the vasectomy code (55250).
This means you cannot bill separately for the semen analysis. However, payer policies can vary, so
check with individual payers.
General Tips for Male Genital System Coding:
 Anatomical Knowledge: A solid understanding of male reproductive anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved and the approach (open, laparoscopic).
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies, particularly regarding the
bundling of postoperative semen analysis with vasectomy codes.
This subsection is generally less complex than some of the other surgical sections, but accurate coding still
requires attention to detail and a good understanding of the procedures involved. Focus on the key
distinctions mentioned above, and you should be well-prepared for the CPC exam and real-world coding
scenarios.

Female Genital System (56405-58999) & Maternity (59000-59999)

These subsections cover procedures involving the female reproductive organs and maternity care.
1. Obstetrical Care:
 Global OB Packages: The majority of routine obstetrical care is bundled into global OB codes.
These global codes cover all the routine antepartum care, the delivery itself, and routine
postpartum care.
o 59400: Vaginal delivery, including antepartum care, delivery, and postpartum care.
o 59510: Cesarean delivery, including antepartum care, delivery, and postpartum care.
 Separate Procedures: While routine care is bundled, separate procedures performed during the
antepartum, delivery, or postpartum periods can be billed separately. Examples include:
o Cerclage: A procedure to reinforce the cervix to prevent premature delivery.
o External Cephalic Version (ECV): A procedure to turn a breech baby.
 Complications: Care for complications during pregnancy or delivery is typically billed separately.
This includes conditions like preeclampsia, gestational diabetes, and postpartum hemorrhage.
2. Hysterectomy:
 Approaches: Hysterectomies (removal of the uterus) can be performed via different approaches:
o Abdominal (58150-58152): Involves an incision in the abdomen.
o Vaginal (58260-58294): Performed through the vagina.
o Laparoscopic (58541-58554): Minimally invasive approach using a scope and small
incisions.
 Types: Hysterectomies are further classified by the extent of the procedure:
o Total vs. Supracervical: A total hysterectomy removes the entire uterus, including the
cervix. A supracervical hysterectomy removes the body of the uterus, leaving the cervix in
place.
o With or Without Removal of Tubes/Ovaries (Salpingo-oophorectomy): This indicates
whether the fallopian tubes and/or ovaries are also removed along with the uterus.
 Code Specificity: Accurate coding requires careful attention to the approach, type of
hysterectomy, and whether other structures are removed.
3. Procedures on Ovaries/Fallopian Tubes:
 Salpingo-oophorectomy (58940-58960 series): These codes cover procedures involving the
ovaries and fallopian tubes, including removal (oophorectomy, salpingectomy, salpingo-
oophorectomy).
 Ectopic Pregnancy: Surgical codes (59120-59151) exist for treating ectopic pregnancies
(pregnancies that develop outside the uterus). Coding depends on the location of the ectopic
pregnancy and the surgical approach.
4. Vulva, Vagina, Cervix:
  Common Procedures: This category includes a variety of procedures, such as:
o Labiaplasty: Surgical modification of the labia.
o Colporrhaphy: Repair of the vaginal wall.
o Cervical Conization: Removal of a cone-shaped piece of tissue from the cervix.
o Loop Electrosurgical Excision Procedure (LEEP): A procedure using an electrical loop to
remove tissue from the cervix.
 Approach: Pay attention to whether a laparoscopic or open approach is used, as this can affect
code selection.
General Tips for Female Genital System and Maternity Coding:
 Anatomical Knowledge: A thorough understanding of female reproductive anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved, the approach (open, laparoscopic, vaginal), and any additional
procedures performed.
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings. For obstetrical
care, documentation should include details of antepartum visits, the delivery, and postpartum care.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies, particularly regarding global
OB packages and separate billing for complications or other procedures.
These subsections can be complex, particularly with the various approaches and types of procedures
available. Thorough study, practice, and attention to detail are essential for accurate coding.

H. Nervous System (60000-64999)

 Craniotomy and Craniectomy Procedures
 Spinal Fusion and Decompression Procedures
 Peripheral Nerve Repair and Destruction
Nervous System (61000-64999)
This subsection covers procedures involving the brain, spinal cord, and peripheral nerves. It's a complex
section requiring a strong understanding of neuroanatomy and surgical techniques.
1. Cranial Procedures:
  Craniotomy/Craniectomy: These procedures involve opening the skull. Common indications
include:
o Tumor Removal (61500-61510 range): Coding depends on the location and size of the
tumor.
o Hematoma Evacuation: Removing a collection of blood (hematoma) from the brain.
o Aneurysm Repair: Repairing a weakened blood vessel in the brain to prevent rupture.
 Shunt Procedures: These procedures are used to drain cerebrospinal fluid (CSF) from the brain.
A common example is a ventriculoperitoneal shunt (62223), which drains CSF from the ventricles
of the brain to the abdomen.
2. Spinal Procedures:
 Laminectomy (63000-63047): This procedure involves removing part of the vertebral lamina (part
of the bony arch of the vertebra) to relieve pressure on the spinal cord or nerves.
 Diskectomy: This procedure involves removing a damaged intervertebral disc.
 Spinal Fusion (22600-22614 range): This procedure fuses two or more vertebrae together to
stabilize the spine.
 Instrumentation (22840-22851): Spinal instrumentation (rods, screws, plates) is often used in
conjunction with spinal fusion. It's crucial to know when instrumentation is separately reportable
and when it's bundled into the spinal fusion code. Generally, if the instrumentation is placed at the
same surgical session as the fusion, it is bundled. If it is placed at a subsequent session, it may be
billed separately.
3. Peripheral Nerves:
 Common Procedures: This category includes procedures such as:
o Neuroplasty: Decompression or freeing up of a nerve.
o Nerve Grafts: Repairing a damaged nerve using a graft from another part of the body.
o Carpal Tunnel Release (64721): A procedure to relieve pressure on the median nerve in
the wrist.
 Separate Coding: Each distinct nerve or group of nerves is typically coded separately if distinct
anatomical areas are involved. For example, if neuroplasty is performed on multiple nerves in the
same limb, each nerve may be coded separately.
General Tips for Nervous System Coding:
 Anatomical Knowledge: A thorough understanding of neuroanatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved, the approach (open, minimally invasive), and any additional
procedures performed.
  Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings. For spinal
procedures, documentation should clearly identify the specific vertebrae involved.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies, particularly regarding spinal
instrumentation and other complex procedures.

I. Eye and Ocular Adnexa (65000-69999)

1. Cataract Extraction and Lens Replacement
2. Glaucoma and Retinal Procedures
Eye and Ocular Adnexa (65000-68899)
This subsection covers procedures involving the eye and its surrounding structures, including the eyelids,
conjunctiva, cornea, lens, retina, and optic nerve.
1. Cataract Extraction:
 Phacoemulsification vs. Extracapsular: These are two different techniques for cataract
extraction:
o Phacoemulsification: Uses ultrasound to break up the cataract and then remove it. This is
the more common method today.
o Extracapsular Cataract Extraction: Involves removing the lens in one piece.
 IOL Insertion: Insertion of an intraocular lens (IOL) is typically included in the cataract extraction
code unless the code description specifically states otherwise. Don't bill separately for the IOL
insertion in most cases.
2. Glaucoma Procedures:
 Common Procedures: This category includes a variety of procedures to treat glaucoma, such as:
o Trabeculectomy: A surgical procedure to create a new drainage pathway for fluid in the
eye.
o Shunt Insertion: Placement of a shunt to drain fluid from the eye.
o Laser Procedures: Using lasers to treat different types of glaucoma.
 Initial vs. Subsequent: It's crucial to distinguish between initial glaucoma surgery and subsequent
surgeries on the same eye. Codes often differentiate between these scenarios.
3. Eyelid Procedures:
  Blepharoplasty: This procedure involves surgically modifying the eyelids to correct drooping or
excess skin. It's important to note that blepharoplasty codes can be found in two different sections
of the CPT manual:
o Integumentary System (15820-15823): These codes are typically used when the
blepharoplasty is performed for cosmetic reasons.
o Eye and Ocular Adnexa (67900-67908): These codes are used when the blepharoplasty is
performed for functional reasons, such as to correct visual impairment caused by drooping
eyelids. The reason for the procedure must be clearly documented to support the correct
code selection.
General Tips for Eye and Ocular Adnexa Coding:
 Anatomical Knowledge: A thorough understanding of eye anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved, the approach (open, minimally invasive), and any additional
procedures performed.
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings. For eyelid
procedures, the reason for the procedure (cosmetic vs. functional) must be clearly documented.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies.
This subsection requires careful attention to detail, particularly regarding the distinction between cosmetic
and functional blepharoplasty and the differentiation between initial and subsequent glaucoma procedures.

J. Auditory System (69000-69999)

1. Tympanostomy (Ear Tube Placement)
2. Cochlear Implant Procedures
3. Mastoidectomy and Ear Reconstruction
Auditory System (69000-69990)
This subsection covers procedures involving the external, middle, and inner ear.
1. Ear Procedures:
 Myringotomy (69420) vs. Tympanostomy (69433-69436): These are common childhood
procedures.
o Myringotomy (69420): Involves making a small incision in the eardrum to drain fluid.
 o Tympanostomy (69433-69436): Involves placing a small tube (tympanostomy tube or "ear
tube") in the eardrum to prevent fluid buildup. These codes include the myringotomy. The
codes are differentiated by whether or not a tube was inserted and, if so, the type of tube.
 Mastoidectomy (69501-69511): This procedure involves removing part of the mastoid bone
(located behind the ear). Different codes are used based on the extent of the mastoidectomy.
 Stapedectomy: This procedure involves removing the stapes bone (a small bone in the middle
ear) and replacing it with a prosthesis, often to treat otosclerosis.
 Cochlear Implant (69930): This procedure involves implanting a device in the inner ear to improve
hearing.
2. Operating Microscope (69990):
 Add-on Code: CPT code 69990 (Use of operating microscope) is an add-on code. This means it is
only reported in addition to the primary procedure code. It is never reported as a standalone code.
 Bundling: Many microsurgical procedures now include the use of the operating microscope in
their code descriptions. If the primary procedure code already includes the use of the operating
microscope, you cannot bill 69990 separately. Carefully read the code descriptions to determine if
the operating microscope is included.
 When to Report 69990: Only report 69990 when the operating microscope is used and the
primary procedure code does not include it.
General Tips for Auditory System Coding:
 Anatomical Knowledge: A thorough understanding of ear anatomy is essential.
 Procedure Details: Pay close attention to the details of the procedure performed, including the
specific structures involved and the extent of the procedure.
 Documentation Detail: Detailed documentation is crucial. The operative report should clearly
describe the procedure performed, including any complications or unusual findings.
 Code Descriptions: Always read the CPT code descriptions carefully.
 Bundling Rules: Be aware of bundling rules and NCCI edits.
 Payer Policies: Check with individual payers for their specific policies.
The Auditory System subsection is generally less complex than some of the other surgical sections, but it's
important to understand the distinctions between the various procedures and to use the operating
microscope code (69990) correctly. Careful review of the code descriptions and operative reports is
essential for accurate coding.

Key Guidelines & Bundling vs. Separate Procedures

National Correct Coding Initiative (NCCI) Edits:
  Purpose: NCCI edits are crucial for preventing unbundling and ensuring proper payment for
surgical procedures. They identify code pairs that should not be billed together because one
procedure is considered inherently included in the other.
 Column 1/Column 2 Edits: NCCI edits are presented in tables. Column 1 represents the
"comprehensive" code, and Column 2 represents the "component" code (the one that is bundled).
If both codes are billed together without a proper modifier, only the Column 1 code will be paid.
 Modifier -59 or X{EPSU}: These modifiers are used to appropriately unbundle procedures only
when the NCCI criteria are met. This typically means the procedures were performed at a separate
site, during a separate session, or represent a distinct procedural service. Improper use of these
modifiers can lead to audits and claim denials. The X modifiers (XE, XS, XP, XU) are more specific
and preferred by some payers when applicable.

 Maintained by CMS to prevent unbundling.

 Some procedures are always included in others if performed on the same site/encounter.
 Check column 1/column 2 code pair edits.
 Use modifier -59 or X{EPSU} (XU, XE, etc.) to unbundle only when criteria are met (distinct
procedure, separate site, etc.).
Separate Procedure:
 Meaning: The phrase "(separate procedure)" in a code description indicates that the
procedure is usually included in a more extensive procedure when performed at the same
time, same site, and by the same provider.
 When to Bill Separately: You can only bill a "separate procedure" separately if it is truly
independent, unrelated to the primary procedure, or performed on a different site. Clear
documentation is essential to support separate billing.
 The phrase “(separate procedure)” in a CPT® code description means the procedure is integral
to a more extensive surgery.
 Only code separately if it’s independent or unrelated to the primary procedure.
Add-On Codes
 Identification: Add-on codes are identified by a "+" symbol in the CPT manual.
 Standalone Codes: Add-on codes cannot be billed alone. They must be reported in
conjunction with the primary procedure code.
 Examples: You provided good examples. +11001 is used for each additional 10% of body
surface area debrided, and +23350 is used for each additional tendon repaired in certain
hand/finger tendon repair procedures.
 Identified with a “+” symbol.
 Cannot be used alone; must be reported with a primary procedure.
 Example:
o +11001 for each additional 10% of body surface area debrided.
 o +23350 for each additional tendon in certain repairs.
Lesion Excisions and Repairs
 Simple Repairs: Simple wound closures are typically included in the lesion excision code. You
generally cannot bill separately for a simple closure.
 Intermediate or Complex Repairs: Intermediate or complex closures may be billed separately
depending on the code descriptor instructions and payer guidelines. Carefully review the notes in
the CPT manual and payer policies.
 Simple closure is bundled into the excision code.
 Intermediate or complex closures may require separate coding based on code descriptor
instructions.

Common Surgical Modifiers

-50: Bilateral Procedure:

Use: Used when a procedure is performed on both sides of the body during the same session.
Unilateral vs. Bilateral Codes: Some codes are inherently unilateral (one side), while others are
inherently bilateral. Carefully check the code description. If a code is inherently unilateral, you
would use modifier -50 to indicate a bilateral procedure. If a code is inherently bilateral, you would
not use modifier -50. RT/LT modifiers may be required by some payers for bilateral procedures.
 Use for procedures performed on both sides of the body during the same session.
 Some codes are inherently unilateral; check if RT/LT or -50 is appropriate.

-51: Multiple Procedures

 Use: Used when more than one procedure (other than E/M services) is performed during the same
session by the same provider.
 Exempt Codes: Some codes are exempt from modifier -51. These are typically add-on codes or
codes that already include multiple procedures. These codes are often identified by the "circle-
arrow" symbol (↻) in the CPT manual.
 Note: Many payers, including Medicare, have significantly reduced their use of modifier -51. They
often prefer that each procedure be listed on a separate line.
 Used when more than one procedure (excluding E/M) is performed in the same session by the
same provider.
 Some codes are exempt from -51, indicated by the ↻ (circle arrow) symbol in CPT®.
 -59: Distinct Procedural Service
 Use: Used to break an NCCI edit when the procedures are performed at a separate site, during a
separate session, or represent a distinct procedural service. This modifier should be used
cautiously and only when the criteria are truly met.
 X Modifiers: The X modifiers (XE, XS, XP, XU) are more specific alternatives to modifier -59 and are
preferred by some payers. They provide more detail about why the procedures are distinct.
 Used to break an NCCI edit if the procedure was performed at a separate site or separate
session from the primary procedure.
 Some payers prefer X-modifiers (XE, XS, XP, XU).

-58: Staged or Related Procedure

Use: Used when a procedure is planned or staged prospectively, or is a more extensive procedure
performed during the postoperative period of another surgery.

 Used when:
o A procedure is planned/staged prospectively.
o A more extensive procedure follows an initial surgery during the post-op period.

-78: Unplanned Return to OR for a Related Procedure

 Same provider, within the post-op period.
 Used for a complication or related issue requiring a return to the OR.
Use: Used when the same provider performs a related procedure during the postoperative period of the
original surgery due to a complication or other related issue. This indicates an unplanned return to the
operating room.

-79: Unrelated Procedure During Post-Op Period

 Used when a new or unrelated problem requires surgery during the global period of a previous
procedure.
 Use: Used when a new or unrelated problem occurs during the global period of a prior surgery, and
the same provider performs a procedure to address this unrelated problem.

-24 (E/M Only): Unrelated E/M During Post-Op Period

 Used when a provider evaluates a completely different condition during the post-op period of a
previous surgery.
  Use: Used when the provider sees the patient for a completely different condition than the
surgery's reason during the postoperative period.

-25 (E/M Only): Significant, Separately Identifiable E/M on the

Same Day as a Procedure
 Used when an E/M service is provided beyond the typical preoperative evaluation for a minor
procedure.
 Use: Used when a significant, separately identifiable E/M service is performed on the same day as
a minor procedure. The E/M service must be above and beyond the usual pre- and post-operative
care associated with the minor procedure.

Practical examples of surgical coding scenarios

1. Example 1: Removal of Benign Lesion
 Key Information: 1.5 cm benign lesion, right arm, 2.0 cm total excision diameter (lesion +
margins).
 Code Selection: You correctly identified the code range (11400-11406). The excised diameter is
the key measurement. Even though the lesion itself is 1.5cm, you must include the margins taken.
1.5cm + 0.25cm margin + 0.25cm margin = 2.0cm. Therefore, 11402 (1.1-2.0cm) is the correct
code.
 Closure: You correctly noted that the simple closure is included in the excision code.
2. Example 2: Open Reduction Internal Fixation (ORIF) of Radius
 Key Information: Displaced distal radius fracture, open reduction, internal fixation (plates and
screws).
 Code Selection: You correctly identified 25607 as the appropriate code. This code specifically
describes an open treatment of a distal radius fracture with internal fixation.
 Hardware: You correctly pointed out that the hardware (plates and screws) is included in this code.
It is not billed separately.
3. Example 3: Partial Colectomy with Anastomosis
 Key Information: Laparoscopic partial colectomy, descending colon, primary anastomosis.
 Code Selection: You correctly identified 44204 as a likely code. However, it is crucial to confirm
that no other procedures were performed that might be bundled. For example, if a coloproctostomy
or stoma creation was also performed, a different code or additional codes might be necessary.
Carefully review the operative report and code descriptions.
4. Example 4: Bilateral Knee Arthroscopy
 Key Information: Right knee: medial meniscectomy. Left knee: lateral meniscectomy.
  Code Selection: You correctly identified the base codes (29881 for medial or lateral
meniscectomy).
 Bilateral Modifier: You correctly mentioned the use of modifier -50 or RT/LT. Payer preference
varies. Some payers require the -50 modifier for bilateral procedures, while others prefer or require
the RT (right) and LT (left) modifiers to be appended to each side's code. Always check payer
guidelines.
 Combined Meniscectomy: Your note about 29880 is also correct. If both the medial and lateral
menisci are removed in the same knee, 29880 is the appropriate code (and is not bilateral).
5. Example 5: Cholecystectomy with Cholangiography
 Key Information: Laparoscopic cholecystectomy with cholangiography.
 Code Selection: You correctly highlighted the importance of the code descriptor. If the
cholecystectomy code description specifically includes the cholangiography, you
cannot bill for the cholangiography separately. 47563 is a good example of a code that
includes the cholangiography.
 Separate Cholangiography: If the cholecystectomy code does not include the
cholangiography, and the cholangiography is performed and documented, it may be
billed separately. However, payer policies can vary, so always check.
General Tips for Surgical Coding Examples:
 Read the Entire Operative Report: Don't just skim the report. Read it carefully to
understand all the procedures performed.
 Identify Key Words: Look for key words in the operative report that can help you identify
the correct CPT codes.
 Use the CPT Index: The CPT index is a valuable tool for finding potential codes.
 Read the Code Descriptions: Always read the complete code description in the CPT
manual to ensure the code accurately describes the procedure performed.
 Check for Bundling Rules: Be aware of bundling rules and NCCI edits.
 Consider Modifiers: Determine if any modifiers are necessary to accurately reflect the
services performed.
 Check Payer Policies: Always check with individual payers for their specific policies.

