Introduction to CPT®,

Surgery Guidelines, HCPCS, and

Modifiers

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers

 The Current Procedural Terminology (CPT®)
• Copyrighted and maintained by American Medical
Association (AMA)
• Used with other codes sets to report healthcare services
performed in the United States
• Established as an indexing/coding system to standardize
terminology among physicians and other providers

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 2

 Introduction to CPT®
• Instructions for use of the CPT ® code book
– Unlisted procedure
– CPT ® use by any qualified health care professional
– Parenthetical notes
– Accuracy and quality of coding
• Related guidelines
• Parenthetical instructions
• Other coding resources

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 3

 Introduction to CPT®
• The CPT® code set includes three categories of medical
nomenclature with descriptors.
– Category I
– Category II
– Category III

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 4

 Category I CPT® Codes
• Five-digit numerical code, eg 12345
• Over 7,000 service codes, plus titles and modifiers
• Reviewed and updated annually
• Mandatory to report for services and reimbursement

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 5

 Category I CPT® Codes
The CPT® coding manual divides Category I CPT® codes
into six main section titles:
– Evaluation and Management (99201–99499)
– Anesthesiology (00100-01999)
– Surgery (10021-69990)
– Radiology (70010-79999)
– Pathology and Laboratory (80047-89398)
– Medicine (90281-99607)

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 6

 Category I CPT® Codes
• Section titles have subsections divided by anatomic location, procedure,
condition, or descriptor subheadings.

• The subheadings, structured by CPT® conventions, may list alternate coding

suggestions in parenthetical instructions.

• Example:
• Section: Surgery (10021-69990)
• Subsection: Integumentary System
• Subheading: Skin, Subcutaneous and Accessory Structures
• Category: Debridement
Alternate coding » (For dermabrasions, see 15780 – 15783)
» (For nail debridement, see 11720-11721)
suggestions » (For burn(s), see 16000-16035)
» (For pressure ulcers, see 15920-15999)

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 7

 Category I CPT® Codes
Specific guidelines presented at the beginning of each section identify correct
coding protocols.

Example:
Section, Surgery
Subsection: Cardiovascular System (33010-37799)
Guideline:
Selective vascular catheterizations should be coded to include introduction and
all lesser order selective catheterizations used in the approach (e.g., the
description for a selective right middle cerebral artery catheterization includes
the introduction and placement catheterization of the right common and
internal carotid arteries).

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 8

 Category II CPT® Codes
• Alphanumeric format, with the letter “F” in the last position, eg,
0001F
• Optional “performance measurement” tracking codes
• Physician Quality Reporting System (PQRS)
• Example:
– A physician counsels a patient regarding prescribed Statin therapy
for coronary artery disease.
– Report:
• 4013F Statin therapy prescribed or currently being taken (CAD)
• Appropriate level office visit code
(99211–99215).

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 9

 Category II CPT® Codes
Due to the constant expansion of identifiable measures for quality
patient care, the AMA lists criteria on their website:

http://www.ama-assn.org/ama/pub/physician-resources/solutions-man
aging-your-practice/coding-billing-insurance/cpt/about-cpt/category-ii
-codes.shtml

Physician Quality Reporting Initiative (PQRS)

http://www.cms.gov/PQRS/

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 10

 Category III CPT® Codes
• Temporary codes
• Alphanumeric structure, with a “T” in the last position, eg, 1234T
• Can be reported alone, without an additional Category I code
• Example
– 0262T Implantation of catheter-delivered prosthetic pulmonary valve,
endovascular approach

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 Category III CPT® Codes
• Updated twice a year
– January 1
– July 1
• Implemented six months after

• Updates are published on AMA’s website:

http://www.ama-assn.org/go/CPT

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 12

 Category III CPT® Codes
If a Category III code is available,
this code must be reported
instead of a Category I unlisted code

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 The CPT® Coding Manual
• CPT® Sections
• Section Guidelines
• Section Table of Contents
• Notes
• Category II codes (0001F – 7025F)
• Category III codes (0019T – 0318T)
• Appendices A-O
• Alphabetic Index

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 CPT® Guidelines
• Referenced in the introduction of each section and
subsection of the CPT® manual

• Applicable to the section being referenced

• Define the information necessary for choosing the

correct code

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 15

 CPT® Conventions and Iconography
Used throughout the CPT® manual and include:
– Indentations
– Code symbols - iconology
– Parenthetical instructions

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 CPT® Conventions and Iconography
Example:
11000 Debridement of extensive eczematous or infected
Indentation
skin; up to 10% of body surface.

