NEW PROCEDURAL CODING – CPT STUDY GUIDES SOLUTION
Procedure Code - Code identifying medical treatment or diagnostic services. When a patient
sees a physician, each procedure and service performed is reported on a health care claim using
a standardized procedure code. Procedure codes represent medical procedures, such as
surgery and diagnostic tests, and medical services, such as an examination to evaluate a
patient's condition.
Code Linkage - Connection between a service and a patient's condition or illness. On correct
insurance claims, each reported service is connected to a diagnosis that supports the procedure
as necessary to investigate or treat the patient's condition in that health care setting. Health
plans analyze this connection between the diagnostic and procedural information, called code
linkage, to evaluate the medical necessity of the reported charges.
Procedure codes must be verified and then used to report physician's services. Physician, a
medical coder, clearinghouse coder, or a medical administrative assistant may be responsible
for the selection of procedure codes. Note that it is the physician's responsibility to report the
correct CPT code. To be sure that the procedure codes, and the diagnosis codes, are correctly
linked and valid, a medical administrative assistant, coder, or clearinghouse would review the
documentation in the patient's medical record to be sure it supports the codes. A query may be
communicated to the physician to resolve outstanding questions. By verifying all information
and following the rules of correct coding, medical administrative assistants ensure that the
provider receives the maximum appropriate reimbursement for procedures and services.
Current Procedural Terminology (CPT) - Contains the standardized classification system for
reporting medical procedures and services. The HIPAA-required set of procedure codes is the
CPT, published by the American Medical Association (AMA) and is called the CPT. An updated
edition of the CPT is available every year to reflect changes in medical practice. Newly
developed procedures are added, some are changed, and old ones that have become obsolete
are deleted. These changes are available in print and in an electronic file for medical offices that
use a computer-based version of the CPT.
New CPT codes are released on October 1 of each year and must be used for services dated the
following January 1 or later. The CPT codes as of the date of service -- not the date of claim
preparation -- are required by HIPAA. Encounter forms, the PMP, and any other computer
systems that store CPT codes must also be updated.
Category I Codes - Procedure codes found in the main body of the CPT. Category I codes --
which are most of the codes in the CPT -- are five-digit numbers with no decimals. They are
organized into six sections: (1) Evaluation and Management (E/M); (2) Anesthesia; (3) Surgery;
(4) Radiology; (5) Pathology and Laboratory; and (6) Medicine.
, Organization of CPT - With the exception of the first section, Evaluation and Management
(E/M), the CPT is arranged in numerical order from start to end. Codes for E/M are listed first,
out of numerical order, because they are used most often.
The six primary sections of the CPT Category I codes are divided into subsections. The
subsections are further divided into headings according to the type of test, service, or body
system. Code number ranges included on a particular page are found in the upper-right corner.
This makes locating a code faster after using the index.
Section Guidelines - Usage notes at the beginnings of CPT sections. The CPT book as well as all
sections opens with section guidelines that apply to its procedures. The section guidelines
information should be read carefully before a procedure code is chosen.
Bullet Symbol - A bullet (a solid circle) indicates a new procedure code. The bullet symbol
appears next to the code only the year that it is added.
Triangle Symbol (pointing upward) - A triangle indicates that the code's descriptor has changed.
It appears only in the year the descriptor is revised.
Facing Triangles Symbol (points face each other) - Facing triangles enclose new or revised text
other than the code's descriptor.
Add-on Codes (+) - Procedure performed and reported in addition to a primary procedure. A
plus sign (+) next to a code in the main text indicates an add-on code. Add-on codes describe
"secondary procedures" that are commonly carried out in addition to a primary procedure.
Add-on codes usually use phrases such as "each additional" or "list separately in addition to the
primary procedure" to show that they are NEVER used as stand-alone codes.
Bullet Inside a Circle (Moderate Sedation) - Moderate sedation is moderate, drug-induced
depression of consciousness during which patients can respond to verbal commands. The bullet
inside a circle, in CPT, next to a code means that moderate sedation is part of the procedure
that the surgeon performs. This means that for compliant coding, moderate sedation is not
billed in addition to the code.
Lightning Bolt Symbol/FDA Approval Pending - The lightning bolt symbol is used with vaccine
codes that have been submitted to the Federal Drug Administration (FDA) and are expected to
be approved for use soon. The codes CANNOT be used until approved, at which point this
symbol is removed.
Resequenced Codes (# symbol) - CPT procedure codes that have been reassigned to another
sequence. As new procedures are developed and widely adopted, CPT has encountered
situations where there are not enough numbers left in a particular numerical sequence of codes
to handle all new items that need to be included. Also, at times codes need to be regrouped
into related procedures for clarity.