 Overuse of Unbundled Codes

 Unbundling occurs when related procedures are reported separately instead of using a bundled code that
includes all components. It's important to review the National Correct Coding Initiative (NCCI) edits to
ensure procedures are appropriately bundled. Reporting "separate procedure" codes without justifying them
can lead to audit risks. Always check the guidelines to avoid unbundling.
 Incorrect Lesion Measurement
  For excision codes, it's crucial to measure the lesion size and the surrounding margins to ensure correct
code selection. Failure to add the required margins to the lesion's diameter can result in underreporting.
Additionally, the defect size after excision should not be confused with the lesion size. Always follow the
CPT’s specific instructions to ensure accuracy.
 Missing or Incorrect Modifiers
 Modifiers like -59 (Distinct Procedural Service) or -XU (Unusual Non-Overlapping Service) are essential for
reporting separate procedures or unique circumstances. Omission can lead to claim denials. The modifier -
51 (Multiple Procedures) must be used correctly—incorrect use, especially on codes that are exempt, can
trigger an audit. Be mindful of which codes require -51 and which don’t.
 Global Period E/Ms
 Services provided during a global period should be billed correctly. When an Evaluation and Management
(E/M) service is unrelated to the procedure performed, the modifier -24 (Unrelated E/M Service by the Same
Physician During a Global Period) should be used. Failing to use this modifier may result in denials or
confusion during claims processing.
 Inaccurate Fracture Coding
 Different approaches (closed, open, or percutaneous) must be accurately documented and coded.
Additionally, follow-up care such as casting is typically included in the fracture treatment code. Missing this
can lead to overcoding or claims confusion. Always verify the approach and follow-up care included in
fracture codes.
 Ignoring Subsection Guidelines
 CPT surgical subsections often have unique definitions for procedures like partial vs. total excision or
arthroscopic compartments. Not consulting these specific guidelines can lead to incorrect coding, affecting
reimbursement and triggering audits. Be sure to understand the distinctions within each surgical subsection
and follow the guidelines closely.

Introduction to Radiology Coding

1. Radiology’s Role in Healthcare
Radiology plays a critical role in healthcare by providing diagnostic imaging, therapeutic interventions, and
guidance for procedures. It encompasses multiple imaging modalities, such as:
 X-ray (Radiography): Used for detecting fractures, infections, and other conditions.
 Fluoroscopy: Provides real-time imaging, often used for guiding procedures.
 Ultrasound (US): Utilized for imaging soft tissues and guiding biopsies.
 Computed Tomography (CT): Offers detailed cross-sectional images, commonly used in
emergency settings.
 Magnetic Resonance Imaging (MRI): Produces detailed images of soft tissues, often
used in neurological and musculoskeletal diagnostics.
 Nuclear Medicine (including PET scans): Provides functional imaging to detect disease
at the cellular level.
  Interventional Radiology (IR): Involves minimally invasive procedures, like biopsies and
catheter placements, guided by imaging.
2. CPT® Radiology Section (70000–79999)
The CPT® radiology codes fall under the 70000 series, covering diagnostic, therapeutic, and interventional
services. Key subsections include:
 Diagnostic Radiology: Includes X-rays, CT, MRI, and ultrasound.
 Radiologic Guidance: Used for image-guided procedures like biopsies.
 Breast Imaging: Includes mammography and related services.
 Radiation Oncology: Codes for radiotherapy and related treatments.
 Nuclear Medicine: Codes for imaging procedures like PET scans and other nuclear studies.
3. Importance for the CPC Exam
Radiology accounts for approximately 4–6% of the CPC exam. While it is not as large as surgery, radiology
coding questions can be quite detailed, testing knowledge in areas such as:
 Component reporting (technical vs. professional)
 Use of contrast material
 Modifier usage (e.g., -TC for technical component, -26 for professional component)
 Bundling rules in interventional radiology

Radiology Coding Fundamentals

1. Technical vs. Professional Components
Radiology services are often divided into two components:
 Technical Component (TC): Includes the use of equipment, supplies, and the work of the
technician.
 Professional Component (26): Refers to the physician’s interpretation of the images and the
report.
When coding for these services, it's important to note:
 Global Code (no modifier): Used when both components (technical and professional) are provided
by the same entity.
 Modifier -26: Used when billing only for the professional component (interpretation).
 Modifier -TC: Used when billing only for the technical component (equipment, technician).

Imaging Views & Series

For diagnostic X-rays, codes often specify the number of views (e.g., “2 views,” “3 views”). It's crucial to
ensure the number of views or series matches the documentation. For example, a chest X-ray might be
documented as "2 views" (PA and lateral), and the correct code should reflect this.
 Contrast Material
Contrast material is used in various imaging procedures to enhance visibility:
 With Contrast: The patient receives contrast material during the procedure.
 Without Contrast: The imaging is done without any contrast material.
 With and Without Contrast: Refers to a two-phase study, such as in some CT or MRI procedures.
Each of these scenarios will have distinct CPT® codes.
4. Supervision and Interpretation (S&I)
Some older radiology codes include the term "S&I" (supervision and interpretation), which indicates that the
professional component must be paired with a corresponding procedure code. This has been largely
replaced by updated bundling instructions, but it's still important to understand for coding accuracy.
5. Documentation Requirements
A written radiology report is required for the professional component. The report must include:
 Findings: What the radiologist observed during the study.
 Impressions: The radiologist’s interpretation of the findings.
 Measurements: Such as the size of lesions or any abnormalities found in the imaging.

Radiology Subsections in CPT®

A. Diagnostic Radiology (Conventional X-ray)
 Chest X-rays (71045–71048) – Differentiated by the number of views (e.g., 1 view, 2 views, etc.).
 Abdominal X-rays (74018–74021) – Also specified by the number of views and sometimes
differentiated by the type of series.
 Skeletal/Extremities – Codes for X-rays of different body parts like hands, wrists, and knees, with
attention to unilateral vs. bilateral.
 Spine X-rays – Codes vary by region and number of views, with specialized views like obliques
requiring a distinct code.
 Other Diagnostic Radiology – Notes codes for full versus limited studies, like an "entire spine
survey."
B. Diagnostic Ultrasound (76500–76999)
 General Ultrasound – Includes abdominal, pelvic, and retroperitoneal ultrasounds, distinguishing
complete vs. limited exams.
 Obstetric Ultrasound – Covers different trimesters, types of exams (e.g., transabdominal vs.
transvaginal), and multiple gestations.
  Vascular Ultrasound – Includes codes for duplex scanning of veins and arteries, as well as
Doppler use.
 Breast Ultrasound – Includes codes for unilateral studies and potential use of modifier -50 for
bilateral studies.
 Ultrasound Guidance – Used for procedures like biopsies, requiring specific guidance codes.
C. Radiologic Guidance (Fluoroscopy, CT Guidance, MRI Guidance)
 Fluoroscopy – Codes for central venous access, needle placement, and therapeutic injections.
 CT Guidance – Used for needle placement and similar procedures, with checks for whether
guidance is included in the primary code.
 MRI Guidance – Similar rules as CT guidance, for real-time MRI guidance when not bundled into
the main code.
D. Breast Mammography (77061–77067)
 Screening Mammography – Standard codes for bilateral 2-view mammography.
 Diagnostic Mammography – Codes for unilateral or bilateral mammography for follow-up or
suspected abnormalities.
 Tomosynthesis (3D Mammography) – Specialized codes, and payer policies may vary.
E. Bone/Joint Studies (77071–77084)
 Bone Surveys – Includes DEXA scans for osteoporosis/osteopenia and whole-body surveys for
myeloma or metastatic disease.
 Bone Age Studies – Uses standard X-ray codes with possible specialized interpretation for bone
age.
 MRI of Bone/Joint – MRI codes with distinctions for extremities, joints, and non-joint areas.
F. Radiation Oncology (77261–77799)
 Treatment Management – Codes for treatment planning, medical physics consultation, and
radiation management.
 Therapeutic Procedures – Codes for brachytherapy, external beam radiation, and daily
treatments.
 Documentation – Requires detailed records of the planning, simulation, and treatment phases.
G. Nuclear Medicine (78012–79999)
 Diagnostic Nuclear Medicine – Includes bone scans, SPECT, PET scans, and tracer
administration.
 Cardiac Nuclear Medicine – Codes for myocardial perfusion imaging, including variations for
stress/rest and imaging sessions.
 PET/CT – Specific codes for combined PET/CT procedures, particularly in oncology or neurology.
II. Interventional Radiology (IR)
 Definition – Involves imaging-guided procedures like angiography, stent placement, embolization,
drainage, and biopsies.
 Vascular IR – Codes for angiography and therapeutic interventions, with special attention to
catheter placement and selectivity.
 Non-Vascular IR – Includes drainage and biopsy procedures, often bundled with imaging
guidance.
 Component Coding – Distinguishes between diagnostic and therapeutic components, ensuring
proper coding for each.
 Common Pitfalls – Reporting errors like diagnostic angiography post-intervention or incorrect
selective catheter placement.
III. Modifiers Specific to Radiology
 -26 – Used when coding only the professional component (interpretation/report).
 -TC – Used for the technical component (equipment and technician).
 -76 / -77 – For repeat procedures by the same or another physician.
 -50 – For bilateral procedures, especially in imaging (e.g., mammography).
 -59 / X-Modifiers – Used for unbundling distinct procedures, particularly in IR.

I. Documentation & Reporting Requirements

 Order: A valid order from a treating provider is generally required for radiology services. This order
specifies the type of exam needed.
 Clinical Indication: Medical necessity is paramount. The documentation must clearly state the
reason for the imaging study (e.g., chest pain, injury, screening). On the CPC exam, scenarios will
always provide a clinical justification.
 Interpretation/Report: The radiologist's report is essential. It must detail the findings (normal or
abnormal), conclusions/impressions, and any recommendations. Without a report, the professional
component cannot be billed.
 Contrast Details: If "with contrast" is specified in the code, the documentation must confirm that
contrast was actually used. Oral contrast alone does not qualify for codes specifying intravenous or
intra-arterial contrast. The type of contrast used (IV, intra-arterial, etc.) should be documented.
 Multiple Studies: If multiple imaging studies are performed on the same day, each must be
medically necessary and documented separately. Simply ordering multiple studies does not justify
billing for all of them if they are not medically necessary.
 VII. Common Pitfalls & Audit Risks
 Over-Coding Views: Accurate counting of views is crucial for X-ray coding. Don't report a 3-view
code if only 2 views were documented.
 Failure to Use Correct Component Modifiers: Modifier -26 (Professional Component) is used
when the radiologist provides the interpretation only. Modifier -TC (Technical Component) is used
when the facility provides the equipment and supplies, but no interpretation. Failure to use these
modifiers correctly can lead to claim denials or duplicate billing issues.
 Unbundling IR Procedures: Interventional radiology (IR) procedures often involve both diagnostic
and interventional components. Be careful not to unbundle imaging guidance that is already
included in the main procedure code. A diagnostic angiogram performed before an intervention in
the same vascular territory is typically bundled unless there is a new clinical justification for the
diagnostic study.
 Wrong Code for Contrast: Pay close attention to the code descriptions regarding contrast. Don't
use a "with and without contrast" code if only "with contrast" was performed, and vice versa.
Document the number of contrast sequences performed.
 Incorrect Bilateral Reporting: Some imaging codes are inherently bilateral, meaning they cover
both sides. Appending the -50 modifier to these codes is incorrect and can lead to overpayment.
Carefully review the code descriptions.
 Time of Interpretation: If the radiology interpretation is done on a different day or in a different
location than the imaging study, it can raise coding and billing questions about who can bill the
professional component. Payer policies vary.
VIII. Best Practices for CPC Exam Success
 Familiarize Yourself with Code Descriptors: This is absolutely crucial. Pay close attention to
keywords like "complete," "limited," "with contrast," "without contrast," and the specific views
included in X-ray codes.
 Use Parenthetical Notes: Parenthetical notes in the CPT manual provide valuable instructions.
Pay attention to "do not report with" notes and cross-references to other codes.
 Check NCCI Edits: NCCI edits are essential for preventing unbundling. Pay particular attention to
edits related to interventional radiology procedures. Use modifier -59 (or X modifiers) only when
the criteria for distinctness are met.
 Watch for Radiology "Unilateral" vs. "Bilateral": Carefully determine whether a code is
inherently unilateral or bilateral. Use modifier -50 (or RT/LT) only when appropriate.
 Practice Real-World Scenarios: Working through realistic scenarios is the best way to prepare
for the CPC exam. The examples you provided are excellent. Focus on understanding the
rationale behind the code selection.
 Modifiers -26 and -TC: These modifiers are frequently tested on the CPC exam. Make sure you
understand the precise circumstances under which each modifier should be used.
 IX. Putting It All Together
 Radiology in Context: Radiology codes are often integrated into complex scenarios on the CPC
exam that involve multiple procedures and services. Practice coding these types of scenarios.
 Medical Necessity & Documentation: Always ensure that medical necessity is clearly
documented for each imaging study, especially when multiple studies are performed on the same
day.
 Cross-Referencing: In real-world coding, you will often need to consult multiple resources,
including CPT guidelines, payer policies, and NCCI tables. For the CPC exam, focus on the
information provided in the scenario and your CPT manual.
 Confidence Through Practice: Consistent practice is key to success. Work through as many
sample questions as possible, paying close attention to the details of each scenario. Focus on the
technical vs. professional components, the number of views in X-rays, and the use of contrast.

Introduction to Pathology & Laboratory Coding

 Scope:
o Pathology & laboratory services cover a wide range of tests, including basic blood work,
specialized genetic tests, microbiology cultures, and surgical pathology.
o Focus on understanding the difference between the different types of tests and services,
from routine to advanced.
 CPT® Section Range:
o Pathology and lab codes are found in the 80000–89999 range in CPT®.
o They’re organized by methodology (e.g., immunoassay, molecular diagnostics), specimen
type (e.g., blood, urine, tissue), or specialty (e.g., cytopathology, histopathology).
 Exam Relevance:
o Around 4–6% of the CPC exam focuses on pathology and laboratory coding.
o Focus on coding for routine lab tests, understanding panels versus individual tests,
surgical pathology, drug assays, and guidelines for genetic/molecular testing.
II. Key Concepts & Organization in CPT®
 Panels vs. Individual Tests:
o Panel codes (e.g., 80048 for basic metabolic panel) bundle a group of related tests.
o If any part of the panel is missing, report the individual tests instead. Don’t report a panel
code plus individual tests for the same analyte unless clinically necessary.
 Bundled vs. Separate Codes:
 o Watch out for bundled codes, especially when multiple tests are performed using different
methodologies.
o Avoid double billing: If a panel test is reported, do not separately report individual tests
unless necessary, or if the tests overlap in some way, clarify with additional modifiers.
 Specimen vs. Test Method:
o Some codes are based on test methodology (e.g., immunoassay), while others are
based on the specific substance tested (e.g., glucose).
o Recognize the distinction between coding for the specimen type (blood, urine) and the
method used (chromatography, immunoassay).
 Professional vs. Technical Component:
o Path/Lab codes usually include both technical services (equipment, reagents) and
professional services (interpretation). If separate, use modifiers like -26 (interpretation)
or -TC (technical component).
o Surgical pathology codes may require separate reporting for interpretation and technical
services depending on the arrangement.

Major Subsections of Pathology & Laboratory

The Path/Lab section is divided into several subsections, each with its own range of codes:

Organ/Disease-Oriented Panels (80047-80081)

 Definition: You've accurately defined panels. They are pre-determined groupings of tests
commonly ordered together to assess a specific organ system or disease process. This bundling
streamlines billing and is often more cost-effective than ordering each test individually.
 Examples of Common Panels: Your examples are excellent and cover some of the most
frequently encountered panels:
o 80048: Basic Metabolic Panel (BMP): It's important to note that the specific components
of the BMP can sometimes vary slightly depending on the lab. However, the core
components you listed (sodium, potassium, chloride, CO2, BUN, creatinine, glucose, and
total calcium) are generally consistent.
o 80053: Comprehensive Metabolic Panel (CMP): As you pointed out, the CMP includes
all the tests in the BMP plus additional liver function tests (albumin, total protein, ALP, ALT,
AST, and bilirubin). If a CMP is performed, you would not bill a BMP separately.
o 80061: Lipid Panel: This panel typically includes total cholesterol, HDL cholesterol, and
triglycerides. If LDL cholesterol is calculated, it is not billed separately. However, if LDL
cholesterol is directly measured, it may be billed separately in some cases. Always check
payer guidelines.
 o 80076: Hepatic Function Panel: This panel focuses on liver function and includes
albumin, total and direct bilirubin, alkaline phosphatase, ALT, AST, and total protein.
 Rules for Panel Coding:
o "All or None" Rule: This is the most critical rule for panel coding. All tests listed in the
panel descriptor must be performed to use the panel code. If even one test is missing, you
cannot use the panel code. Instead, you must code each individual test separately.
o Additional Tests: If additional tests beyond those included in the panel are performed,
you can bill those tests separately, in addition to the panel code. However, the medical
necessity for the additional tests must be clearly documented. Be careful not to double bill
for any tests that are already included in the panel.
o Unit of Service: Panels are typically considered one unit of service, even though multiple
tests are performed. You would not report separate line items for each individual test within
the panel. The panel code represents the entire service.
Additional Tips for Panel Coding:
 Know the Panel Components: Become familiar with the typical components of common panels.
This will help you quickly determine if a panel code is appropriate or if individual tests need to be
coded.
 Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to ensure that all tests included in the panel were performed. Note any additional tests
that were performed as well.
 Check for NCCI Edits: Be aware of National Correct Coding Initiative (NCCI) edits related to
panels and individual tests. Some combinations may not be allowed.
 Payer Policies: Payer policies can vary slightly regarding panel coding. Always check with
individual payers for their specific guidelines.
 Documentation is Key: Thorough documentation is essential. The lab report must clearly indicate
which tests were performed and the results. If additional tests beyond the panel are performed, the
medical necessity for these tests must be documented.
Mastering panel coding is crucial for accurate and efficient billing in the pathology and laboratory section.
The "all or none" rule is the most important concept to remember. Careful review of the lab report and code
descriptions is essential.