Iconography + 11001 each additional 10% of the body surface

(Symbol)
(List separately in addition to code for primary procedure)

Parenthetical
Instruction (Use 11001 in conjunction with 11000)

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 17

 CPT® Conventions and Iconography
; The semicolon and the conventional use of indentions

The use of the semicolon divides the description of a code

into two parts:
• The “stand-alone” code or the “common portion of the
procedure” code descriptor.
• The indented descriptor is dependent on the preceding
“stand-alone” code

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 CPT® Conventions and Iconography
Example:
00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise
specified
00162 radical surgery
00164 biopsy, soft tissue

Interpreted:
00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise
specified.
00162 Anesthesia for procedures on nose and accessory sinuses; radical surgery
00164 Anesthesia for procedures on nose and accessory sinuses; biopsy, soft
tissue

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 CPT® Conventions and Iconography
+ The “add-on” code symbol - Add-on codes are never reported
alone

Example:
+43283 Laparoscopy, surgical, esophageal lengthening procedure (eg,
Collis gastroplasty or wedge gastroplasty) (List separately in
addition to code for primary procedure)

(Use 43283 in conjunction with 43280, 43281, 43282)

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 CPT® Conventions and Iconography
The red circle - new procedure code

Example:
 31648 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed, with removal of bronchial valve(s), initial lobe

 The (blue) triangle - code revision

Example:
 38240 Hematopoietic progenitor cell (HPC); allogenic transplantation per donor
Appendix B: 38240 Bone marrow or blood-derived peripheral stem Hematopoietic progenitor
cell transplantation (HPC); allogenic transplantation per donor

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 21

 CPT® Conventions and Iconography
 The facing triangles - indicate new and revised text other than the
procedure descriptors

• Example:
24363 Arthroplasty, elbow; with membrane (eg, fascial); with distal humerus and proximal
ulnar prosthetic replacement (eg, total elbow)

(For revision of total elbow implant, see 24370, 24371)

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 CPT® Conventions and Iconography
 The circle with a line through it - exempt from the use of
modifier 51

Example:
93612 Intraventricular pacing

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 CPT® Conventions and Iconography
The bulls eye - includes moderate sedation

Example:
43200 Esophagoscopy, rigid or flexible; diagnostic, with or
without collection of specimen(s) by brushing or washing
(separate procedure)

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 CPT® Conventions and Iconography
The lightening bolt symbol - codes for vaccines that are
pending FDA approval.

Example:
90661 Influenza virus vaccine, derived from cell cultures, subunit,
preservative and antibiotic free, for intramuscular use

AMA CPT® “Category I Vaccine Codes” website:

www.ama-assn.org

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 CPT® Conventions and Iconography
# The number symbol – Resequenced, out of numerical order

Example:
46947 Code is out of numerical sequence.
See 46700-46947.

# 46947 Hemorrhoidopexy (for prolapsing internal

hemorrhoids) by stapling

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 CPT® Code Basics
• Review medical documentation thoroughly and gather additional
reports
• Reference the alphabetical index for a CPT® numerical code
and/or code range.
– Condition
– Procedure or service
– Anatomic site
– Synonyms, eponyms and abbreviations
• Review the numerical code and/or code range for specific
descriptions
• Follow CPT® Guidelines, Conventions and Iconology
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 27
 CPT® Code Basics
• Index:
– Ear Wax
see Cerumen
– Cerumen
Removal………………..69210
– Removal
Cerumen
Auditory Canal, External……………….69210
• Auditory System
69210 Removal impacted cerumen (separate procedure), one or
both ears

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 Separate Procedure
Example:
69210 Removal impacted cerumen (separate procedure), one
or both ears

69222 Debridement, mastoidectomy cavity, complex (eg,

with anesthesia or more than routine cleaning).