Procedure Code - Code identifying medical treatment or diagnostic services. When a patient
sees a physician, each procedure and service performed is reported on a health care claim using
a standardized procedure code. Procedure codes represent medical procedures, such as
surgery and diagnostic tests, and medical services, such as an examination to evaluate a
patient's condition.
Code Linkage - Connection between a service and a patient's condition or illness. On correct
insurance claims, each reported service is connected to a diagnosis that supports the procedure
as necessary to investigate or treat the patient's condition in that health care setting. Health
plans analyze this connection between the diagnostic and procedural information, called code
linkage, to evaluate the medical necessity of the reported charges.
Procedure codes must be verified and then used to report physician's services. Physician, a
medical coder, clearinghouse coder, or a medical administrative assistant may be responsible
for the selection of procedure codes. Note that it is the physician's responsibility to report the
correct CPT code. To be sure that the procedure codes, and the diagnosis codes, are correctly
linked and valid, a medical administrative assistant, coder, or clearinghouse would review the
documentation in the patient's medical record to be sure it supports the codes. A query may be
communicated to the physician to resolve outstanding questions. By verifying all information
and following the rules of correct coding, medical administrative assistants ensure that the
provider receives the maximum appropriate reimbursement for procedures and services.
Current Procedural Terminology (CPT) - Contains the standardized classification system for
reporting medical procedures and services. The HIPAA-required set of procedure codes is the
CPT, published by the American Medical Association (AMA) and is called the CPT. An updated
edition of the CPT is available every year to reflect changes in medical practice. Newly
developed procedures are added, some are changed, and old ones that have become obsolete
are deleted. These changes are available in print and in an electronic file for medical offices that
use a computer-based version of the CPT.
New CPT codes are released on October 1 of each year and must be used for services dated the
following January 1 or later. The CPT codes as of the date of service -- not the date of claim
preparation -- are required by HIPAA. Encounter forms, the PMP, and any other computer
systems that store CPT codes must also be updated.
Category I Codes - Procedure codes found in the main body of the CPT. Category I codes --
which are most of the codes in the CPT -- are five-digit numbers with no decimals. They are
organized into six sections: (1) Evaluation and Management (E/M); (2) Anesthesia; (3) Surgery;
(4) Radiology; (5) Pathology and Laboratory; and (6) Medicine.
, Organization of CPT - With the exception of the first section, Evaluation and Management
(E/M), the CPT is arranged in numerical order from start to end. Codes for E/M are listed first,
out of numerical order, because they are used most often.
The six primary sections of the CPT Category I codes are divided into subsections. The
subsections are further divided into headings according to the type of test, service, or body
system. Code number ranges included on a particular page are found in the upper-right corner.
This makes locating a code faster after using the index.
Section Guidelines - Usage notes at the beginnings of CPT sections. The CPT book as well as all
sections opens with section guidelines that apply to its procedures. The section guidelines
information should be read carefully before a procedure code is chosen.
Bullet Symbol - A bullet (a solid circle) indicates a new procedure code. The bullet symbol
appears next to the code only the year that it is added.
Triangle Symbol (pointing upward) - A triangle indicates that the code's descriptor has changed.
It appears only in the year the descriptor is revised.
Facing Triangles Symbol (points face each other) - Facing triangles enclose new or revised text
other than the code's descriptor.
Add-on Codes (+) - Procedure performed and reported in addition to a primary procedure. A
plus sign (+) next to a code in the main text indicates an add-on code. Add-on codes describe
"secondary procedures" that are commonly carried out in addition to a primary procedure.
Add-on codes usually use phrases such as "each additional" or "list separately in addition to the
primary procedure" to show that they are NEVER used as stand-alone codes.
Bullet Inside a Circle (Moderate Sedation) - Moderate sedation is moderate, drug-induced
depression of consciousness during which patients can respond to verbal commands. The bullet
inside a circle, in CPT, next to a code means that moderate sedation is part of the procedure
that the surgeon performs. This means that for compliant coding, moderate sedation is not
billed in addition to the code.
Lightning Bolt Symbol/FDA Approval Pending - The lightning bolt symbol is used with vaccine
codes that have been submitted to the Federal Drug Administration (FDA) and are expected to
be approved for use soon. The codes CANNOT be used until approved, at which point this
symbol is removed.
Resequenced Codes (# symbol) - CPT procedure codes that have been reassigned to another
sequence. As new procedures are developed and widely adopted, CPT has encountered
situations where there are not enough numbers left in a particular numerical sequence of codes
to handle all new items that need to be included. Also, at times codes need to be regrouped
into related procedures for clarity.