Urinalysis (81000-81099)
This subsection covers a variety of tests performed on urine specimens, ranging from routine urinalysis to
more specialized analyses.
1. Routine Urinalysis:
 With/Without Microscopy: This is the primary distinction in coding routine urinalysis.
 o Codes like 81001 typically describe a routine urinalysis with microscopic examination.
o Codes like 81000 often describe a routine urinalysis without microscopic examination. It's
essential to know whether a microscopic exam was performed.
 81003: Automated Analysis without Microscopy: This code is specifically for automated
urinalysis performed without a microscopic examination. This distinction is important, as some
automated systems may perform a limited microscopic exam, and that would necessitate a
different code.
2. Qualitative vs. Quantitative:
 Qualitative: These tests determine the presence or absence of a substance or characteristic.
Dipstick tests, which provide a color change to indicate the presence of certain substances (e.g.,
glucose, protein, blood), are examples of qualitative tests.
 Quantitative: These tests measure the amount of a substance present. For example, measuring
the milligrams per deciliter (mg/dL) of protein in urine is a quantitative test.
 Code Selection: The distinction between qualitative and quantitative tests is crucial for proper
code selection. Make sure you understand which type of test was performed.
3. Urine Pregnancy Tests:
 81025: Urine Pregnancy Test, by Visual Color Comparison (Qualitative): As you noted, 81025
is specifically for qualitative urine pregnancy tests performed by visual color comparison.
 Serum Pregnancy Tests: Serum (blood) pregnancy tests are not reported with codes from the
Urinalysis section. They are reported with codes from the Chemistry or Immunoassay sections, as
they involve measuring specific hormones in the blood. The specific code will depend on the
methodology used.
General Tips for Urinalysis Coding:
 Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to determine which tests were performed, whether a microscopic examination was done,
and whether the tests were qualitative or quantitative.
 Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific wording regarding microscopic examination, qualitative vs. quantitative tests, and any
other relevant details.
 Distinguish Between Urine and Serum Tests: Remember that urine and serum (blood) tests are
coded differently. Urine tests are found in the Urinalysis section, while serum tests are typically
found in the Chemistry or Immunoassay sections.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines.
The Urinalysis subsection is generally straightforward, but accurate coding requires careful attention to
detail and a good understanding of the different types of tests performed. The key distinctions to remember
are with/without microscopy, qualitative vs. quantitative, and urine vs. serum testing.

Molecular Pathology (81161–81479)

This subsection covers highly specialized genetic and molecular tests. It's a rapidly evolving area, so
staying up-to-date with coding changes is crucial.
1. Overview:
 You correctly define the scope as covering genetic testing for specific genes, biomarkers, and
molecular assays. This includes tests for inherited conditions, cancer diagnostics, infectious
diseases, and pharmacogenomics (how genes affect a person's response to drugs).
 The division into Tier 1 and Tier 2 codes is a key organizational principle.
2. Tier 1 Codes:
 You provide a good example: 81211 (BRCA1 & BRCA2 gene analysis, full sequence). Tier 1 codes
are very specific. They describe the exact gene or region being tested, the method used (e.g.,
sequencing, deletion/duplication analysis), and the scope of the test (e.g., full sequence, targeted
mutation analysis).
 Accurate code selection depends on matching all these elements to the test performed.
3. Tier 2 Codes:
 You correctly describe Tier 2 codes as "umbrella" codes for less common genetic tests. They are
organized by complexity, reflecting the technical resources and data analysis required.
 Choosing the correct Tier 2 code is based on the specific test performed and its complexity, not just
the gene or condition. This often requires consulting with the laboratory to understand the details of
the assay.
 Tier 2 codes are less specific than Tier 1 codes and require careful documentation to support the
level of complexity billed.
4. Multiplex and NGS Testing:
 Next Generation Sequencing (NGS) is a powerful technology that allows for the simultaneous
testing of multiple genes or genomic regions. Codes like 81432 and 81433 are used for specific
NGS panels, such as hereditary breast cancer gene panels.
 It's crucial to check if a specific Tier 1 code exists for a gene before resorting to a more general
Tier 2 or NGS code. If a Tier 1 code accurately describes the test, that is usually the preferred
code. Using a Tier 2 or NGS code when a Tier 1 code is available could be considered
downcoding.
General Tips for Molecular Pathology Coding:
 1. Understand the Test: This is paramount. You must understand exactly what the test is designed
to detect and how it is performed. Don't just rely on the test name.
2. Read the Code Descriptions Carefully: Every word matters. Pay close attention to the specific
genes, methods, and scope described in the codes.
3. Consult with the Lab: Don't hesitate to contact the laboratory for clarification. They can provide
valuable information about the details of the test and help you choose the correct code.
4. Stay Up-to-Date: Molecular pathology is a rapidly changing field. New tests and codes are
frequently introduced, and existing codes may be revised. Stay current with coding updates.
5. Check for NCCI Edits: Be aware of NCCI edits and bundling rules, especially with NGS panels
and other complex tests.
6. Payer Policies: Payer policies can vary significantly for molecular pathology testing. Always check
with individual payers for their specific requirements, including preauthorization requirements and
coverage policies.
7. Documentation is Essential: Clear and detailed documentation is crucial. The lab report must
clearly identify the specific genes or regions tested, the methods used, and the results. For Tier 2
codes, the documentation must support the level of complexity billed.
Molecular pathology coding can be very complex. Accurate coding requires a combination of scientific
knowledge, coding expertise, and meticulous attention to detail. Consulting with experienced coders and
laboratory professionals is often necessary.

Chemistry (82009–84830)
This large subsection covers a vast array of tests performed on various bodily fluids and tissues to measure
the amounts of specific chemical substances (analytes).
1. Specific Analytes:
1. You correctly point out the wide range of analytes covered, from electrolytes and metabolites to
enzymes, hormones, and vitamins.
2. Method-Specific: A crucial aspect of chemistry coding is that codes often specify the method used
to measure the analyte (e.g., spectrophotometry, immunoassay, chromatography). Accurate code
selection depends on knowing the specific method used by the lab.
2. Glucose Testing:
1. Blood Glucose vs. Glucose Tolerance Tests: It's essential to distinguish between these:
1. Blood Glucose Tests (e.g., 82947, 82948, 82962): These are typically single-point-in-time
measurements of blood glucose levels. The codes may differentiate between methods or
whether the test is performed using a glucose meter.
2. Glucose Tolerance Tests (GTTs) (82951-82952): These tests involve measuring blood
glucose levels at multiple intervals after the patient ingests a specific amount of glucose.
 They assess how the body processes glucose over time. GTT codes include multiple
measurements.
2. Glycated Hemoglobin (A1c): You correctly identify 83036 or 83037 as the codes for A1c. The
specific code depends on the methodology used by the lab.
3. Enzyme Assays:
1. You provide good examples of common enzyme assays: 84460 (AST), 84450 (ALT), 84075
(alkaline phosphatase).
2. Coding Multiple Enzymes: *If multiple enzymes are tested, each is typically coded separately
unless they are part of a panel (as discussed in the previous section on Organ/Disease-Oriented
Panels). Don't assume that multiple enzyme tests are bundled; check the code descriptions and
NCCI edits.
4. Toxicology/Drug Testing:
1. Basic Chemistry Codes: Some basic chemistry codes might be used for certain drug levels, such
as lithium (80178).
2. Therapeutic Drug Assays or Drug Assay Categories: More complex drug assays or
confirmations are usually found in specific sections dedicated to drug testing, such as the
Therapeutic Drug Assays or Drug Assay categories. These sections often have codes for specific
drugs or classes of drugs, and they may differentiate between qualitative (presence/absence) and
quantitative (amount) tests.
General Tips for Chemistry Coding:
1. Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to identify the specific analytes tested, the methods used, and the results.
2. Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific analytes, methods, and units of measure described in the codes.
3. Understand the Terminology: Chemistry coding requires a specialized vocabulary. Make sure
you understand the meaning of key terms related to the analytes and methods used.
4. Pay Attention to Units of Measure: Many chemistry tests are reported with specific units of
measure (e.g., mg/dL, mmol/L). Make sure you understand how to report these correctly.
5. Check for NCCI Edits: Be aware of NCCI edits and bundling rules, particularly for tests that may
be included in panels or other procedures.
6. Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines, especially for drug testing and other specialized assays.
The Chemistry subsection is large and requires careful attention to detail. Accurate coding depends on
understanding the specific analytes tested, the methods used, and the reporting units. Consulting with
laboratory professionals can be helpful, especially for less common or more complex assays.

Hematology and Coagulation (85002–85999)

This subsection covers tests related to blood cells (hematology) and blood clotting (coagulation).
1. Hematology:
1. 85025: Complete Blood Count (CBC) with Automated Differential: This is a very common test.
A CBC with automated differential provides information about the different types of blood cells (red
blood cells, white blood cells, and platelets) and their characteristics. The "differential" refers to the
breakdown of the different types of white blood cells.
2. 85027: CBC without Differential: This code is used when a CBC is performed without a
differential count of white blood cells. This might be done if the physician only needs basic
information about the blood cells (e.g., red blood cell count, hemoglobin, hematocrit).
3. Other Hematology Tests: The Hematology subsection also includes codes for other tests related
to blood cells, such as:
1. Reticulocyte Counts: These tests measure the number of young red blood cells
(reticulocytes) in the blood, which can be helpful in evaluating anemia.
2. Erythrocyte Sedimentation Rate (ESR): This test measures the rate at which red blood
cells settle in a tube, which can be elevated in certain inflammatory conditions.
2. Coagulation:
1. PT (Prothrombin Time) = 85610: This test measures how long it takes for blood to clot. It is often
used to monitor the effectiveness of anticoagulant medications (blood thinners) like warfarin.
2. aPTT (Activated Partial Thromboplastin Time) = 85730: This is another test that measures how
long it takes for blood to clot. It is also used to monitor anticoagulant medications, particularly
heparin.
3. D-dimer Test (85379): This test measures the level of D-dimer, a substance that is produced when
blood clots are broken down. An elevated D-dimer level can be a sign of a blood clot, such as a
deep vein thrombosis (DVT) or pulmonary embolism (PE).
3. Special Hematology:
1. Hemoglobin Electrophoresis (e.g., 83020): This test separates different types of hemoglobin, the
protein that carries oxygen in red blood cells. It is used to diagnose conditions like sickle cell
anemia and thalassemia.
2. Specialized RBC Tests: Other specialized red blood cell tests might include tests for specific
enzyme deficiencies or membrane abnormalities.
3. Factor Assays for Clotting Factors: These tests measure the levels of specific clotting factors in
the blood. They are used to diagnose bleeding disorders like hemophilia, which is caused by a
deficiency in Factor VIII or Factor IX.
General Tips for Hematology and Coagulation Coding:
1. Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to determine which tests were performed and the results.
 2. Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific tests described in the codes.
3. Understand the Terminology: Hematology and coagulation coding requires a specialized
vocabulary. Make sure you understand the meaning of key terms related to blood cells and blood
clotting.
4. Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
5. Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines.
The Hematology and Coagulation subsection is generally straightforward, but accurate coding requires
careful attention to detail and a good understanding of the different types of tests performed. The key
distinctions to remember are between CBC with and without differential, the different coagulation tests (PT,
aPTT, D-dimer), and the various special hematology tests.

Immunology (86000–86849)
This subsection covers tests related to the immune system, including serologic tests, allergy tests, and
other immunoassays.
1. Serologic Tests:
1. Infectious Diseases: Serologic tests are commonly used to diagnose infectious diseases by
detecting antibodies or antigens related to specific pathogens. You correctly mention the examples
of HIV-1/HIV-2 antibody tests (86701-86703). It's important to select the correct code based on the
specific antibodies being tested.
2. Autoimmune Conditions: Serologic tests are also used to diagnose autoimmune conditions,
where the body's immune system attacks its own tissues. Rheumatoid factor (86431) and ANA
tests (86038, 86039) are common examples. ANA testing can be complex; different codes may be
used depending on the specific method used and the antibodies being measured.
2. Allergy Testing:
1. Skin Tests: You correctly note that skin tests for allergies (e.g., prick tests, intradermal tests) are
typically found in the Medicine section (95004-95078), not the Immunology section.
2. In Vitro Allergy Tests: Some allergy tests, particularly in vitro tests that measure specific IgE
antibodies, are found in the Immunology section.
3. 86003: Allergen-Specific IgE: This code is used for allergen-specific IgE tests. Each allergen
tested is coded separately. However, some labs may use bulk codes for multiple allergens, so
check payer guidelines and lab practices.
3. Immunoassays:
1. You provide good examples: 86308 (Heterophile antibody test, e.g., Monospot) and 86255
(Fluorescent noninfectious agent antibody test).
 2. Variety of Tests: The Immunoassay section covers a wide range of tests that use antibodies or
antigens to detect and measure various substances in the body. This includes tests for hormones,
tumor markers, and other analytes.
General Tips for Immunology Coding:
1. Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to determine which tests were performed and the results. Pay close attention to the
specific antibodies or antigens being measured.
2. Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific tests described in the codes, including the methods used and the units of measure.
3. Understand the Terminology: Immunology coding requires a specialized vocabulary. Make sure
you understand the meaning of key terms related to the immune system and the tests being
performed.
4. Check for NCCI Edits: Be aware of NCCI edits and bundling rules. Some immunology tests may
be bundled with other procedures.
5. Check Payer Policies: Payer policies can vary significantly, especially for allergy testing and other
specialized immunology tests. Check with individual payers for their specific guidelines, including
coverage policies and preauthorization requirements.
6. Allergen Coding: Pay close attention to the coding guidelines for allergen-specific IgE tests.
Remember that each allergen is typically coded separately.
The Immunology subsection can be complex due to the wide variety of tests and the specialized
terminology. Accurate coding requires careful attention to detail and a good understanding of the tests
being performed. Consulting with laboratory professionals can be helpful, especially for less common or
more complex immunology tests.

Transfusion Medicine (86850–86999)

This subsection covers procedures related to blood transfusions, including blood typing, crossmatching,
and the handling of blood products.
1. Blood Typing and Crossmatching:
1. ABO Grouping (86900-86901): These codes are used to determine a person's ABO blood type (A,
B, AB, or O). The specific code depends on the method used.
2. Rh Typing (86905-86906): These codes determine a person's Rh factor (positive or negative).
Again, the specific code depends on the method used.
3. Compatibility Tests (Crossmatches) (86920-86922): Crossmatching is a crucial step before a
blood transfusion to ensure that the donor's blood is compatible with the recipient's blood. Different
codes are used depending on the type of crossmatch performed.
4. 86930: Frozen Blood Units: This code is for the thawing and preparation of frozen blood units.
2. Blood Unit Handling:
1. 86945: Irradiation of Blood Products: Irradiation of blood products is done to prevent
transfusion-associated graft-versus-host disease (TA-GVHD) in certain patients.
2. 86960: Autologous Blood Collection: This code is for the collection of blood from a patient for
their own future use (autologous transfusion).
3. Inclusions and Separate Billing: It's crucial to understand what services are included in the
transfusion codes and what can be billed separately. For example, certain blood typing and
crossmatching procedures are required before a transfusion and are typically included in the
transfusion administration codes. Don't bill them separately unless the payer allows it and it is
medically necessary. Always check payer guidelines.
General Tips for Transfusion Medicine Coding:
1. Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to determine which tests were performed and the results. Pay close attention to the
specific blood types, Rh factor, and crossmatch results.
2. Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific tests and procedures described in the codes, including the methods used.
3. Understand the Terminology: Transfusion medicine coding requires a specialized vocabulary.
Make sure you understand the meaning of key terms related to blood typing, crossmatching, and
blood products.
4. Check for NCCI Edits: Be aware of NCCI edits and bundling rules. Many transfusion medicine
procedures are bundled together.
5. Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines, particularly regarding what services are included in transfusion
administration codes and what can be billed separately.
6. Blood Product Codes: Be aware that there are separate codes for the actual blood products
themselves (e.g., packed red blood cells, platelets, plasma). These are not CPT codes; they are
typically HCPCS Level II codes.
The Transfusion Medicine subsection is relatively small, but it's crucial to understand the specific
procedures involved and the coding rules. Accurate coding depends on careful attention to detail and a
good understanding of the tests and procedures performed. Consulting with laboratory professionals or
transfusion medicine specialists can be helpful, especially for complex cases.

Microbiology (87003–87999)
This subsection covers the identification of microorganisms, including bacteria, fungi, viruses, and
parasites.
1. Culture and Sensitivity (C&S):
  87040: Blood Culture for Bacteria: This code is specifically for culturing blood to detect the
presence of bacteria (bacteremia).
 87070-87077: Culture of Other Specimens: These codes cover culturing specimens from various
sources other than blood, such as throat swabs, sputum, wound cultures, urine cultures, etc. The
specific code depends on the source of the specimen and the type of organism being sought.
 Additional Codes for Identification and Susceptibility Testing: C&S testing often involves
multiple steps. The initial culture identifies whether an organism is present. If an organism is
identified, additional tests may be performed:
o Identification: Further testing may be done to determine the specific species of bacteria or
fungus.
o Susceptibility Testing: If a bacterial pathogen is identified, susceptibility testing is often
performed to determine which antibiotics will be effective against it (antibiogram). These
additional tests are coded separately.
2. Virology:
 87252: Tissue Culture for Virus Isolation: This code describes a traditional method of growing
viruses in cell culture.
 Molecular Tests for Viruses: Many viral tests today are molecular tests that detect the virus's
genetic material (DNA or RNA). These tests are often performed using techniques like PCR
(polymerase chain reaction) and are typically found in the 876XX series. You provide the correct
example of 87635 for SARS-CoV-2 testing. It's important to select the correct code based on the
specific virus being tested and the method used.
3. Parasitology:
 87177: Ova & Parasites Exam: This is a common test to detect parasites in stool specimens.
 Additional Codes for Special Stains or Concentrations: If special stains or concentration
techniques are used in the ova & parasites exam, these may be coded separately.
4. Molecular Infectious Testing:
 87500-87599 Range: These codes cover a broad range of molecular tests for bacterial, viral, and
fungal pathogens, often using PCR-based methods. You give good examples: 87510 (Gardnerella)
and 87536 (HIV-1 quantification).
 Multiplex Testing and Bundling: Many molecular tests are now multiplex tests, meaning they can
detect multiple pathogens simultaneously. Coding for multiplex tests can be complex. Some
multiplex tests have specific codes that cover the entire panel of pathogens tested. Other multiplex
tests may require separate codes for each pathogen detected. Carefully review the code
descriptions and payer guidelines to ensure accurate coding and avoid unbundling issues.
General Tips for Microbiology Coding:
 Read the Lab Report Carefully: The lab report is your primary source of information. Carefully
review it to determine which tests were performed, the specific organisms identified, and the
results. Pay close attention to the source of the specimen.
  Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific organisms, methods, and specimen types described in the codes.
 Understand the Terminology: Microbiology coding requires a specialized vocabulary. Make sure
you understand the meaning of key terms related to microorganisms, culture techniques, and
susceptibility testing.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules. Many microbiology tests are
bundled together, especially culture and sensitivity testing.
 Check Payer Policies: Payer policies can vary significantly, especially for molecular infectious
disease testing. Check with individual payers for their specific guidelines, including coverage
policies, preauthorization requirements, and rules for multiplex testing.
 Specimen Source: The source of the specimen (blood, wound, throat, etc.) is critical for code
selection in many microbiology tests.
 Organism Identification: Accurate identification of the specific organism is essential for selecting
the correct code.
The Microbiology subsection can be complex due to the many different types of organisms and tests.
Accurate coding requires careful attention to detail, a good understanding of microbiology principles, and
staying up-to-date with the latest coding guidelines and payer policies. Consulting with laboratory
professionals can be very helpful, particularly for less common or more complex microbiology tests.