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 National Correct Coding Initiative (CCI)
• Implemented by CMS
• Promotes correct coding methodologies
• Controls the improper assignment of codes that results in
inappropriate reimbursement

Medicare publishes CCI:

http://www.cms.hhs.gov/NationalCorrectCodInitEd/

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 Column1/Column 2 Edits
Modifier
0=not
* = In Deletion allowed
existence Date 1=allowed
Column Column prior to Effective *=no 9=not
1 2 1996 Date data applicable
11042 0213T 20100701 * 0
11042 0216T 20100701 * 0
11042 0228T 20101001 * 0
11042 0230T 20101001 * 0
11042 10060 19960101 * 1
11042 11000 19960101 * 1
11042 11001 19960101 19960101 9
11042 11040 * 19960101 * 1
11042 11041 * 19960101 * 1
11042 11100 19970101 * 1

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 Sequencing
• Based on RBRVS
– Physician Work
– Practice Expense
– Professional Liability/Malpractice Insurance

• Highest RBRVS listed first.

www.cms.hhs.gov/PhysicianFee-Sched/
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 32
 CPT® Assistant
• Articles answering everyday coding questions
• CCI bundling information
• E/M billing guidance
• Current code use and interpretation
• Case studies demonstrating practical application of codes
• Anatomical illustration charts and graphs for quick reference
• Information for appealing insurance denials
• Information to validate code usage when audited

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 CPT® Appendices
Appendix A - Modifiers categorized as:
– Modifiers applicable to CPT® codes
– Anesthesia Physical Status Modifiers
– CPT® Level I Modifiers approved for Ambulatory Surgery
Center (ASC) Hospital Outpatient Use
– Level II (HCPCS/National) Modifiers

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 CPT® Appendices
• Appendix B - changes and additions to the CPT® codes
from the previous year

• Appendix C - clinical E/M examples for different

specialties

• Appendix D – Add-on Codes

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 CPT® Appendices
• Appendix E – Exempt from the use of modifier 51 (multiple
procedures)

• Appendix F – Exempt from the use of Modifier 63 (procedures

performed on infants less than 4kg)

• Appendix G – Include Moderate (Conscious) Sedation

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 CPT® Appendices
• Appendix H – Alphabetic Index of Performance Measures by
Clinical Condition or Topic
– Available only on the AMA website
– www.ama-assn.org.

• Appendix I – Genetic Testing Code Modifiers

– Removed with deletion of molecular pathology stacking codes.

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 CPT® Appendices
• Appendix J - Electrodiagnostic Medicine Listing of Sensory,
Motor, and Mixed Nerves
– Assigns each sensory, motor, and mixed nerve with its appropriate nerve
conduction study code
– Table containing maximum number of studies
• Appendix K - Product Pending FDA Approval
– Identified throughout the CPT® book with a lightening bolt symbol
– For updated vaccine approvals by the FDA, visit the AMA CPT®
Category I Vaccine Code information on their website:
www.ama-assn.org/ama/pub/category/10902.html

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 CPT® Appendices
• Appendix L - Vascular Families
– Based on the assumption that a vascular catheterization has a starting point
of the aorta
– Illustrates vascular “families” that emerge from the aorta using brackets to
identify the order of vessels.
• Appendix M - Crosswalk to Deleted CPT® Codes
– Crosswalks noting the deleted CPT® codes and descriptors from the
previous year to the current year.
– Essential when updating charge masters, charge capture documents, etc.

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 CPT® Appendices
• Appendix N - Summary of Re-sequenced CPT® Codes This
listing is a summary of CPT® codes not appearing in numeric
sequence. This allows for existing codes to be relocated to an
appropriate location.
• Appendix O - Multianalyte Assays with Algorithmic Analyses -
– This is a listing of administrative codes for Multianalyte Assays with
Algorithmic Analyses (MAAA) procedures. These are typically unique to
a single clinical laboratory or manufacturer.

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 CPT® Global Surgical Package
• Includes a standard package of preoperative,
intraoperative, and postoperative services

• Payer policies may vary

• May be furnished in any service location

– For example, a hospital, an ambulatory surgical center
(ASC), or physician office
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 41
 CPT® Global Surgical Package
(found in the Surgery Guidelines, page 58)
Included in the surgery package and not separately billable:
– Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
– Subsequent to the decision for surgery, one related E/M encounter on the
date immediately prior to or on the date of procedure (including history
and physical)
– Immediate postoperative care, including dictating operative notes, talking
with the family and other physicians or other qualified health care
Inclusive

professionals
– Evaluating the patient in the postanesthesia recovery area
– Writing orders
– Typical postoperative follow-up care

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 CMS Global Surgical Package
• Major Surgery: Has a preoperative period of 1 day with
90 days for the postoperative period.

• Minor Surgery: The preoperative period is the day of the

procedure with a postoperative period of either 0 or 10
days depending on the procedure.

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 CMS Global Surgical Package
GLOB PRE INTRA POST
HCPCS DESCRIPTION DAYS OP OP OP
22521 Percut vertebroplasty lumb 10 0.1 0.8 0.1
22522 Percut vertebroplasty ZZZ
addl 0 0 0
22523 Percut kyphoplasty thor 10 0.1 0.8 0.1
22524 Percut kyphoplasty lumbar 10 0.1 0.8 0.1
22525 Percut kyphoplasty add-on
ZZZ 0 0 0
22526 Idet single level 10 0.1 0.8 0.1
22527 Idet 1 or more levels ZZZ 0 0 0
22532 Lat thorax spine fusion 90 0.1 0.69 0.21
22533 Lat lumbar spine fusion 90 0.1 0.69 0.21
22534 Lat thor/lumb addl segZZZ 0 0 0
22548 Neck spine fusion 90 0.1 0.69 0.21
22551 Neck spine fuse&remove addl90 0.1 0.69 0.21
22552 Addl neck spine fusionZZZ 0 0 0
Source: www.cms.gov, RVU12A

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 CMS Global Surgical Package
• MMM and XXX
– Global concept does not apply
• YYY
– Subject to individual pricing
• ZZZ
– Always included in the global period

Global period days for Medicare patients may be accessed on the

CMS website: http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 45

 Global Package Modifiers
• 54 Surgical care only
• 55 Postoperative management only
• 56 Preoperative management only

GLOB PRE INTRA POST

HCPCS DESCRIPTION DAYS OP OP OP
22521 Percut vertebroplasty lumb 10 0.1 0.8 0.1
22548 Neck spine fusion 90 0.1 0.69 0.21

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 Global Package Modifiers
• 24 Unrelated E/M by the same physician or other qualified health
care professional during a postoperative period

• 25 Significant, separately identifiable evaluation and management

service by the same physician or other qualified health care
professional on the same day of the procedure or other service

• 57 Decision for surgery

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 47

 Global Package Modifiers
• 58 Staged or related procedure or service by the same physician or
other qualified health care professional during the postoperative
period

• 78 Unplanned return to the operating/ procedure room by the same

physician or other qualified health care professional following
initial procedure for a related procedure during the postoperative
period

• 79 Unrelated procedure or service by the same physician or other

qualified health care professional during the postoperative period

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 Global Package Modifiers
• 58 Staged or related procedure or service by the same physician or
other qualified health care professional during the postoperative
period

• Example:
– March 2 – Breast Biopsy
– March 6 – Modified radical mastectomy

– Add modifier 58 to the modified radical mastectomy

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 49

 Global Package Modifiers
• 78 Unplanned return to the operating/ procedure room by the same
physician or other qualified health care professional following
initial procedure for a related procedure during the postoperative
period

• Example:
– January – Gastric bypass (90 day global period)
– March – Incisional hernia on the bypass incision, taken back to the
operating room for incisional hernia repair.

– Add modifier 78 to the hernia repair

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 Global Package Modifiers
• 79 Unrelated procedure or service by the same physician or other
qualified health care professional during the postoperative period

• Example:
– January – Amputated DIP joint (finger)
– March – Below the knee amputation

– Add modifier 79 to the below the knee amputation

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 Surgical Modifiers
• 22 – Increased Procedural Service

• 50 - Bilateral Procedure

• 51 - Multiple Procedures

• 52 - Reduced Services

• 53 - Discontinued Procedure
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 52
 Modifier 22 – Increased Procedural Service
• Services required to perform the procedure are
significantly greater than usually reported with the
procedure

• Bill with the operative report

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 53

 Modifier 22 – Increased Procedural Service

Example:
A patient has a colonoscopy and a polyp is removed. The removal
of the polyp causes excessive bleeding and an extra 30 minutes is
spent controlling the bleeding. Modifier 22 would be added to the
surgical code and the operative report and/or letter would be sent
with the claim to the payer.

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 Modifier 50 - Bilateral Procedure
Check with payers on how to submit:
– One line item with modifier 50
Example: 20610-50
– Two line items with modifier 50 on the second code
Example: 20610
20610-50
– Two lines using RT/LT
Example: 20610-RT
20610-LT

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 Modifier 50 - Bilateral Procedure
• Pay close attention to code descriptions.