Anatomic Pathology (88000–88099)

This subsection covers the examination of tissues and organs, primarily from autopsies (postmortem
examinations).
1. Autopsy (Postmortem) Examinations:
 88000-88037 Range: These codes cover autopsies. The specific code depends on the extent of
the examination:
o Gross Only: The pathologist examines the organs with the naked eye.
o Gross and Microscopic: The pathologist examines the organs with the naked eye and
microscopically.
 Level of Detail: Different levels of detail are recognized in the codes. There may be separate
codes for examining specific body regions or organs (e.g., brain only, chest only, etc.), in addition to
codes for more complete autopsies. Careful review of the code descriptions is essential.
2. Forensic vs. Clinical:
 Billing: You correctly point out that forensic autopsies are typically not billable in the same way as
clinical autopsies. Forensic autopsies are usually performed for legal or investigative purposes and
are often funded by government agencies. Clinical autopsies, on the other hand, are performed for
medical purposes to determine the cause of death or to study disease.
  CPC Exam: You're also correct that the CPC exam rarely delves into the nuances of forensic
autopsies. However, it's good to have a general understanding of the distinction between forensic
and clinical autopsies. The exam is more likely to focus on coding clinical autopsies.
General Tips for Anatomic Pathology Coding:
 Read the Pathology Report Carefully: The pathology report is your primary source of
information. Carefully review it to determine the extent of the autopsy examination (gross only vs.
gross and microscopic) and the specific organs or body regions examined.
 Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific details described in the codes, including the level of detail of the examination.
 Understand the Terminology: Anatomic pathology coding requires a specialized vocabulary.
Make sure you understand the meaning of key terms related to anatomy and pathology.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines. Autopsies may have specific reimbursement policies.
 Documentation is Key: Detailed documentation is essential to support the code billed. The
pathology report should clearly describe the gross and microscopic findings for each organ or body
region examined.
The Anatomic Pathology subsection is relatively small, but accurate coding depends on understanding the
different levels of autopsy examination and the distinction between gross and microscopic examination.
Careful review of the pathology report and code descriptions is essential.
This is a good overview of the remaining Pathology and Laboratory subsections, including Cytogenetics,
Surgical Pathology, In Vivo Tests, and Other Lab Services. Let's expand on each with more detail and
coding tips:

Cytogenetics (88230–88299)
 Chromosomal Analysis:
o You provide good examples: 88230 (tissue culture) and 88262 (chromosomal analysis with
15-20 cells counted).
o These tests are used to identify genetic abnormalities, such as Down syndrome (Trisomy
21), translocations, deletions, and other chromosomal rearrangements. The specific code
often depends on the type of specimen, the method used, and the number of cells
analyzed.
 FISH (Fluorescence In Situ Hybridization):
o You correctly mention the codes for FISH probes (e.g., 88271-88275).
o Coding for FISH can be complex. It's essential to note the number of probes used and the
number of cells analyzed. Different codes may apply depending on the specific probes and
the scope of the analysis.
 Surgical Pathology (88300–88399)
 Specimen Examination Levels:
o You accurately describe the level system (88300-88309). These codes are based on the
type of specimen and the complexity of the examination.
o You provide good examples: 88305 (small biopsies) and 88307 or 88309 (complex
resections). It's crucial to select the correct level based on the pathologist's work and the
nature of the specimen. 88300 represents a gross examination only. 88302-88309 include
both gross and microscopic examination.
o Each code represents the gross and microscopic examination and the final diagnosis.
 Special Stains and Immunohistochemistry:
o You correctly identify the codes for special stains (88312-88313) and immunohistochemical
stains (IHC) (88341-88342).
o Special stains are used to highlight specific tissue structures or substances. IHC uses
antibodies to identify specific antigens in tissue sections. Codes for IHC are typically
reported per specimen block or group of blocks.
 Frozen Sections:
o You correctly identify the codes for frozen sections (88331 for the first block, 88332 for
each additional block).
o Frozen sections are typically performed during surgery for rapid intraoperative diagnosis.
 Electron Microscopy:
o You correctly mention 88348 for ultrastructural studies. Electron microscopy is used to
examine tissues at a very high magnification, often to diagnose specific pathologies.

In Vivo (Transcutaneous) Lab Tests (88400–88499)

 Transcutaneous Testing:
o You provide the example of 88400 for transcutaneous bilirubin.
o These tests are performed directly on the patient's skin, often using non-invasive methods.
o You're right that these are less commonly tested on the CPC exam, but it's good to be
aware of them.

Other Pathology and Laboratory Services (88720–89399)

 Therapeutic Drug Assays:
 o You correctly note that these can also be found in the 80150-80299 range. There can be
overlap in coding for therapeutic drug assays.
o It's essential to distinguish between quantitative (measuring the level) and qualitative
(presence/absence) tests.
 Reproductive Medicine Lab Services:
o You correctly mention the codes for these specialized services (89250-89398).
o These procedures, while specialized, can appear in exam scenarios, so it's good to be
familiar with them.
General Tips for these Pathology Subsections:
 Read the Pathology/Lab Report Carefully: This is your primary source of information. Pay close
attention to the specific tests performed, the methods used, and the results.
 Know the Code Descriptions: Carefully read the CPT code descriptions. Pay close attention to
the specific details mentioned, including the type of specimen, the method used, and any specific
criteria for code selection (e.g., number of cells counted, number of probes used, levels of
complexity).
 Understand the Terminology: These subsections require a specialized vocabulary. Make sure
you understand the meaning of key terms related to cytogenetics, surgical pathology, and the
various tests performed.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines.
 Documentation is Key: Detailed documentation is essential to support the codes billed. The
pathology or lab report must clearly describe the procedures performed, the findings, and the
interpretations.
These remaining subsections of Pathology and Laboratory can be challenging due to the specialized nature
of the tests and the complexities of the coding rules. Thorough study, practice, and consultation with
experienced coders or laboratory professionals are highly recommended.

Coding Guidelines & Rules (Pathology/Lab)

 Medical Necessity: You correctly emphasize that every test must be ordered for a medically
necessary reason. The exam scenarios will always provide the clinical justification.
 Panels: The "all or none" rule is crucial. Use the panel code only if all components are performed.
Code individual tests if any component is missing. Additional tests beyond the panel are coded
separately.
 Repeat Testing: Modifier -91 is only for medically necessary repeat testing on the same day to
assess changes in the patient's condition. It is not for repeats due to equipment malfunction or
errors.
  Specimen vs. Separate Encounters: Multiple specimens from different sites are typically coded
separately. For cytopathology/histopathology, each distinct specimen might get a separate code, or
they may be grouped if from the same site. Carefully read the code descriptions.
 Professional Component (-26) and Technical Component (-TC): You accurately describe the
use of these modifiers. -26 is for the interpretation only, and -TC is for the technical component
(equipment, supplies). Global billing is used when the same entity provides both.
 Unbundling vs. Add-On Codes: You give good examples of add-on codes for special stains and
IHC. Unbundling is a major audit risk. Always check CPT parenthetical notes and NCCI edits.

Example Path/Lab Coding Scenarios

Your examples are well-chosen and illustrate common coding issues:
 CMP: Correct coding of the panel (80053) and the separate TSH (84443) if performed.
 Surgical Pathology Biopsy: Correct use of 88305. Each distinct lesion is a separate specimen
and may warrant a separate code.
 CBC with Auto Diff: Correct use of 85025. A manual differential (85007 or 85009) is only added if
medically necessary and not already included in the automated count.
 Repeat Glucose Test: Correct use of 82947 and consideration of modifier -91 if medically justified.
 Ultrasound Guidance: Correctly points out that guidance is often bundled. This applies to both
surgical and radiological procedures.

Common Pitfalls & Audit Triggers (Pathology/Lab)

Your list of pitfalls is excellent and covers the major areas of risk:
 Incorrect Panel Use: A major issue.
 Double Billing: Another common mistake.
 -91 Misuse: A frequent target of audits.
 Missing Medical Necessity: Especially critical for genetic testing.
 Pathology Levels: Requires careful review of the documentation.
 Failing to Note Each Specimen: Can lead to undercoding or overcoding.

Best Practices for CPC Exam Success (Pathology/Lab)

Your tips are spot on:
 Common Lab Codes: Knowing these is essential.
 Pathology Subsections: Surgical pathology is frequently tested.
  CPT® Instructions: Absolutely critical.
 Key Phrases: Helpful for quick identification.
 Modifiers: -26 and -91 are frequently tested.
 Time Management: Don't overthink simple questions.
VIII. Putting It All Together (Pathology/Lab)
You summarize the key points perfectly. Precision is paramount in pathology/lab coding.

Overview of the Medicine Section (90000–99999)

This is a great introduction to the Medicine section. You accurately describe its scope and provide a
comprehensive list of the subsections. The point about overlapping code ranges is important. While codes
may fall within a certain numerical range, they are conceptually grouped based on the section of the CPT
manual where they are located. Your breakdown of the major categories is very helpful for understanding
the organization of this large section. This overview provides a solid foundation for studying the Medicine
section.

Cardiology Services (92900–93799)

This subsection covers a wide range of diagnostic and therapeutic procedures related to the cardiovascular
system.
1. Electrocardiograms (ECG/EKG):
 93000: ECG with 12 Leads: This is the most common ECG code. It includes the tracing and the
interpretation. This is considered the global service.
 93005: Tracing Only (Technical Component): This code is used when the facility or technician
performs the ECG tracing, but the physician separately interprets it.
 93010: Interpretation and Report Only (Professional Component): This code is used when the
physician interprets the ECG and writes a report, but the tracing is done elsewhere.
 It's crucial to use the correct component code (93005 or 93010) when the service is split. Billing
93000 when only one component is provided is incorrect.
2. Holter Monitors / Ambulatory ECG:
 93224-93227: Holter Monitoring: These codes cover Holter monitoring (typically 24-48 hours).
The codes differentiate between the global service (93224), the technical component (93225), and
the professional component (93227). Make sure you understand which components were
provided. The global code includes scanning analysis, interpretation, and report.
3. Cardiac Stress Tests:
 93015: Cardiovascular Stress Test, Complete: This code covers a complete stress test,
including physician supervision, tracing, interpretation, and report.
  Component Coding (93016-93018): Just like ECGs and Holter monitors, stress tests can have
separate component codes:
o 93016: Physician supervision only.
o 93017: Tracing only.
o 93018: Interpretation and report only.
 Accurate component coding is essential when different providers are involved.
4. Echocardiography (Echo):
 93306: TTE (Transthoracic Echo) Complete: This code covers a complete transthoracic
echocardiogram with spectral and color Doppler.
 93307: TTE without Doppler: This code is used when Doppler is not performed.
 93320-93325: Doppler Add-on Codes: These are add-on codes that are reported in addition to
the base echocardiography code if Doppler is performed and not already included in the primary
code. Many current echocardiography codes include Doppler, so these add-on codes are used
less frequently than they once were.
 93350: Stress Echocardiography: This procedure combines exercise or pharmacologic stress
with echocardiography. Be careful when coding stress echo. If both rest and stress images are
performed, check for codes that bundle both. If not bundled, each may be coded separately.
5. Cardiac Catheterization:
 Complex Procedures: Cardiac catheterization procedures are complex and require careful code
selection. Codes vary based on the vessel approach (right heart, left heart, combined), whether
coronary angiography is performed, and whether ventriculography is included.
 93452-93461: These codes describe detailed left, right, and combined heart catheterizations with
or without coronary angiography and ventriculography. Understanding the specific procedures
performed is essential for accurate coding.
 Add-on Codes: Add-on codes are used for additional procedures performed during the
catheterization, such as intravascular ultrasound (IVUS) or imaging guidance.
6. Pacemaker & ICD Programming:
 93279-93298: Programming or Interrogation: These codes are for the programming or
interrogation of pacemakers and ICDs. They are distinct from the insertion or removal of these
devices, which are surgical procedures and are coded in the Cardiovascular System section of the
Surgery chapter.
General Tips for Cardiology Coding:
 Read the Report Carefully: The physician's report is your primary source of information. Carefully
review it to identify all the procedures performed and the findings.
 Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific details described in the codes, including the components included in each code.
  Understand the Terminology: Cardiology coding requires a specialized vocabulary. Make sure
you understand the meaning of key terms related to the cardiovascular system and the procedures
performed.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules. Many cardiology procedures
are bundled together.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines. This is particularly true for complex procedures like cardiac catheterization
and electrophysiologic studies.
 Component Coding: Pay close attention to component coding for ECGs, Holter monitors, and
stress tests. Use the correct component code only when the service is split between providers.
Cardiology coding can be complex, particularly with procedures like cardiac catheterization and
electrophysiologic studies. Accurate coding requires careful attention to detail, a good understanding of
cardiology principles, and staying up-to-date with the latest coding guidelines and payer policies.
Consulting with experienced coders or cardiology specialists can be very helpful.

Immunization Administration & Vaccines (90460–90749)

This section covers the administration of vaccines and toxoids, as well as the vaccines/toxoids themselves.
Accurate coding requires understanding the different administration methods and age-based distinctions.
1. Administration Codes:
 90460-90461 (Ages 18 and Under, with Counseling): These codes are used for immunization
administration for patients 18 years of age and younger when face-to-face counseling is provided
by the physician or other qualified healthcare professional (QHP).
o 90460: Reported for the first vaccine component administered.
o 90461: Reported for each additional vaccine component administered. It is crucial to
understand that “component” refers to each distinct vaccine given and not the number of
injections. For example, the MMR vaccine is one component even though it protects
against three different diseases.
 90471-90474 (No Counseling or Patients Over 18): These codes are used for immunization
administration when no face-to-face counseling is provided, or for any patient over 18 years of age,
regardless of counseling.
o 90471: Injection (single or first).
o 90472: Each additional injection.
o 90473: Intranasal/oral (first).
o 90474: Each additional intranasal/oral.
 The key distinction between the 90460/90461 series and the 90471-90474 series is the presence
or absence of counseling for patients 18 and under. For patients over 18, counseling status does
not affect the code selection.
2. Vaccine/Toxoid Codes:
 907xx Series: These codes are used to report the vaccine or toxoid product itself. Each vaccine
has a specific code. Examples include codes for influenza, hepatitis, MMR, and varicella vaccines.
 Administration + Vaccine Product: Typically, both the administration code and the vaccine
product code must be reported. The only exception is when the vaccine product is supplied by the
government. In this case, you might only bill for the administration, and you may need to use a
modifier (e.g., SL or other local modifier) as required by the payer. Always check payer guidelines.
3. Multiple Vaccines:
 When multiple vaccines are administered during the same encounter, each vaccine product code
and each administration code must be reported.
 *For pediatric patients (18 and under) with counseling for each vaccine, use 90460 for the first
component, and 90461 for each additional component in that vaccine if it has multiple components.
If another vaccine is administered, use 90460 again for the first component of the second vaccine
and 90461 for any additional components. If no counseling is provided, or the patient is over 18,
use the appropriate codes from the 90471-90474 series.
4. Vaccine Counseling:
 The presence or absence of documented face-to-face counseling with the patient or guardian is
the determining factor for choosing between the 90460/90461 series (with counseling, ages 18 and
under) and the 90471-90474 series (no counseling or patients over 18). Thorough documentation
of the counseling is essential when using 90460/90461.
General Tips for Immunization Coding:
 Read the Documentation Carefully: The medical record is your primary source of information.
Carefully review it to determine which vaccines were administered, the age of the patient, and
whether counseling was provided.
 Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific details described in the codes, including the age restrictions, administration routes, and
counseling requirements.
 Understand the Terminology: Immunization coding requires a specialized vocabulary. Make sure
you understand the meaning of key terms related to vaccines and immunization administration.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines, especially regarding the reporting of vaccines supplied by the government.
 Accurate Reporting: Report each vaccine product and each administration separately. Do not
combine codes inappropriately.
Immunization coding can be complex due to the various administration methods, age-based distinctions,
and counseling requirements. Accurate coding requires careful attention to detail, a good understanding of
the coding rules, and thorough documentation
 Dialysis (90935–90999)
This subsection covers services related to dialysis for patients with end-stage renal disease (ESRD).
Dialysis codes are complex and require careful attention to detail.
1. Hemodialysis & Peritoneal Dialysis:
 90935: Hemodialysis, Single Evaluation: This code is for a single hemodialysis treatment
evaluation. It is typically used when a patient receives a single, isolated hemodialysis treatment.
 90937: Hemodialysis Requiring Repetitive Evaluations: This code is used when a patient
requires repetitive hemodialysis evaluations. This is the code typically used for patients on chronic
hemodialysis.
 Peritoneal Dialysis (90945-90947): These codes cover peritoneal dialysis. The specific code
depends on whether the service is a full or partial service. Full service typically includes all aspects
of the dialysis treatment, while a partial service may involve only certain components. Carefully
read the code descriptions to understand what is included in each level of service.
2. ESRD Monthly Capitation Services:
 90951-90970: ESRD Monthly Services: These codes are used for monthly services provided to
ESRD patients who are receiving dialysis, either at home or in an outpatient dialysis facility. These
codes are often referred to as "capitation" codes because they represent a bundled payment for all
the services provided during the month.
 Age and Visits: The specific code is selected based on the patient's age and the number of face-
to-face visits with the physician during the month. You provide a good example: 90960 (patient
aged 20+ with 4 or more visits). It is crucial to document the number of visits and the patient's age
to select the correct code.
3. Special Documentation:
 Time/Visits, ESRD Status, Dialysis Setting: You correctly identify the key documentation
requirements. The medical record must clearly specify:
o The total time spent providing dialysis services or the number of face-to-face visits with the
physician during the month (for capitation codes).
o The patient's ESRD status.
o The dialysis setting (in-center vs. home).
General Tips for Dialysis Coding:
 Read the Medical Record Carefully: The medical record is your primary source of information.
Carefully review it to identify the type of dialysis performed (hemodialysis or peritoneal dialysis), the
number of treatments or visits, the patient's age, and the dialysis setting.
 Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific details described in the codes, including the definitions of "full service" and "partial
service" for peritoneal dialysis, and the age and visit requirements for the monthly capitation codes.
  Understand the Terminology: Dialysis coding requires a specialized vocabulary. Make sure you
understand the meaning of key terms related to dialysis and ESRD.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines, particularly regarding the documentation requirements for dialysis
services.
 Accurate Reporting: Report the specific type of dialysis provided, the number of treatments or
visits, and the patient's age. Do not combine codes inappropriately.
Dialysis coding can be complex due to the different types of dialysis, the monthly capitation codes, and the
specific documentation requirements. Accurate coding requires careful attention to detail, a good
understanding of the coding rules, and thorough documentation. Consulting with experienced coders or
dialysis specialists can be very helpful.