• Some codes specify ‘unilateral’ and include a parenthetical

statement.
Example: 50592 – Ablation, 1 or more renal tumor(s),
percutaneous, unilateral, radiofrequency

• Some codes say 1 or both.

Example: 69210 – Removal impacted cerumen (separate
procedure), 1 or both ears
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 Modifier 51 - Multiple Procedures
• More than one procedure performed at the same session by the same provider

• Not used on E/M services, Physical Medicine or Rehabilitation Services, the

provision of supplies such as vaccines or codes designated as ‘add-on’ codes.

Example:
An orthopedic surgeon performs a closed treatment of a femoral shaft fracture
on the left leg and a closed treatment of a right knee dislocation during the
same operative session. It would be coded as 27500-LT and 27552-51-RT.

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 57

 Modifier 52 - Reduced Services
• Procedure partially reduced at provider discretion
• Service not completed in its entirety

• Example:
43770 Laparoscopy, surgical, gastric restrictive procedure;
placement of adjustable gastric restrictive device

(For individual component placement, report 43770 with modifier

52)

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 Modifier 53 - Discontinued Services
• Procedure terminated due to:
– Extenuating circumstances
– Circumstances threatening the well-being of the patient
• Do not use:
– Elective cancellation prior to induction of anesthesia

Example:
A patient who is having a surgical procedure and after the administration of
general anesthetic exhibits unstable vital signs. At the recommendation of the
anesthesiologist the surgeon decides to terminate the procedure.

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 Modifier 59 – Distinct Procedural Service
• Procedures not normally reported together
• Different Session or Patient Encounter
• Different Procedure or Surgery
• Different Site or Organ System
• Separate Incision/Excision
• Separate Lesion

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 Modifier 59 – Distinct Procedural Service
Example:
A patient had a colonoscopy and a lesion is removed proximal to
the splenic flexure. During the same colonoscopy a biopsy is taken
of a different lesion. Both codes are reportable using modifier 59
on the second procedure.

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Modifier 63 - Procedures Performed on Infants Less than 4kg

• Increased work intensity

– Temperature control
– Obtaining IV access
– Maintenance of homeostasis

• Read the “Note” in the description to make sure you’re

using the modifier correctly

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 Modifier 76 - Repeat Procedure
or Service by Same Physician or Other Qualified Health Care
Professional
Example:
A patient who goes to the Emergency Room with a trauma to the
chest. A two-view chest x-ray is taken that shows a pneumothorax.
After a chest tube is placed a repeat two-view chest x-ray is taken
to verify the placement of the chest tube. You would report 71020
and 71020-76.

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 Modifier 77 - Repeat Procedure
or Service by Another Physician or Other Qualified Health Care
Professional
Example:
A patient who sees the family practitioner for chest pain and the
physician does an EKG and then refers the patient to a cardiologist.
The patient is able to see the cardiologist on the same day and the
cardiologist performs a repeat EKG. The second EKG would be
reported with modifier 77.

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 Multiple Surgeon Modifiers
• 62 – Two Surgeons
– Work together as primary surgeons
– Perform distinct parts of a procedure
– Dictate op report of their distinct part
– Each will submit the same code and append modifier 62

• 66 – Surgical Team
– Highly complex procedures
– Require differently specialties
– Modifier 66 appended to procedures coded by the surgical team

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 Assistant Surgeon Modifiers
• 80 – Assistant Surgeon
– Assistant surgeon present for entire or substantial portion of the operation
– Reports the same surgical procedure with modifier 80 appended
• 81 – Minimum Assistant Surgeon
– Circumstances present that require the services of an asst surgeon for a short time.
Minimal assistance.
– Reports the same surgical procedure with modifier 81 appended
• 82 – Assistant Surgeon (when qualified resident surgeon not available)
– Used in a teaching hospital that employs residents
– No residents available and another surgeon is used

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 66

 Ancillary Modifiers
• Global – a procedure containing both a technical and a
professional component

• Modifier 26 – Professional Component

• Modifier TC – Technical Component

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 67

 Ancillary Modifiers
Example:
A patient comes to the office with wheezing and congestion. The
physician takes a 2-view chest X-ray using his or her own
equipment and sends it out to be read by a radiologist. The office
would code 71020-TC for the use of the equipment (technical)
– The radiologist would bill 71020-26 for his/her interpretation and
report (professional service).
– If the office took the X-ray and also did the interpretation and report,
they would code 71020 – without any modifiers – to indicate they
did the global service…..both the technical and professional
components