Chemotherapy & Therapeutic Infusions (96360–96549)

This section covers the administration of intravenous infusions and injections, including chemotherapy,
therapeutic infusions, and hydration. Proper coding requires careful attention to the type of infusion, the
duration, and the sequence of administration.
1. Hierarchy of Infusions:
 You accurately describe the CPT® infusion hierarchy: Chemotherapy > Non-chemotherapeutic >
Hydration. This hierarchy is critical for coding multiple concurrent infusions. The highest-level
infusion is always coded first.
 96360-96361: Hydration Infusions: These codes are specifically for hydration infusions.
 96365-96379: Therapeutic/Diagnostic Infusions and Injections: These codes are for infusions
and injections of therapeutic or diagnostic substances (e.g., antibiotics, electrolytes).
 96401-96549: Chemotherapy/Highly Complex Drugs: These codes are used for the
administration of chemotherapy and other highly complex drugs or biologic agents. This category
also includes some monoclonal antibody infusions and certain immunotherapies, even if they are
not strictly chemotherapy drugs. Always consult the CPT guidelines for specific drugs.
2. Initial vs. Subsequent or Concurrent Infusions:
1. You correctly point out that the initial infusion code is based on the primary reason for the infusion.
2. *Subsequent or concurrent infusions are reported with separate add-on codes. These add-on
codes are used to report additional infusions given at the same time or sequentially.
3. Time-Based Threshold: You correctly mention the 15-minute threshold. Infusions are typically
defined as lasting more than 15 minutes. *If the administration time is less than 15 minutes, it is
usually coded as an injection (IV push) rather than an infusion.
3. Push vs. Infusion:
 1. IV Push: Typically refers to an injection given over a short period, usually less than 15 minutes.
2. Infusion: Refers to a drug administered continuously over a longer period, typically 15 minutes or
more.
3. Documentation: Accurate coding depends on clear documentation of the start and stop times or
the total infusion duration. Without this information, it can be difficult to determine whether to code
an injection or an infusion.
4. Chemotherapy Complexity:
1. You correctly note that chemotherapy codes cover not just traditional cancer drugs but also certain
monoclonal antibodies and immunotherapies. This is an important point, as some providers may
incorrectly assume that only traditional chemotherapy drugs are reported with these codes.
2. Documentation: Thorough documentation is essential for chemotherapy administration. The
medical record must clearly indicate the drug name, dosage, route of administration, and start and
stop times of the infusion.
General Tips for Infusion Coding:
1. Read the Documentation Carefully: The medical record is your primary source of information.
Carefully review it to identify the type of infusion, the duration, the drugs administered, and the
sequence of administration.
2. Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific details described in the codes, including the infusion hierarchy, time thresholds, and
add-on code rules.
3. Understand the Terminology: Infusion coding requires a specialized vocabulary. Make sure you
understand the meaning of key terms related to infusions and injections.
4. Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
5. Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines.
6. Accurate Reporting: Report each infusion separately, following the proper hierarchy and using
add-on codes when appropriate. Do not combine codes inappropriately.
7. Time-Based Coding: Infusion codes are often time-based. Accurate documentation of infusion
start and stop times is crucial for correct code selection.
Infusion coding can be complex, particularly when multiple infusions are given concurrently or sequentially.
Accurate coding requires careful attention to detail, a good understanding of the coding rules, and thorough
documentation

Injection & Infusion Coding Tips

1. Route of Administration:
  You correctly point out that the route of administration is crucial for code selection. The 96372-
96379 range (for non-chemotherapy infusions and injections) includes codes for various routes,
including:
o IM (Intramuscular)
o IV Push
o IV Infusion
o Subcutaneous
o Intra-arterial
 Example: If a patient receives an intramuscular injection of a therapeutic drug, you would select a
code from this range that specifically describes an IM injection. The route must be documented
clearly.
2. Subsequent or Sequential Infusions:
1. You correctly address the coding of multiple drugs given via different routes or at different times.
Each administration is coded separately.
2. Add-on codes are essential for reporting subsequent or sequential infusions. For example, 96366
is used for each additional hour of the same infusion. If a different drug is infused, even via the
same route, a separate primary code is often required, followed by any applicable add-on codes
for additional time.
3. Example: A patient receives an IV infusion of Drug A for 2 hours, followed by an IV infusion of Drug
B for 1 hour. You would likely report the initial infusion of Drug A with the appropriate code, then
use 96366 for the additional hour of Drug A. Then, you would report a separate code for the initial
infusion of Drug B, as it is a different drug.
3. Modifiers:
1. You correctly mention modifiers -59 (Distinct Procedural Service) and -XU (Separate Encounter,
Same Day) as potentially being used in some situations. However, you're also right that the
infusion codes themselves, particularly with the use of add-on codes, often capture the distinct
nature of separate infusions or separate IV lines. Modifiers are less frequently needed in infusion
coding than in some other areas of CPT coding.
2. When used, modifiers like -59 or -XU would be applied to the administration code (not the drug
code).
3. Example: If two infusions are given at separate sites or during separate encounters on the same
day, and this is not already reflected in the coding, then you might consider using a modifier.
However, this is less common than simply using the appropriate combination of primary and add-
on infusion codes.
4. Bundling with E/M:
 1. You correctly state that administration codes typically do not bundle with an E/M service if the
patient's sole purpose for the visit is the infusion/injection. In this case, the infusion/injection is the
primary service.
2. However, if a significant and separately identifiable E/M service is performed and documented in
addition to the infusion/injection, then modifier -25 (Significant, Separately Identifiable Evaluation
and Management Service by the Same Physician or Other Qualified Health Care Professional on
the 1 Same Day of a Procedure or Other Service) 2 can be appended to the E/M code. The E/M
service must be above and beyond the usual pre- and post-service care associated with the
infusion/injection.

3. Example: A patient comes in for a scheduled chemotherapy infusion. The physician also performs
a problem-focused E/M service to address a new complaint (e.g., nausea related to the
chemotherapy). *In this case, you could report the chemotherapy administration code and the E/M
code with modifier -25 appended, provided the E/M service is documented as being significant and
separately identifiable.
Key Considerations for Infusion/Injection Coding:
1. Accurate Timing: Precise documentation of infusion start and stop times is essential for accurate
coding, especially for time-based infusions.
2. Drug Name and Dosage: The specific drug administered and the dosage are not part of the
administration code. These are reported separately using the appropriate drug codes (often
HCPCS Level II codes).
3. Infusion Sequence and Compatibility: If multiple drugs are infused, the sequence of
administration is important for coding purposes. Also, ensure that the drugs are compatible and
can be infused concurrently if that is the chosen method.
4. Add-on Code Usage: Master the rules for using add-on codes for additional infusions, additional
hours, and concurrent infusions.
5. Payer Policies: Always check payer policies for specific guidelines on infusion and injection
coding.
6. Documentation is Paramount: Thorough and accurate documentation is crucial for supporting
the codes billed. The documentation must clearly describe the route of administration, the start and
stop times (or duration) of each infusion, the drugs administered, and any significant and
separately identifiable E/M services provided.

Psychiatric Services (90785–90899)

 Psychiatric Diagnostic Evaluations:
o 90791: Psychiatric Diagnostic Evaluation (No Medical Services): This code is used
when the evaluation does not include medical services (e.g., prescribing medication). It
focuses solely on the diagnostic assessment.
 o 90792: Psychiatric Diagnostic Evaluation with Medical Services: This code is used
when the evaluation includes medical services, such as prescribing medication, ordering
lab tests, or other medical interventions.
 Psychotherapy:
o Time-Based Codes (90832, 90834, 90837): These codes are for individual psychotherapy
and are time-based. Accurate documentation of the session length is crucial.
 90832: 16-37 minutes
 90834: 38-52 minutes
 90837: 53+ minutes
o Family Psychotherapy (90846, 90847):
 90846: Family psychotherapy without the patient present.
 90847: Family psychotherapy with the patient present.
o Add-on Codes for Psychotherapy (+90836, +90838): These are add-on codes used
when psychotherapy is performed in conjunction with an E/M service on the same date by
the same provider. They are reported in addition to the E/M code.
 +90836: Add-on code for psychotherapy (16-37 minutes) with E/M.
 +90838: Add-on code for psychotherapy (38-52 minutes) with E/M.
 Interactive Complexity (90785):
o This is an add-on code used when the psychotherapy session involves interactive
complexity, such as complex communication difficulties, the involvement of third parties
(e.g., interpreters, family members), or unusual patient behavior that makes the session
more challenging.
 Multiple Family Group Psychotherapy (90849, 90853):
o 90849: Multiple family group psychotherapy.
o 90853: Group psychotherapy (not specifically multi-family).
VIII. Other Common Medicine Services
 Pulmonary Services:
o 94010: Spirometry: Basic spirometry. Additional codes are used if pre- and post-
bronchodilator testing is performed (e.g., 94060).
o 94640: Bronchodilator Treatment.
o 94664: Inhaler Training: Demonstration and evaluation of patient's use of an inhaler.
 Neurology & Sleep Studies:
 o 95782-95811: Polysomnography (Sleep Studies): These codes are complex and
differentiate by age, the number of parameters measured (EEG, EOG, EMG, etc.), and the
presence of CPAP titration. Careful review of the code descriptions is essential.
o 95816-95822: EEG (Electroencephalogram): Codes for awake/asleep EEGs, extended
monitoring, etc.
 Allergy Testing:
o 95004: Percutaneous Skin Tests (Prick Tests): Reported per allergen.
o 95024: Intradermal Tests.
o 95044: Patch Tests: Reported per test.
 Medical Nutrition Therapy (97802-97804):
o These codes cover dietary counseling and nutritional therapy. They differentiate between
individual and group sessions.
o Payer coverage can vary, but partial coverage may be available for certain conditions
(e.g., diabetes, renal disease).
 Osteopathic & Chiropractic Manipulation:
o 98925-98929: Osteopathic Manipulative Treatment (OMT): Codes are based on the
number of body regions treated.
o 98940-98943: Chiropractic Manipulative Treatment (CMT): Codes are based on the
number of spinal regions treated, with a separate designation for extraspinal treatment.
 Physical Medicine & Rehabilitation (97010-97799):
o This large section covers a variety of modalities and therapeutic procedures. *Many of
these codes are time-based, with the time typically specified as per 15 minutes. Accurate
documentation of the total time spent is crucial.
 Preventive Medicine Counseling (99401-99404):
o These codes are for preventive medicine counseling, separate from E/M services for
diagnosing and treating illness. They are time-based.
 Telemedicine:
o You correctly identify some of the key telemedicine codes. This area is rapidly evolving, so
it's crucial to stay up-to-date with the latest coding guidelines and payer policies. Codes
may differentiate between phone E/M, online digital E/M, and synchronous audio-video
telehealth.
General Tips for these Medicine Subsections:
 Read the Documentation Carefully: The medical record is your primary source of information.
Carefully review it to identify the specific services provided, the duration of sessions or treatments,
and any other relevant details.
  Know the Code Descriptions: Read the CPT code descriptions carefully. Pay close attention to
the specific details described in the codes, including time requirements, included services, and any
specific criteria for code selection.
 Understand the Terminology: These subsections require a specialized vocabulary. Make sure
you understand the meaning of key terms related to the various services provided.
 Check for NCCI Edits: Be aware of NCCI edits and bundling rules.
 Check Payer Policies: Payer policies can vary, so it's important to check with individual payers for
their specific guidelines.
 Accurate Reporting: Report the specific services provided accurately and completely. Do not
combine codes inappropriately or undercode services provided.
 Documentation is Key: Detailed documentation is essential to support the codes billed. The
medical record must clearly describe the services provided, the time spent (when applicable), and
any other relevant details.

Documentation & Billing Considerations

 Time-Based Codes: You correctly emphasize the importance of accurate time documentation for
many Medicine section codes (psychotherapy, infusions, therapy). Start and stop times or total
minutes must be documented.
 Supplies & Additional Procedures: Supplies are generally bundled into the procedure code, with
some specific exceptions. Check CPT and payer guidelines for details.
 Medical Necessity: Clear documentation of medical necessity is essential for all services. The
reason for the service must be clearly stated (e.g., diagnosis, symptoms, or other clinical
indicators).
 Split/Shared Services: Accurate use of split codes or modifiers (-26, -TC) is crucial when services
are shared between providers.
 Modifiers: You correctly list several key modifiers:
o -25: Significant, Separately Identifiable E/M Service by the Same Physician or Other
Qualified Health Care Professional on the Same Day of 1 a Procedure or Other Service. 2
The E/M must be above and beyond the usual pre- and post-service care for the
procedure.
o -59/X{EPSU}: Distinct Procedural Service. Used to indicate that a procedure is distinct and
separate from another procedure that might otherwise be bundled. The -X{EPSU}
modifiers are more specific than -59 and should be used when available.
o -76/-77: Repeat Procedure or Service by Same Physician or Other Qualified Health Care
Professional/by Another Physician or Other Qualified Health Care Professional. Used
when a procedure is repeated on the same day.
X. Common Pitfalls & Audit Risks
This is an excellent list of common errors:
 Incorrect Component Billing: Especially in cardiology. Understanding global vs. professional vs.
technical components is essential.
 Infusions and Injections: Accurate coding of initial, subsequent, and concurrent infusions, as well
as proper use of add-on codes, is crucial. Time documentation is essential.
 Chemo vs. Non-Chemo Infusions: Using chemo administration codes for non-chemo drugs is a
common and costly mistake.
 Missing Counseling Documentation for Pediatric Vaccines: If billing 90460, counseling must
be documented.
 Psychotherapy Time Thresholds: Accurate time documentation is essential for psychotherapy
codes. Exceeding the documented time can lead to audit issues.
 Multiple Therapy Services: Proper coding and documentation of time for physical, occupational,
and speech therapy are crucial. The 8-minute rule (for Medicare in practice) and standard CPT
time increments (on the exam) must be followed.
XI. Best Practices for CPC Exam Success
These tips are excellent:
 Familiarize with Key Code Families: Knowing the common code ranges is very helpful.
 Understand Component vs. Global: This is a frequent source of exam questions.
 Check Time & Documentation: Time is a critical factor in many Medicine section codes.
 Modifier Mastery: Understanding the appropriate use of common modifiers is essential.
 Don't Overthink: Break down complex questions into smaller parts.
 Practice: Working through practice scenarios is the best way to prepare for the exam. Your
suggested examples are excellent.
Key Takeaways for the Medicine Section:
 Documentation is Paramount: Thorough and accurate documentation is essential for supporting
all services billed in the Medicine section.
 Time is Critical: Many codes are time-based, so accurate time documentation is crucial.
 Modifiers are Important: Understanding the proper use of modifiers is essential for accurate
coding and avoiding audit risks.
 Payer Policies Matter: Always check payer policies for specific guidelines.
 Practice Makes Perfect: Working through practice scenarios is the best way to master Medicine
section coding.

Introduction to HCPCS Level II

 Definition & Purpose: You accurately define HCPCS Level II codes as alphanumeric codes used
for products, supplies, and services not included in CPT. Your examples (DME, prosthetics,
orthotics, drugs, ambulance) are spot-on.
 Payer Requirements: You correctly state that Medicare, Medicaid, and many commercial payers
require HCPCS Level II codes for billing certain items.
 Exam Relevance: Your estimate of 4-6% of the CPC exam focusing on HCPCS Level II is
accurate. The scenarios you mention (injectable drugs, DME, wound care, orthotics, ambulance)
are common exam topics.
 Difference from CPT®: You clearly distinguish between CPT (professional services) and HCPCS
Level II (supplies, equipment, some non-physician services). The point about overlap is important;
some services could potentially be coded with either CPT or HCPCS Level II, depending on the
specific circumstances and payer rules.

II. HCPCS Code Structure

 Alphanumeric Format: You correctly describe the letter + 4 digits format. The point about the
letter often indicating a broad category is helpful for remembering code ranges.
 Major HCPCS Ranges: Your breakdown of the major code ranges is excellent. This is a very
helpful overview for the CPC exam:
o A Codes: Ambulance, supplies, nutrition.
o B Codes: Enteral/parenteral therapy.
o C Codes: Outpatient PPS (hospital outpatient).
o D Codes: Dental (CDT, but can appear in HCPCS references).
o E Codes: Durable Medical Equipment (DME).
o G Codes: Temporary procedures/services (Medicare).
o H Codes: Behavioral health (Medicaid).
o J Codes: Injectable drugs, chemotherapy.
o K Codes: Temporary DME (Medicare).
o L Codes: Orthotics and prosthetics.
o M Codes: Miscellaneous services (rarely used).
o P Codes: Pathology/lab (Medicare).
o Q Codes: Temporary codes (skin substitutes, biosimilars).
o R Codes: Respiratory/diagnostic measures.
o S Codes: Temporary national codes (private payers).
 o T Codes: State-specific Medicaid codes.
 Temporary vs. Permanent Codes: You correctly explain the difference and the greater frequency
of updates for temporary codes. This is important for staying current with coding changes.
III. Common HCPCS Categories and Examples
This is the most valuable section for CPC exam preparation. Your examples are well-chosen and cover the
most frequently tested areas:
 Durable Medical Equipment (DME): Your definition and examples are excellent. The emphasis on
medical necessity and documentation is critical. Remember that DME must be durable, used for a
medical purpose, appropriate for home use, and expected to last for a certain period.
 Orthotics & Prosthetics (O & P): Your examples are helpful. The point about custom fitting vs.
prefabricated and the documentation requirements are important.
 Medical & Surgical Supplies: Your examples are good. Remember that these are often reported
per unit. Payer coverage guidelines must be followed.
 Ambulance & Transportation: Your examples are helpful. Modifiers indicating origin and
destination are essential.
 Drugs & Biologicals (J Codes): Your explanation is excellent. The point about dosage units is
crucial. Accurate calculation of units based on the amount administered is essential.
 Vaccines & Immunizations: You correctly point out the use of Q or G codes for some vaccines
and the potential overlap with CPT codes. Always check payer guidelines.
 Enteral and Parenteral Nutrition: Your explanation is good. Coverage is often dependent on the
patient's specific medical condition.
 Miscellaneous or Unlisted Codes: You correctly describe the use of these codes when a specific
code doesn't exist. Extra documentation is always required.
Key Takeaways for HCPCS Level II Coding:
 Know the Code Ranges: Familiarize yourself with the letter prefixes and the general categories
they represent.
 Understand Unit Reporting: Many supplies and drugs are reported per unit, so accurate
calculation is essential.
 Check Payer Policies: Payer policies can vary significantly, so always check with individual
payers for their specific guidelines.
 Documentation is Crucial: Thorough and accurate documentation is essential for all HCPCS
Level II codes, especially for DME, orthotics/prosthetics, and unlisted codes.
 Stay Up-to-Date: HCPCS Level II codes are updated regularly, so it's important to stay current
with coding changes.

HCPCS Modifiers
 Level II Modifiers: You correctly describe them as two-character alpha or alphanumeric.
Emphasize that these are HCPCS Level II specific and distinct from CPT modifiers.
 Examples of Common HCPCS Modifiers: Your list is comprehensive. Here are some key points:
o LT/RT: Crucial for laterality. Always consider laterality when coding DME,
orthotics/prosthetics, and some procedures.
o GA: Absolutely essential when an ABN is obtained. Do not bill Medicare for potentially
non-covered services without an ABN if you expect denial.
o GY: Indicates statutory exclusion. This is important for compliance.
o GZ: Indicates expected denial without an ABN. Use this when you know Medicare won't
pay and the patient hasn't signed an ABN.
o KX: Indicates that medical necessity requirements have been met. Often required for
certain DME and therapy services. Know the specific criteria for the relevant LCD/NCD.
o NU: New equipment purchase.
o RR: Rental.
o UE: Used equipment purchase.
 Importance for Reimbursement: Accurate modifier use is paramount. Missing or incorrect
modifiers can lead to claim denials, payment delays, or incorrect payments.

Documentation and Medical Necessity

 Detailed Written Orders: You correctly outline the requirements for DME. The order must be
detailed enough to justify the medical necessity and allow for proper dispensing. For
orthotics/prosthetics, documentation of the fitting process and expected functional improvement is
critical.
 Proof of Delivery (POD): POD is often required for DME and supplies. Keep signed PODs on file.
 Drug Administration Amount: Accurate dosage calculation and documentation are essential for J
codes. The billed units must match the administered dosage.
 ABN (Advance Beneficiary Notice): You correctly explain its purpose. Obtain the ABN before
providing the service if you believe Medicare may deny payment.
 LCDs and NCDs: These are essential resources. You must be familiar with applicable LCDs and
NCDs to ensure coverage and avoid denials.

Billing and Reimbursement Considerations

 Rental vs. Purchase: Medicare often has specific rules regarding rental vs. purchase of DME.
Understand the capped rental rules.
  Quantity Limits: Many supplies have quantity limits. Exceeding these limits requires justification
and/or prior authorization.
 Date of Service: Accurate date of service reporting is crucial. For monthly supplies, the billing date
must align with the delivery and usage period.
 Bundling vs. Separately Billable: Understanding bundling rules is essential to avoid overbilling.
 Private Payers vs. Medicare: Payer policies vary significantly. Always check with the specific
payer for their guidelines.
VII. Example HCPCS Level II Coding Scenarios
Your examples are very good:
 DME Wheelchair: Excellent. Remember the NU or RR modifier.
 Orthotics: Good example. Document the fitting, medical justification, and laterality.
 Drug Injection: Excellent example of dosage calculation. Double-check your math!
 Diabetic Supplies: Good example. Be aware of quantity limits and payer policies.
 Ambulance Transport: Good example. Accurate origin and destination modifiers are crucial.
VIII. Common Pitfalls & Audit Risks
Your list is excellent and covers the most frequent errors:
 Incorrect Modifiers: Modifier errors are a common cause of denials.
 Wrong Quantity Calculation: Dosage miscalculations are a significant audit risk.
 Unlisted/Misc. Codes: Overuse of unlisted codes without proper documentation will trigger audits.
 Lack of Medical Necessity: Services that are not medically necessary will be denied.
 Failure to Follow LCD/NCD Criteria: Compliance with LCDs and NCDs is essential to avoid
denials.
IX. Best Practices for CPC Exam Success
These tips are excellent for exam preparation:
 Memorize Common HCPCS Categories: This will significantly speed up your code lookup
process.
 Focus on Drug Calculation: Practice dosage calculations extensively. This is a frequently tested
area.
 Modifier Mastery: Know the specific purpose of each modifier.
 Check the Code Descriptor: Pay close attention to units of measure and any specific instructions.
 Familiarize with Payer-Specific Notations: While the exam focuses on Medicare, be aware of S
and T codes.
Key Takeaways for HCPCS Level II Coding:
 Documentation is Paramount: Thorough and accurate documentation is required for all HCPCS
Level II codes.
 Units of Measure are Critical: Pay close attention to the units of measure. Incorrect calculations
can lead to significant billing errors.
 Modifiers are Essential: Use modifiers correctly to avoid denials and ensure proper payment.
 Payer Policies Must Be Followed: Always check payer-specific guidelines.
 LCDs and NCDs are Crucial: Compliance with LCDs and NCDs is mandatory.

Foundations of Healthcare Compliance

 Importance of Compliance: Ensuring compliance with laws, payer policies, and organizational
standards is crucial for avoiding fraud, abuse, and waste, and ensuring accurate reimbursement.
Certified coders must follow compliance guidelines to protect organizations and prevent penalties.
 Role of a Compliance Program: Many healthcare entities have formal compliance programs that
include written policies, a compliance officer, regular training, auditing, and mechanisms for
reporting violations. The OIG provides guidance for establishing effective compliance programs.
 Exam Relevance: Regulatory compliance and common healthcare laws (e.g., HIPAA, False
Claims Act, Stark Law) make up about 5-7% of the CPC exam.
II. Fraud, Abuse, and Regulatory Oversight
 Fraud vs. Abuse:
o Fraud involves intentional misrepresentation for unauthorized benefits (e.g., billing for
services not rendered).
o Abuse is unintentional misuse (e.g., upcoding due to poor documentation).
 Key Enforcement Agencies:
o OIG: Investigates fraud, issues guidance, and publishes the OIG Work Plan.
o DOJ: Prosecutes criminal healthcare fraud cases.
o CMS: Oversees program integrity for Medicare/Medicaid.
o MACs: Handle local coverage, audits, and claim reviews.
 Red Flags: Billing for non-performed services, upcoding, kickbacks, unbundling, and unnecessary
tests/procedures.
III. Major Laws and Regulations
 False Claims Act (FCA): Prohibits submitting false claims for government healthcare programs.
Whistleblower provisions allow reporting fraud, with penalties including triple damages and per-
claim fines.
 Stark Law: Prohibits physician self-referral for Medicare/Medicaid patients to entities with which
they have financial relationships unless an exception applies.
 Anti-Kickback Statute (AKS): Prohibits paying for referrals for federally funded healthcare
services. Violators may face criminal penalties, including fines and jail time.
 Civil Monetary Penalties Law (CMPL): Authorizes OIG to seek penalties for healthcare fraud
offenses, with penalties ranging from $10,000 to $50,000 per violation.
 HIPAA: Sets national standards for privacy and security of patient information. Violations may
result in civil fines or criminal charges.
 HITECH Act: Strengthens HIPAA enforcement, requiring breach notifications and increasing
penalties for noncompliance. Encourages adoption of electronic health records (EHR).

OIG Compliance Guidance & Work Plan

 OIG Work Plan:
o The OIG Work Plan is published annually and outlines areas of focus for the upcoming
year, such as specific specialties, services, or risk areas.
o Coders and compliance officers should be aware of potential audits or scrutiny on specific
codes, helping ensure compliance with current regulations.
 Seven Components of an Effective Compliance Program (per OIG): These components are
crucial for establishing and maintaining an effective compliance program:
o Written policies and procedures: Documented policies to guide the organization in
meeting regulatory standards.
o Designation of a compliance officer/committee: Appointing individuals or teams
responsible for overseeing the program.
o Effective training and education: Ongoing training to ensure employees are familiar with
compliance requirements and updates.
o Effective lines of communication: Channels for employees to report issues or concerns
without fear of retaliation.
o Auditing and monitoring: Regular reviews of compliance practices to identify risks or
violations.
o Enforcement and discipline: Clear consequences for violations of policies or non-
compliance.
o Prompt response to detected problems and corrective action: Immediate actions to
address non-compliance and prevent recurrence.
 Audit Risk Areas:
 o Evaluation & Management (E/M) overcoding: Overbilling for E/M services without
appropriate documentation.
o Modifier misuse: Incorrect or unsupported use of modifiers like -59, which may affect
reimbursement.
o Incident-to billing errors: Mistakes related to billing for services rendered by non-
physician practitioners.
o Improper diagnosis coding: Incorrect coding that doesn't accurately reflect the patient's
condition.
o Lack of documentation: Failing to provide proper documentation to support the services
rendered.
V. Payment Methodologies & Insurance Basics
 Fee-for-Service (FFS):
o Providers are reimbursed for each service provided. In Medicare Part B, payment is
determined by the Medicare Physician Fee Schedule (MPFS), factoring in RVUs (Work
RVU + Practice Expense RVU + Malpractice RVU), a conversion factor, and geographic
adjustments.
 Capitation:
o Providers are paid a fixed amount per patient per period, regardless of the number of
services provided. This model is often seen in HMOs or managed care plans.
 Prospective Payment Systems (PPS):
o DRG (Diagnosis-Related Group): Used for hospital inpatient payments under
Medicare Part A. Payment is based on the patient’s DRG, which bundles all services
related to an inpatient stay.
o APC (Ambulatory Payment Classification): Used for hospital outpatient services,
grouping services into APCs for payment.
o RUG (Resource Utilization Group): Used for skilled nursing facilities.
o CMG (Case-Mix Group): Used for inpatient rehabilitation facilities.
 RBRVS (Resource-Based Relative Value Scale):
o Determines payments under MPFS for physician services. Each CPT® code has a total
RVU (relative value unit) multiplied by a conversion factor. This model considers the
time, skill, and intensity involved in delivering services.
 Global Periods:
o Surgical codes may include a global period (0-, 10-, or 90-days), meaning routine post-
operative care is bundled in the payment.
o This includes pre-op, intra-op, and post-op care.
 o For unrelated procedures during the global period, modifiers like -79 (unrelated
procedure) or -24 (unrelated E/M service during postoperative period) may be used.

National Correct Coding Initiative (NCCI) & Bundling Edits

 Purpose of NCCI:
o The National Correct Coding Initiative (NCCI), maintained by CMS (Centers for
Medicare & Medicaid Services), is designed to prevent improper payments by
disallowing certain code combinations that are typically part of one another or are mutually
exclusive.
o NCCI edits ensure that payments are accurate and avoid overpayment for services that
are not separate or independent.
o NCCI edits are divided into:
 Procedure-to-Procedure (PTP) Edits: Identify code pairs that should not be
billed together unless a valid modifier is used.
 Medically Unlikely Edits (MUEs): Limit the maximum units of a service allowed
for a code on a single date of service.
 PTP Edits:
o If Code A is considered the primary procedure, Code B will typically be bundled unless
there’s a valid reason (such as a different site or session) to use the modifier -59 or an X-
modifier (e.g., X{EPSU} modifiers).
o For instance, if sedation is included in the code descriptor for a procedure, a moderate
sedation code should not be separately billed.
 MUEs (Medically Unlikely Edits):
o Each code has an MUE limit, which indicates the maximum number of units allowed for
that code on a single date of service (e.g., a max of 2 units).
o If a provider bills more than the MUE, the claim may be denied or partially paid unless valid
documentation is provided to justify the additional units or an appropriate override
mechanism is in place.
 Modifier -59 and X-Modifiers:
o Modifier -59 indicates a distinct procedural service, commonly used to override an
NCCI edit when a claim includes separate services that are legitimate and can be
supported by documentation.
o X-modifiers (e.g., XE, XP, XS, XU) are more specific versions of -59 and are preferred by
Medicare. Each represents a more granular explanation for the distinct procedural service:
 XE: Separate encounter
 XS: Separate structure/organ/lesion
 XP: Separate practitioner
 XU: Unusual non-overlapping service
 Checking NCCI Tables:
o Coders can review the NCCI tables or use encoder software to verify if certain code pairs
fall under a Column 1/Column 2 relationship.
 Column 2 is generally the code that is bundled into Column 1.
 If an NCCI edit says "modifier allowed = 1", the edit can potentially be overridden
with -59/X-modifiers if clinically justified.
 If the edit says "modifier allowed = 0", no override is allowed.

HIPAA Transactions & Code Sets

  Standard Transactions:
o HIPAA (Health Insurance Portability and Accountability Act) mandates the use of standard
electronic formats for healthcare transactions such as:
 837P for professional claims
 837I for institutional claims
 270/271 for eligibility inquiries
 835 for remittance advice
o Code sets used for these transactions:
 ICD-10-CM for diagnoses
 CPT®/ HCPCS for procedures
 CDT for dental procedures
 Privacy & Security:
o Coders must adhere to HIPAA regulations regarding the privacy and security of patient
data, ensuring minimal necessary disclosure and secure transmission.
o Violations can occur if PHI (Protected Health Information) is not properly secured or is
shared inappropriately, resulting in legal consequences.
 Breach Notification:
o If unsecured PHI is compromised, covered entities must notify the affected individuals, the
OCR (Office for Civil Rights), and potentially the media (for large breaches).
o Timely and proper notification is critical for compliance.

Medical Necessity & Documentation

1. Medical Necessity Definition:
o Services or supplies must be reasonable and necessary for the diagnosis or treatment of
an illness or injury.
o Medicare’s standard: Services must be “safe and effective,” consistent with
symptoms/diagnosis, not for convenience, and furnished at an appropriate level.
2. LCD (Local Coverage Determination):
o MACs (Medicare Administrative Contractors) may publish LCDs, which clarify the
medical necessity for certain services.
o Claims that do not meet LCD criteria may be denied.
3. Advance Beneficiary Notice (ABN):
o For Medicare patients, if a service may be denied for lack of medical necessity, providers
must provide an ABN.
o Correct usage of GA or GZ modifiers is crucial to indicate that liability is shifted to the
patient or that no ABN was provided.
4. Documentation Must Support:
o Proper documentation is essential for supporting diagnoses (ICD-10-CM) and
procedures (CPT®).
o Notes should reflect the provider’s rationale, treatment plan, and outcomes/findings.

Ethical Coding Practices

1. AHIMA & AAPC Code of Ethics:

o Coders must ensure accuracy and integrity in coding, avoid fraudulent practices,
protect patient privacy, and continue updating their skills.
2. Professional Integrity:
 o Coders should not engage in unethical requests, such as coding a higher E/M service than
the documentation supports.
o Educating providers about proper documentation is vital, especially when patterns
suggest upcoding or incomplete documentation.
3. Audit Readiness:
o Maintain comprehensive coding policies, conduct internal audits, and correct errors
promptly.
o An audit trail should be kept for any changes made to codes or documentation
clarifications.

Common Pitfalls & Audit Risks

 Upcoding or Downcoding:
o Upcoding: Reporting a higher E/M service level than documentation supports.
o Downcoding: Reporting a lower service level than what was performed.
 Unbundling:
o Billing procedures separately that are typically included in a global surgical package or
normally part of another code’s descriptor.
 Inadequate Documentation:
o Missing signatures, dates, or key details.
o Failing to prove medical necessity or justify repeated services.
 Poor ABN Practices:
o Not providing an ABN when required, leading to potential write-offs.
o Incorrect use of ABN modifiers causing claim denial or patient liability issues.
 Modifier Misuse:
o Incorrect use of modifier -59 instead of identifying a legitimate distinct service.
o Failing to use modifiers -24, -25, or -57 in the context of E/M during surgical or global
periods.
 HIPAA Violations:
o Disclosing PHI without proper authorization.
o Leaving printed encounter forms visible, sending unencrypted emails with PHI, etc.

Best Practices for CPC Exam Success

1. Know the Major Laws:

o Familiarize yourself with key laws like the False Claims Act, Stark Law, Anti-Kickback
Statute, and HIPAA.
o Be able to distinguish between fraud and abuse.
2. Brush Up on Payment Methods:
o Understand key payment systems like DRGs, APCs, RBRVS, and capitation, and how
they affect coding.
3. Study NCCI Concepts:
o Practice identifying Column 1/Column 2 code pairs and understanding modifier use.
o Be familiar with the difference between “0” and “1” indicators in NCCI edits.
4. HIPAA & Privacy:
o Understand what constitutes PHI and de-identified data.
o Recognize situations that could result in HIPAA breaches or require patient authorization.
5. Documentation Requirements:
 o Ensure the provider’s documentation supports the level of service or procedure, and that
medical necessity is justified.

Specific Question Types & Pitfalls

1. E/M Leveling: You correctly point out the shift to MDM or time-based leveling for many E/M
services. This is a critical change. Pay close attention to how the question is framed. If it's a 2023
or later scenario, history/exam elements are less important for code selection in most cases. Focus
on the level of medical decision making (straightforward, low, moderate, or high complexity) or the
total time spent.
1. Example: A question describes a patient encounter with a new problem, requiring
extensive review of records and a discussion of multiple treatment options. The MDM is
likely high complexity.
2. Complex Surgery Questions: These questions often involve multiple procedures performed
during the same operative session. Your advice is spot on:
1. Identify the primary procedure.
2. Determine which other procedures are bundled into the primary procedure.
3. Identify procedures requiring separate coding and whether add-on codes are appropriate.
4. Be very aware of the global surgical package definition and NCCI edits.
5. Example: A question describes a laparoscopic cholecystectomy with intraoperative
cholangiography. The cholangiography might be bundled, depending on the specific
circumstances and payer rules.
3. Anesthesia: Anesthesia questions frequently involve base units, time units, and physical status
modifiers. Familiarity with these components is essential. You'll likely need to calculate total
anesthesia units.
1. Base units are assigned to each anesthesia procedure code.
2. Time units are calculated based on the duration of the anesthesia service.
3. Physical status modifiers (P1-P6) reflect the patient's overall health.
4. Qualifying circumstance codes (e.g., +99100 for anesthesia complicated by emergency
conditions) may also be relevant.
5. Example: A question might state that an anesthesia procedure has a base unit value of 5,
the anesthesia time was 90 minutes, and the patient's physical status is P2. You would
need to calculate the total anesthesia units (base units + time units) and apply the
appropriate physical status modifier.
4. ICD-10-CM Laterality: Laterality is crucial in ICD-10-CM. Never default to "unspecified" if laterality
is clearly documented. For injuries, the 7th character is essential for indicating initial encounter,
subsequent encounter, or sequela.
1. Example: A patient presents with a fracture of the right femur. The ICD-10-CM code must
specify the right side. If the patient is seen for follow-up care for the same fracture, the 7th
character must indicate a subsequent encounter.
5. Drug Calculations (HCPCS J-Codes): Dosage calculations are a very common source of errors.
*Double-check your math every time. Pay close attention to the units specified in the code
descriptor (e.g., per mg, per 10 mg, per unit).
1. Example: A question states that 75 mg of a drug is administered. The J code descriptor
states "per 25 mg." The correct number of units to bill is 3 (75 mg / 25 mg/unit = 3 units).
6. Compliance Scenarios: Compliance questions often test your knowledge of fraud and abuse laws
and regulations. Be familiar with key concepts such as the Stark Law, Anti-Kickback Statute, and
the False Claims Act. You may be asked to identify potential compliance issues or the appropriate
course of action. The ABN is a key component of many compliance scenarios.
 1. Example: A question might describe a situation where a physician is offered a bonus for
referring patients to a particular lab. You might be asked to identify the law that this
potentially violates (Anti-Kickback Statute). Or, a question might describe a scenario where
a service may not be covered by Medicare. You might be asked what step the provider
should take before providing the service (obtain an ABN).