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 Laboratory Modifiers
• 90 – Reference (Outside) Laboratory
– Used to bill for lab services purchased from an outside lab
• 91 – Repeat Clinical Diagnostic Lab Test
– Not used to confirm results
– Not used to repeat a test due to equipment malfunction
• 92 – Alternative Lab Platform Testing
– Single use
– HIV testing

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 Anesthesia Modifiers
• 23 - Unusual Anesthesia

• 47 – Anesthesia by Surgeon

• Physical Status Modifiers

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 HCPCS Level II
• Level I HCPCS is CPT®
– Maintained by AMA
– Identify services and procedures

• Level II HCPCS
– Maintained by CMS
– Identify products, supplies, and services not included in CPT®

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 HCPCS Level II
• A Codes ~ Transportation Services, Med/Surg Supplies, Admin
• B Codes ~ Enteral and Parenteral Therapy
• C Codes ~ Pass-Through Items
• D Codes ~ Dental Procedures
• E Codes ~ Durable Medical Equipment
• G Codes ~ Procedures/Professional Services
• H Codes ~ Alcohol and Drug Abuse Treatment Services
• J Codes ~ Drugs Admin Other Than Oral Method/Chemotherapy Drugs
• K Codes ~ DME Supplies
• L Codes ~ Orthotic/Prosthetic Procedures
• M Codes ~ Medical Services
• P Codes ~ Lab/Path
• Q Codes ~ Temporary Codes
• R Codes ~ Diagnostic Radiology
• S Codes ~ Temporary National Codes (Non-Medicare)
• T Codes ~ Nat’l Codes for State Medicaid Agencies
• V Codes ~ Vision/Hearing Services

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 HCPCS Level II
• Types of Level II Codes
– Permanent National Codes maintained by the CMS HCPCS
Workgroup
• Responsible for additions, deletions, revisions
• Updated annually

– Temporary National Codes maintained by the CMS HCPCS

Workgroup
• Responsible for additions, deletions, revisions
• Updated quarterly

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 73

 HCPCS Level II
Types of Temporary Codes
• G codes
– Professional health care procedures/services with no CPT ® codes
– Example:
• G0412 – G0415 – unilateral or bilateral
• 27215 – 27218 – unilateral only, use modifier 50 for bilateral

• H codes
– Used by State Medicaid Agencies for mental health services such as
alcohol and drug treatment services

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 HCPCS Level II
Dental Codes
– Current Dental Terminology or CDT®
– Separate category of national codes
– Used for billing dental procedures and supplies
– Copyright by the American Dental Association
– Additions, deletions and revisions made by the ADA

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 75

 HCPCS Level II
Coding Conventions

– Bullet indicates new code

– Triangle indicates code description has been revised

– X with line through code and code description means code has been
deleted

– Color Coded Symbols

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 HCPCS Level II
Format:
– Alphabetic Index

– Tabular Index
• Divided into different alpha-numeric sections

– Table of Contents
• List of alpha sections with code ranges and page numbers

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 HCPCS Level II
Appendices:
– Level II modifiers
• May be used with some CPT® codes, i.e., LT/RT
– Table of Drugs
• Names of Drugs, dosage, delivery method, J code
– Medicare References
– Jurisdiction List
– Deleted Code Crosswalk

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 78

 HCPCS Level II Modifiers
• Two alpha characters:
Example: RT – right
LT - left

• One alpha and one numeric character:

Example: F1 – Left hand, second digit
F2 – Left hand, third digit
F3 – Left hand, fourth digit
F4 – Left hand, fifth digit
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 79
 HCPCS Level II Table of Drugs
• Alphabetized by drug name
• Dose/Unit
• Route of administration
• Code(s)

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 80

 HCPCS Level II
• Finding a Code
– Depo Provera 150mg IM for contraception

• Two ways to find it

– Table of Drugs
– Alphabetic Index

• J1055 - Depo Provera 150 mg IM

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 81
 HCPCS Level II
• Finding a Code
– Orthopedic Shoes

• Two ways to find it

– Table of Contents
– Alphabetic Index

• L3204 - High-top orthopedic shoe with pronator for an

infant
Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 82
 HCPCS
• Fewer codes than CPT® and ICD-9-CM
• Smaller textbook

Care still needs to be taken when making a code selection

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers 83

 The End

Introduction to CPT®, Surgery Guidelines, HCPCS, and Modifiers