Key Takeaways for Specific Question Types:

1. Read Carefully: Pay close attention to the details provided in the question stem.
2. Identify the Key Information: What is the primary procedure? What is the dosage? What is the
laterality? What is the level of MDM?
3. Apply the Correct Rules and Guidelines: Use the appropriate coding guidelines and regulations
to answer the question.
4. Double-Check Your Work: Verify your code selection, dosage calculations, and modifier usage.
5. Think Critically About Compliance: Be alert for potential compliance issues and know the
appropriate steps to take.

Modifier Mastery Guide

1. Introduction to Modifiers:

 Definition: Modifiers are additions to CPT® or HCPCS codes that provide crucial extra information
about the service. They explain why a service was performed in a specific way, at a specific time,
or on a specific location. They are essential for accurate coding and payment.
 Usage Principles:
o Specificity: Use a modifier only when the base code does not fully describe the service.
o Support: Every modifier must be supported by clear and concise documentation in the
medical record. No documentation = no modifier = potential denial.
o Placement: Place the modifier(s) in the designated field on the claim form (e.g., Box 24D
on the CMS-1500).
o Caution: Overuse or misuse of modifiers is a red flag for payers and can lead to audits,
denials, and even accusations of fraud or abuse.

2. Common CPT® Modifiers (Numeric):

 -22 (Increased Procedural Services):

o Definition: The service required significantly more work than is typical for that procedure.
This is not for increased time alone; it must be due to the patient's condition.
o Key Rules:
 Detailed documentation is mandatory. Explain the specific factors that increased
the work (e.g., extensive adhesions, unexpected complications, patient's body
habitus).
 Not used for E/M services.
 Example: A laparoscopic cholecystectomy converted to an open procedure due to
extensive adhesions from previous surgeries.
 -24 (Unrelated E/M During Post-op Period):
o Definition: An E/M service provided during the global period of a surgery, but for a
completely unrelated condition.
 o Key Rules:
 The diagnosis and reason for the E/M service must be clearly unrelated to the
surgical procedure.
 Example: Patient post-op for a knee arthroscopy presents with an acute upper
respiratory infection.
 -25 (Significant, Separately Identifiable E/M on Same Day as Minor Procedure): (High-Risk for
Misuse)
o Definition: A significant and separately identifiable E/M service is performed on the same
day as a minor procedure (0- or 10-day global period). The E/M service must be above
and beyond the usual pre- and post-operative care for the minor procedure.
o Key Rules:
 The E/M service cannot be solely for the decision to perform the minor procedure.
 Example: A patient presents for management of hypertension and, during the visit,
a decision is made to excise a skin tag. The E/M for the hypertension is separately
billable.
 -26 (Professional Component):
o Definition: Used when the physician provides the interpretative component of a service
(e.g., reading an X-ray), while the facility provides the technical component (equipment).
o Key Rules:
 Commonly used in radiology and pathology.
 Example: A radiologist interprets a CT scan.
 -50 (Bilateral Procedure):
o Definition: Used when a procedure is performed on both sides of the body during the
same operative session.
o Key Rules:
 Not used if the code description already states "bilateral."
 Some payers prefer RT/LT modifiers instead of -50. Check payer policy.
 Example: Bilateral knee arthroscopy.
 -51 (Multiple Procedures): (Becoming Less Common)
o Definition: Used when multiple procedures (other than E/M) are performed during the
same session.
o Key Rules:
 Many payers now automatically bundle or reprice multiple procedures. Check
payer policy.
 Some procedures are -51 exempt (indicated in the CPT book).
 Example: Repair of multiple tendons in the hand.
 -52 (Reduced Services):
o Definition: The physician intentionally performs a reduced level of service. Not used if the
patient is unable to tolerate the full procedure.
o Key Rules:
 Clear documentation is required explaining why the service was reduced.
 Example: A planned colonoscopy is only completed to the splenic flexure due to
inadequate bowel preparation.
 -53 (Discontinued Procedure):
o Definition: The physician discontinues a procedure after anesthesia is administered due
to life-threatening circumstances or other factors that put the patient at risk.
o Key Rules:
 Not used for patient cancellations before anesthesia.
  Example: A surgical procedure is stopped due to sudden cardiac instability of the
patient.
 -54 (Surgical Care Only):
o Definition: The surgeon performs the surgical procedure only, and another physician
provides the pre- and/or post-operative care.
o Key Rules:
 Used when care is split between providers.
 Example: A surgeon from out of town performs the surgery, and the patient's local
physician provides the post-operative care.
 -55 (Postoperative Management Only):
o Definition: The physician provides only the post-operative care for a surgical procedure
performed by another physician.
o Key Rules:
 Must be used in conjunction with modifier -54.
 Example: A local physician provides post-operative care for a patient whose
surgery was performed by an out-of-town surgeon.
 -56 (Preoperative Management Only): (Less Common)
o Definition: The physician provides only the pre-operative care for a surgical procedure
performed by another physician.
o Key Rules:
 Less commonly used.
 -57 (Decision for Surgery):
o Definition: An E/M service results in the decision for major surgery (90-day global period)
on the same day as the E/M or the next day.
o Key Rules:
 Not used for minor procedures (0- or 10-day global period).
 Example: A patient presents with acute abdominal pain, and the physician
performs an E/M service that leads to the decision for an immediate
appendectomy.
 -58 (Staged or Related Procedure or Service by the Same Physician During the
Postoperative Period):
o Definition: A planned or staged procedure is performed during the post-operative period
of the initial procedure.
o Key Rules:
 The subsequent procedure is typically more extensive than the initial procedure, or
it is a planned part of a staged procedure.
 Example: A patient undergoes initial debridement of a burn and returns several
days later for a more extensive debridement.
 -59 (Distinct Procedural Service): (High-Risk for Misuse)
o Definition: Used to identify procedures or services that are not typically reported together
but are medically necessary and separately identifiable. This is the modifier of last resort.
o Key Rules:
 Must be used only when no other modifier is appropriate.
 Clear documentation is essential.
 X{EPSU} Modifiers: Many payers now require the use of more specific modifiers
in place of -59:
 XE (Separate Encounter): A service is distinct because it occurred during
a separate encounter.
  XP (Separate Practitioner): A service is distinct because it was
performed by a different practitioner.
 XS (Separate Structure): A service is distinct because it was performed
on a separate anatomical structure.
 XU (Unusual Non-Overlapping Service): A service is distinct because it
is a service that does not overlap the usual service included in the primary
procedure.
 Example: Excision of two separate lesions at different sites during the same
session.
 -76 (Repeat Procedure by Same Physician):
o Definition: The same physician repeats

HCPCS Level II Modifiers (Alphabetic):

 -LT (Left Side) / -RT (Right Side):
o Definition: Used to identify the side of the body on which a procedure or service was
performed. Essential for many DME items, orthotics, prosthetics, and some procedures.
o Key Rules:
 Use when the HCPCS code does not inherently specify laterality.
 Some payers prefer -50 (bilateral) for bilateral procedures; others require RT/LT on
separate lines. Always check payer policy.
 Example: E1810-LT (Left knee brace).
 -GA (Waiver of Liability on File):
o Definition: Indicates that an Advance Beneficiary Notice (ABN) has been obtained from
the Medicare beneficiary for a service that may not be covered.
o Key Rules:
 Crucial for protecting providers from financial liability if Medicare denies payment.
 The ABN must be signed by the beneficiary before the service is provided.
 Example: A screening mammogram for a patient under 40 (not usually covered by
Medicare).
 -GY (Statutorily Excluded):
o Definition: Used for services that are specifically excluded from Medicare coverage by
law. No payment is expected.
 o Key Rules:
 No ABN is required.
 Example: Cosmetic procedures, acupuncture (in most cases), and certain routine
foot care.
 -GZ (No ABN on File):
o Definition: The provider expects Medicare to deny payment for the service and has not
obtained an ABN.
o Key Rules:
 The provider is liable for the cost of the service if Medicare denies payment. This
is risky for the provider.
 Example: A non-covered screening test performed without an ABN.
 -KX (Requirements Met):
o Definition: Indicates that all medical necessity requirements or coverage criteria for a
specific service have been met. Often used for therapy services exceeding the therapy cap
or for DME requiring prior authorization.
o Key Rules:
 Detailed documentation supporting the medical necessity is essential.
 Example: A patient receiving physical therapy beyond the therapy cap due to
documented medical necessity.

Documentation Tips for Modifiers:

 Clear Justification: The medical record must clearly explain why the modifier is being used.
Simply appending a modifier without supporting documentation is insufficient and will likely lead to
denials.
 E/M Modifiers (-24, -25, -57): The documentation must clearly demonstrate that the E/M service is
separate and distinct from the procedure or the global period. The diagnosis codes should support
this.
 Anesthesia Modifiers: Document the specific type of anesthesia provided (general, regional,
MAC) and the anesthesiologist's role (personally performed, medically directed). For physical
status modifiers (P3, P4, etc.), the patient's comorbidities must be clearly documented.
 -59 (or X{EPSU} Modifiers): Detailed documentation is essential. Clearly describe the different
site, separate session, distinct lesion, or unusual non-overlapping service. Example: "Two separate
incisions were made for drainage of two distinct abscesses on the patient's left arm. One abscess
was located on the forearm, and the other was located on the upper arm."
 Global Period Modifiers (-58, -78, -79): Clearly document whether the subsequent encounter is
related or unrelated to the original surgery. The diagnosis codes should support the modifier used.
 Example: "-78: Return to the OR for wound dehiscence following a previous abdominal surgery." "-
79: Patient returns to the clinic during the global period for a knee replacement for an unrelated
complaint of back pain."
 Laterality Modifiers (RT/LT): Clearly document which side of the body the procedure or service
was performed on.
 HCPCS Modifiers: Justify the use of each HCPCS modifier with specific details relevant to the
item or service provided.
Example “Tricky” Scenarios:
 -25 vs. -57:
o -25: E/M on the same day as a minor procedure (0- or 10-day global). The E/M is separate
and distinct from the minor procedure.
o -57: E/M that leads to the decision for major surgery (90-day global) on the same day or
the next day.
 -59 vs. Bundling:
o -59: Used only when procedures are distinct and separately identifiable but may be
bundled by NCCI edits. Use X{EPSU} modifiers if required by the payer.
o Bundling: Some procedures are inherently included in other procedures and should not be
billed separately, even with a modifier.
 -22 vs. -52:
o -22: The procedure is more complex than usual, requiring significantly more work. This
increases reimbursement.
o -52: The physician intentionally reduces a portion of the procedure. This reduces
reimbursement.
 RT/LT vs. -50:
o RT/LT: Used to identify the specific side of the body.
o -50: Used for bilateral procedures when the code does not inherently specify laterality.
Check payer preference.

Anesthesia Modifiers:
 AA: Anesthesia by anesthesiologist.
 QK: Medical direction of two, three, or four concurrent anesthesia procedures involving qualified
individuals.
 QX: CRNA service with medical direction by a physician.
 QZ: CRNA service without medical direction by a physician.
HCPCS Modifiers (Beyond RT/LT and GA/GY/GZ/KX):
 NU: New equipment.
 RR: Rental.
 UE: Used equipment.
Key Takeaways:
 Documentation is King: Thorough and accurate documentation is essential for all modifier use.
 Specificity Matters: Choose the most specific modifier that accurately describes the service.
 Payer Policies Vary: Always check payer-specific guidelines for modifier usage.
 Avoid Overuse: Inappropriate modifier use can lead to audits and denials.
By incorporating these enhancements, your modifier guide will be a much stronger tool for CPC exam
preparation and real-world coding practice. Remember, practice with coding scenarios is critical for
mastering modifier application.

Quick Pitfalls & Compliance Considerations:

 Automatic Use of -25 or -59: This is a major red flag for payers and auditors. Never automatically
append these modifiers. They should be used only when the documentation clearly supports their
use. Example of -25 misuse: A patient comes in for a scheduled injection (minor procedure), and
the only E/M service is related to confirming the injection site. This does not warrant a -25 modifier.
Example of -59 misuse: Two procedures performed at the same site during the same session,
where one is inherently included in the other (bundling).
 Failing to Append -24 for Unrelated Post-op Services: This can lead to claim denials. Payers
will assume the service is part of the global surgical package unless -24 is used and the
documentation clearly supports the unrelated nature of the service. Example: A patient in the global
period for a cholecystectomy presents with a new complaint of acute sinusitis. The E/M service for
the sinusitis should be billed with -24.
 Upcoding with -22: Using -22 to bill for a more expensive procedure than was actually performed
is fraudulent. The documentation must thoroughly justify the increased complexity and work
involved in the procedure. Vague or generic statements are insufficient. Example: Simply stating
"increased operative time" is not enough. The documentation must describe the specific
challenges encountered (e.g., extensive adhesions, anatomical variations).
 Inadvertent Overbilling: This can occur when -51 is used inappropriately or when -51 exempt
codes are not recognized. Example of -51 misuse: Appending -51 to procedures that are bundled
or to add-on codes. Example of -51 exempt misuse: Billing multiple procedures separately when
they should be billed together. Always check CCI edits and payer-specific bundling rules.
 Physical Status Modifiers (Anesthesia): Be aware that not all payers reimburse for all physical
status modifiers (P2, P3, P4, etc.) at the same rate. Some payers may have specific rules or
require additional documentation. Do not assume universal policy.
  Global Surgical Package Violations: Billing separately for services included in the global surgical
package is a common compliance issue. Example: Billing separately for routine post-operative
visits. Understand what is included in the global package for each procedure.
 Unbundling: Billing separate codes for services that are bundled into a single code is a form of
fraud or abuse. Example: Billing separately for components of a comprehensive procedure when a
single code exists.
 Lack of Medical Necessity: Services that are not medically necessary will not be paid. Example:
Performing a screening test that is not indicated based on the patient's age, risk factors, or
symptoms.
 Improper Use of Modifiers to Bypass Edits: Using modifiers incorrectly to circumvent NCCI edits
or other bundling rules is a serious compliance violation. Example: Using -59 when a different
modifier or no modifier is appropriate.
Final Tips:
1. Verify Modifier Usage: Always confirm modifier usage with CPT® guidelines, CMS guidelines,
and payer-specific policies. Don't rely on assumptions.
2. Document Thoroughly: Crystal-clear documentation is essential for all modifier use, especially -
22, -24, -25, -59 (and X{EPSU} modifiers), and global period modifiers.
3. Educate Providers and Coders: Regular training for providers and coders on modifier usage,
coding guidelines, and compliance issues is crucial.
4. Maintain an Audit Trail: Keep records of why specific modifiers were used. This will be invaluable
if a claim is questioned or audited.
5. Regular Audits: Conduct regular internal audits to identify and correct potential coding and billing
errors related to modifier use.
6. Stay Updated: Coding rules and payer policies are constantly changing. Stay up-to-date with the
latest guidelines and regulations.
Conclusion:
Mastering modifiers is essential for accurate coding, proper reimbursement, and compliance. Thorough
knowledge of modifier definitions, clinical applications, documentation requirements, and payer rules is
crucial for minimizing audit risk, preventing denials, and ensuring ethical and legal coding practices.
Consistent education, regular audits, and a commitment to accurate documentation are key to achieving
modifier mastery.

NCCI Quick Reference

1. Background & Purpose:
 The National Correct Coding Initiative (NCCI) is a CMS initiative designed to:
o Prevent improper payments: By identifying and disallowing inappropriate code
combinations (unbundling).
 o Enforce coding guidelines: By bundling services that are typically performed together.
o Maintain Medically Unlikely Edits (MUEs): To limit the number of units of service that are
realistically possible for a single procedure on a single date of service.
 Two NCCI Tables: NCCI edits exist for:
o Physician (Practitioner) services: Focus for the CPC exam.
o Hospital Outpatient settings.
 PTP Edits are Key: For the CPC exam, concentrate on understanding and applying Procedure-to-
Procedure (PTP) edits.
2. Types of NCCI Edits:
 A. Procedure-to-Procedure (PTP) Edits:
o Column 1/Column 2 Tables: These tables list code pairs.
 Column 1 Code: The primary or more comprehensive procedure.
 Column 2 Code: The bundled or included procedure.
o Rationale: If both procedures are performed at the same session, same site, and by the
same provider, the Column 2 code is usually not separately payable unless a valid modifier
is used.
o Indicators: Crucial for determining if unbundling is allowed.
 0 = No Modifier Allowed: The two procedures are always bundled. No modifier,
including -59 or X{EPSU} modifiers, can override the edit.
 1 = Modifier Allowed: The two procedures may be unbundled if the services are
separate and distinct (different site, separate session, distinct lesion, etc.) and
supported by documentation. -59 or X{EPSU} modifiers are used.
 B. Medically Unlikely Edits (MUEs):
o Definition: The maximum number of units of a procedure that are reasonable and
justifiable under normal circumstances for a single patient on a single date of service.
o Purpose: To prevent billing for an excessive number of units.
o Level: MUEs can be at the claim line level or the date of service level.
o Key Points:
 Exceeding the MUE may result in claim denial.
 Some MUEs can be appealed with strong documentation justifying the need for
the additional units.
 CPC Exam Tip: Pay close attention to questions that involve "units" or "quantities"
of service. They may be testing your knowledge of MUEs.
3. Applying PTP Edits in Practice:
1. Identify the Code Pair: Determine if the procedures performed are listed as a Column 1/Column 2
pair in the NCCI tables.
2. Check the Indicator: This is critical.
o 0: The procedures are always bundled. Do not unbundle.
o 1: The procedures may be unbundled if they are truly separate and distinct and if the
documentation supports it.
3. Use Modifier -59 or X{EPSU} (if Indicator is 1): Use the appropriate modifier (-59 or the more
specific XE, XP, XS, or XU modifier) to indicate that the services are separate and distinct.
Documentation is essential.
4. Do Not Unbundle If:
o The indicator is 0.
o The procedures were performed at the same site, during the same session, and are not
truly distinct (even if the indicator is 1, the documentation must support the distinctness).
5. Check CPT Guidelines: Some procedures designated as "separate procedures" in CPT are often
subject to NCCI edits.
4. Common Triggers for NCCI Edits:
 Same Lesion/Site vs. Different Lesion/Site: Excisions, biopsies, and destructions performed on
the same lesion during the same session are usually bundled. Different lesions at different sites
may be separately billable with a modifier (if the indicator allows), with proper documentation.
 Endoscopic Procedures: Diagnostic endoscopy is often bundled into a surgical endoscopy
performed in the same anatomical area.
 Lesion Destruction vs. Excision: Destruction of a lesion is often bundled with the excision of the
same lesion.
 Intraoperative Imaging: If the primary procedure includes "with imaging guidance," the imaging
guidance is bundled.
 Add-on Codes: Add-on codes are not typically reported alone. Ensure they are being billed with
the appropriate primary procedure.
 Global Surgical Package: Many procedures performed during the global period of another
surgery are bundled.
5. Step-by-Step Use of NCCI for CPC Exam Scenarios:
1. Identify the Procedures: Determine all procedures performed.
2. Primary vs. Additional: Identify the primary procedure (usually the one with the highest RVU or
the most extensive).
3. Check the NCCI PTP Tables: See if the procedures are a Column 1/Column 2 pair.
 4. Indicator 0: Do not unbundle.
5. Indicator 1: May unbundle if the services are truly distinct and if the documentation supports it.
Use the appropriate modifier.
6. MUE Check: If the question mentions multiple units, consider MUEs.
7. Finalize Coding: Bill appropriately, considering bundling and modifiers.
6. Examples (Enhanced):
1. Endoscopic Sinus Surgery: A diagnostic nasal endoscopy (31231) is performed, followed by a
more extensive endoscopic sinus surgery with biopsy (31237) in the same nasal passage. The
31231 is bundled into 31237. If, however, the diagnostic endoscopy was performed in the
contralateral nasal passage, and this is clearly documented, then 31231 could be billed separately
with a modifier (if the indicator allows).
2. Arthroscopic Knee Procedures: A diagnostic knee arthroscopy (29870) is performed, followed by
a meniscectomy (29880) in the same compartment of the knee. The 29870 is bundled. If the
diagnostic arthroscopy was performed in a different compartment of the knee, and this is
documented, then 29870 may be billed separately with a modifier (if the indicator allows).
3. Lesion Excisions: Excision of a 2 cm malignant lesion on the trunk and a 1 cm benign lesion on
the forearm. These are separate lesions at different sites. They may be billed separately with a
modifier (if the indicator allows) because they are at different sites.
4. Imaging Guidance: A code for a procedure "with imaging guidance" is performed. Do not bill
separately for the imaging guidance.
Key Takeaways:
 NCCI Edits are Crucial: Understanding NCCI edits is essential for proper coding and avoiding
denials.
 Indicators are Key: Pay close attention to the indicator (0 or 1) to determine if unbundling is
allowed.
 Documentation is Paramount: Clear and concise documentation is absolutely essential to
support the use of modifiers to override NCCI edits.
 X{EPSU} Modifiers: Use the most specific modifier possible (XE, XP, XS, XU) when appropriate.
 MUEs Matter: Be aware of MUEs and their potential impact on billing.
MUE Considerations:
 Example: A code has an MUE of 2. The question states the provider reported 4 units. Carefully
analyze the scenario. Is there a medically justifiable reason for exceeding the MUE? Examples:
Bilateral procedures (if not already inherent in the code), multiple lesions, or complex procedures
requiring significantly more material. Without strong justification, the units above the MUE will likely
be denied.
 Key Steps:
 1. Check the MUE Table: Look up the specific code to determine its MUE. The CMS website
provides access to the MUE tables.
2. Assess the Scenario: If the reported units exceed the MUE, carefully evaluate the
scenario. Is there a clear and compelling reason for the additional units? Documentation is
critical.
3. CPC Exam Strategy: On the CPC exam, generally adhere to the MUE unless the
question explicitly states a medically necessary reason for exceeding it. Assume the
scenario represents a typical clinical encounter.
8. Pointers for the CPC Exam:
 Common Bundled Code Pairs: Familiarize yourself with frequently bundled code pairs (e.g.,
biopsy + definitive procedure on the same lesion, diagnostic endoscopy + surgical endoscopy at
the same site, lesion excision + simple closure).
 -59 (and X{EPSU} Modifiers): These modifiers are heavily tested. Ensure you understand the
specific criteria for their use (separate site, separate session, distinct lesion, unusual non-
overlapping service). Documentation is critical.
 Different Lesion/Extremity: These often (but not always) justify unbundling if the NCCI indicator is
"1" and if the documentation is clear. Don't assume automatic unbundling; always check the NCCI
tables and the documentation.
 Indicator 0 vs. 1: Memorize this: 0 = no unbundling allowed; 1 = possible unbundling if
documented.
 Common Surgical Procedures: Study NCCI edits related to common surgical procedures (hernia
repairs, arthroscopies, endoscopies, lesion excisions, lysis of adhesions, etc.).
9. Quick “Cheat Sheet” Chart (Enhanced):
Column 2
Scenario Column 1 Code Indicator Typical Approach
Code
Bundled unless separate site (e.g.,
Diagnostic endoscopy
31237 (surgical 31231 contralateral nasal passage) and
+ surgical endoscopy 1
endo) (diagnostic) documented; use -59 or XE if truly
(same site)
distinct.
Arthroscopic
Usually included if same compartment. If
meniscectomy + 29881 29870 (dx
0 or 1 “1,” must have separate compartment
diagnostic (meniscectomy) arthroscopy)
and documented. If "0," always bundled.
arthroscopy
Excision lesion + Simple Simple closure is always included; never
Excision code 0
simple closure closure code unbundle.
Excision malignant + Excision 120xx code 1 Typically unbundled if separate and
intermediate repair malignant distinct (different site, different
characteristics of wound) and if indicator
 = 1. Check specific code pair and
documentation.
Carefully analyze the scenario. Must see
if scenario justifies >2 units (e.g.,
MUE Over 2 units for
N/A N/A N/A bilateral, multiple lesions). Typically
single procedure
denied if no strong justification and
documentation.
(Note: The actual indicators can differ for each code pair—always reference the official NCCI tables.)
10. Conclusion:
NCCI edits are essential for preventing unbundling and ensuring appropriate payment. For the CPC exam:
1. Know Common Bundled Pairs: Familiarize yourself with frequently encountered code pairs that
are typically bundled.
2. Distinct Services are Key: If a "distinct service" modifier (-59 or X{EPSU}) is suggested, carefully
analyze the scenario to determine if the services are truly distinct (different site, separate session,
etc.) and if the documentation supports it.
3. Indicator is Critical: Remember the significance of the indicator (0 = no override, 1 = possible
override if documented).
4. MUEs Matter: Be aware of typical MUE limits and analyze the scenario for justification of
exceeding those limits. Assume typical usage on the exam unless explicitly stated otherwise.
5. Practice, Practice, Practice: The more you work with NCCI edits, the better you'll understand
them. Use practice exams and coding scenarios to reinforce your knowledge.

Top 200 CPT® Codes: Enhanced Reference List

Important Note: These are brief, paraphrased explanations. Always consult the current CPT® manual for
exact wording and the latest updates.
Section A (Codes 1-50): E/M, Integumentary System
1. 99202: New patient E/M, straightforward/low MDM or problem-focused (2023 guidelines). Key:
Minimal to no risk.
2. 99203: New patient E/M, moderate complexity MDM or expanded problem-focused (2023). Key:
One or more stable chronic conditions.
3. 99204: New patient E/M, moderate/high MDM or detailed history and exam (2023). Key: New
problem with uncertain prognosis or exacerbation of chronic condition.
4. 99205: New patient E/M, high complexity MDM or comprehensive history and exam (2023). Key:
Complex, high-risk problem requiring extensive review.
5. 99211: Established patient E/M, minimal (nurse visit, BP check). Key: Brief encounter, minimal
physician involvement.
6. 99212: Established patient E/M, problem-focused, low MDM. Key: Self-limited or minor problem.
7. 99213: Established patient E/M, expanded problem-focused, low-moderate MDM. Key: Stable
chronic conditions or new uncomplicated problem.
8. 99214: Established patient E/M, moderate MDM. Key: Exacerbation of chronic condition, new
problem with differential diagnoses.
9. 99215: Established patient E/M, high MDM. Key: Complex, high-risk problem requiring extensive
management.
10. 99417: Prolonged service (office), each 15 minutes beyond the highest level E/M code. Key:
Requires documentation of time beyond the typical service.
11. 10021: Fine needle aspiration (FNA) biopsy, without imaging guidance. Key: Superficial lesions.
12. 10022: FNA with imaging guidance (e.g., ultrasound, CT). Key: Deeper lesions, more precise
needle placement.
13. 10120: Incision and removal of foreign body, subcutaneous tissue. Key: Simple removal,
superficial location.
14. 11042: Debridement, subcutaneous tissue, first 20 sq cm. Key: Layer of tissue removed.
15. 11043: Debridement, muscle/fascia, first 20 sq cm. Key: Deeper tissue involvement.
16. 11044: Debridement, bone, first 20 sq cm. Key: Bone involvement.
17. 11102: Tangential biopsy (shave), single lesion. Key: Superficial skin lesion.
18. 11103: Tangential biopsy, each additional lesion. Key: Used with 11102.
19. 11104: Punch biopsy, single lesion. Key: Full-thickness skin sample.
20. 11105: Punch biopsy, each additional lesion. Key: Used with 11104. 21.-26. 11400-11406: Excision,
benign lesion, trunk/arms/legs, by size. Key: Pay attention to the size of the lesion. 27.-29. 11600-
11604: Excision, malignant lesion, trunk/arms/legs, by size. Key: Requires wider margins.
21. 11730: Avulsion of nail plate, partial or complete. Key: Removal of the nail.
22. 11750: Excision of nail and nail matrix. Key: Permanent nail removal. 32.-35. 12001-12032:
Simple/Intermediate repair, wounds, by size and complexity. Key: Simple = superficial closure;
Intermediate = layered closure. 36.-37. 13100-13121: Complex repair, wounds, by site and size.
Key: Requires layered closure and may involve undermining or extensive debridement.
23. 14040: Adjacent tissue transfer (e.g., skin flap), trunk. Key: Moving tissue from a nearby area to
cover the defect.
24. 15271: Skin substitute graft, trunk/arms/legs. Key: Application of a skin substitute. 40.-42. 17000-
17004: Destruction of benign/premalignant lesions (e.g., AKs), by number of lesions. Key:
Cryotherapy, electocautery, etc.
25. (Removed - Redundancy)
26. 17110: Destruction of benign lesions (e.g., warts). Key: Up to 14 lesions.
 27. 19100: Biopsy of breast, percutaneous, without imaging guidance.
28. 19101: Biopsy of breast, open, one lesion.
29. 19120: Excision of breast cyst/fibroadenoma, open.
30. 19303: Mastectomy, simple, complete. Key: Removal of breast tissue only.
31. 19307: Mastectomy, modified radical. Key: Removal of breast tissue and lymph nodes.
32. 20000: Incision of superficial soft tissue abscess. Key: Drainage of pus.
Section B (Codes 51-100): Musculoskeletal System (Upper Extremity)
51. 20200: Muscle biopsy, superficial.
52. 20220: Bone biopsy. Key: Specify bone.
53. 20550: Injection, tendon sheath/ligament/ganglion cyst.
54. 20552: Injection, trigger point(s). Key: 1-2 muscles.
55. 20610: Arthrocentesis, major joint (e.g., knee, shoulder). Key: Aspiration and/or injection.
56. 20930: Bone allograft, spine surgery.
57. 22551: Arthrodesis, cervical spine, anterior approach. Key: Fusion of vertebrae. 58.-59. 23410-
23412: Rotator cuff repair, acute/chronic. Key: Acute = recent injury; chronic = long-standing tear.
58. 23430: Biceps tenodesis. Key: Repair of the biceps tendon at the shoulder.
59. 24357: Tendon repair, elbow.
60. 24400: Elbow arthroplasty. Key: Total elbow replacement.
61. 25000: Incision, extensor tendon sheath, wrist. Key: Release of tendon sheath.
62. 26010: Drainage of finger abscess.
63. 26055: Trigger finger release. Key: Release of tendon causing triggering.
64. 26860: Arthrodesis, thumb CMC joint.
65. 27096: Injection, sacroiliac joint. 68.-69. 27130-27132: Total hip arthroplasty (THA),
primary/revision. Key: Revision = conversion from previous hip surgery.
66. 27236: Open treatment, femoral fracture. Key: Intramedullary fixation.
67. 27301: Incision & drainage, deep abscess, thigh.
68. 27447: Total knee arthroplasty (TKA). 73.-74. 29806-29827: Shoulder arthroscopy,
capsulolabral/rotator cuff repair. Key: Arthroscopic procedures. 75.-76. 29881-29880: Knee
arthroscopy, meniscectomy (medial/lateral or both).
69. 29888: Knee arthroscopy, ACL reconstruction.
70. 30300: Removal of foreign body, nasal passage.
Section D (Codes 151-200): Cardiovascular, Digestive, Hernia Repair
101. 37220: Angioplasty, iliac artery. Key: Initial vessel.
102. 37225: Atherectomy, femoral-popliteal. Key: Initial vessel. Removal of plaque.
103. 37227: Angioplasty + stent, femoral-popliteal. Key: Initial vessel. Placement of stent to
maintain patency.
104. 37609: Ligation of saphenous vein. Key: Radical stripping.
105. 38220: Bone marrow aspiration. Key: Diagnostic procedure.
106. 38221: Bone marrow biopsy. Key: Diagnostic procedure.
107. 38230: Bone marrow harvest. Key: For transplant.
108. 43235: Upper GI endoscopy (EGD), diagnostic. Key: Visualization of esophagus, stomach,
and duodenum.
109. 43239: EGD with biopsy.
110. 43249: EGD with dilation. Key: Widening of a narrowed area.
111.43270: ERCP, diagnostic. Key: Visualization of pancreatic and biliary ducts.
112. 43280: Laparoscopic Nissen fundoplication. Key: For GERD.
113. 43450: Esophageal dilation. Key: Simple, widening of esophagus.
114. 43644: Laparoscopic gastric bypass, Roux-en-Y. Key: Weight loss surgery.
115. 43846: Open gastric bypass, Roux-en-Y. Key: Weight loss surgery.
116. 44140: Colectomy, partial, with anastomosis. Key: Removal of a portion of the colon and
reconnection.
117. 44143: Colectomy, partial, with coloproctostomy. Key: Connection to the rectum.
118. 44204: Laparoscopic colectomy, partial, with anastomosis.
119. 44970: Laparoscopic appendectomy.
120. 45378: Colonoscopy, diagnostic.
121. 45380: Colonoscopy with biopsy.
122. 45384: Colonoscopy with hot biopsy.
123. 45385: Colonoscopy with polypectomy. Key: Snare technique.
124. 45388: Colonoscopy with ablation. Key: Destruction of tumor(s).
125. 46050: Incision and drainage, perirectal abscess.
126. 46221: Hemorrhoidectomy, internal.
127. 46500: Injection, sclerosing solution, hemorrhoids.
 128. 47562: Laparoscopic cholecystectomy, without cholangiogram.
129. 47563: Laparoscopic cholecystectomy, with cholangiogram.
130. 49505: Open inguinal hernia repair, adult.
Section E (Codes 201-250): Hernia Repair, Urinary System
131. 49507: Inguinal hernia repair, child.
132. 49560: Incisional hernia repair, open. Key: Initial, reducible.
133. 49565: Ventral hernia repair, open. Key: Initial.
134. 49568: Mesh implantation, open hernia repair. Key: Add-on code.
135. 49650: Laparoscopic inguinal hernia repair. Key: Initial.
136. 49651: Laparoscopic inguinal hernia repair with mesh. Key: Initial.
137. 49652: Laparoscopic inguinal hernia repair with mesh. Key: Recurrent.
138. 50010: Nephrotomy for drainage. Key: Kidney.
139. 50200: Renal biopsy, percutaneous.
140. 50590: Lithotripsy, ESWL. Key: Extracorporeal.
141. 51600: Injection procedure, cystography.
142. 52000: Cystoscopy, diagnostic.
143. 52005: Cystoscopy with ureteral catheterization.
144. 52224: Cystoscopy with fulguration, small lesion.
145. 52235: Cystoscopy with fulguration, medium lesion.
146. 52240: Cystoscopy with fulguration, large lesion.
147. 52281: Cystoscopy, Botox injection. Key: For urinary incontinence.
148. 52290: Cystourethroscopy, collagen injection. Key: For stress incontinence.
149. 52310: Cystourethroscopy, stone manipulation. Key: Simple.
150. 52356: Cystourethroscopy, ureteroscopy, lithotripsy with stent.
Section F (Codes 251-300): Male Reproductive, Female Reproductive, Endocrine, Nervous System,
Eye/Ear, Radiology
151. 52601: TURP. Key: Transurethral resection of prostate.
152. 54150: Circumcision, newborn.
153. 54530: Orchiectomy.
154. 55250: Vasectomy.
155. 58150: TAH, without tubes/ovaries. Key: Total abdominal hysterectomy.
156. 58152: TAH with BSO. Key: Bilateral salpingo-oophorectomy.
157. 58558: Hysteroscopy with sampling/polypectomy.
158. 58661: Laparoscopic adnexal removal.
159. 58940: Oophorectomy.
160. 59025: Fetal non-stress test (NST).
161. 59320: External cephalic version.
162. 59400: Vaginal delivery, global obstetric care.
163. 59510: C-section, global obstetric care.
164. 59514: C-section delivery only.
165. 60000: Thyroid abscess drainage.
166. 60220: Thyroid lobectomy.
167. 60240: Total thyroidectomy.
168. 60500: Parathyroidectomy.
169. 60650: Laparoscopic adrenalectomy.
170. 62270: Lumbar puncture, diagnostic.
62272: Lumbar puncture, therapeutic.
171. 63030: Lumbar laminectomy, disc excision.
172. 63047: Lumbar laminectomy, decompression.
173. 63650: Spinal neurostimulator implantation.
174. 64483: Epidural injection, lumbar/sacral. Key: With imaging guidance.
175. 64490: Facet joint injection, cervical/thoracic.
176. 64721: Carpal tunnel release.
177. 64772: Sciatic nerve transection/avulsion.
178. 66821: After-cataract laser surgery (YAG).
179. 66984: Cataract extraction with IOL.
180. 67028: Intravitreal injection.
181. 67500: Orbitotomy for drainage.
182. 67900: Eyelid abscess drainage.
183. 68100: Conjunctival biopsy.
184. 69000: External ear abscess drainage.
185. 69436: Tympanostomy.