What are CPT ® Codes?

Current procedural terminology (CPT ®) is a five-digit numeric coding system used to record services provided by or performed under the direct supervision of a physician or non-physician providers. CPT Codes are actually part of the HCPCS Coding System, discussed later in this chapter.

Within CPT ® there are essentially two types of codes: one type for evaluation and management (E&M) services and one type for procedures and other services. In addition to these codes, Medicare and some private health plans recognize extensions or “modifiers,” which are appended to the code to provide further details.

* E&M Codes
* Procedure Codes
* Procedural Modifiers
* Global Periods
* Add-on Codes

E&M Codes

E&M codes are represented by CPT ® code numbers 99201 through 99499. E&M codes are used to describe patient visits and are divided into broad categories such as office visits, hospital visits, and consultations. These categories are then divided even further.

For instance, office visits are categorized as either new or established patients, and hospital visits are categorized as either initial or subsequent. And finally, within each subcategory there are different levels. These levels indicate the varying degrees of effort, time, responsibility, and medical knowledge expended during the visit.

The E&M codes have their own set of modifiers should there be a special circumstance surrounding the visit. You must use one of these modifiers to describe the circumstance and indicate to your carrier that your billing is, therefore, modified.

E&M Modifiers
- 21 Prolonged E&M Services
- 24 Unrelated E&M Service by the Same Physician During a Postoperative Period
- 25 Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service
- 57 Decision for Surgery

Procedure Codes

The second type of code, the procedure code, represents diagnostic and treatment services. For most urological procedures, the appropriate codes can be found in the urinary and male genital sections under CPT ® codes 50010 through 55899. However, some procedures commonly billed by urologists are in other sections. (For example, ultrasound services are listed in the CPT ® code 76xxx series.) Any code, which describes the service rendered, may be billed. (The only exception to this may be “bundling” edits captured in the signed contractual agreement with an insurance carrier or if a Medicare National Correct Coding Initiative (CCI) edit applies.)

Procedural Modifiers

To describe any special surgical circumstance to the payer, you must use the procedural modifiers.

Procedural Modifiers
- 22 Unusual Procedural Service
- 23 Unusual Anesthesia
- 26 Professional Component
- 32 Mandated Service
- 47 Anesthesia by Surgeon
- 50 Bilateral Procedure
- 51 Multiple Procedures
- 52 Reduced Services
- 53 Discontinued Procedure
- 54 Surgical Care Only
- 55 Postoperative Management Only
- 56 Preoperative Management Only
- 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
- 59 Distinct Procedural Service
- 62 Two Surgeons
- 63 Procedure Performed on an Infant
- 66 Surgical Team
- 76 Repeat Procedure by Same Physician
- 77 Repeat Procedure by Another Physician
- 78 Return to the Operating Room for a Related Procedure During the Postoperative Period
- 79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- 80 Assistant Surgeon
- 81 Minimum Assistant Surgeon
- 82 Assistant Surgeon (when qualified resident surgeon not available)
- 90 Reference (Outside) Laboratory
- 91 Repeat Clinical Diagnostic Laboratory Test
- 99 Multiple Modifiers

Global Periods

For each CPT ® code, there is a corresponding global period. These global periods indicate the number of postoperative days of care that are included in the payment for a procedure or surgery. Under Medicare, there are several global periods.

Global Periods
000 – Postoperative care is not included in the payment, but any related evaluation and management work is included if done on the same day
010 – 10 days of postoperative care are included in the payment
090 – 90 days of postoperative care are included in the payment
XXX – Global concept does not apply and any evaluation and management and other services performed may be reported separately on the same day
YYY – Global period is to be set by the carrier (e.g., unlisted surgery codes)
ZZZ – The code is part of another service and falls within the global period for the other service

A service paid on a global basis includes:

* visits and other physician services provided within 24 hours prior to the service
* provision of the service
* visits and other physician services for a specified number of days after the service is provided

Add-on Codes

Some CPT ® procedures are usually done in addition to another (primary) procedure. These codes are termed “add-on codes.” Add-on codes describe additional intra-service work associated with the primary procedure and are always performed with the primary procedure; they are never reported as a stand-alone code. Do not use modifier -51, Multiple Procedure, on an add-on code.

ICD-9-CM Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes indicate the condition, symptoms, problems, complaints, diagnosis, or other reasons for the visit or procedure. In other words, ICD-9 codes justify the use of CPT ® codes. You may list up to four ICD-9 codes on the Medicare claim form, but the first one used must reflect the chief reason for the services provided. Enter only one diagnosis per detail line on the electronic or paper claim. The additional diagnoses are used to describe any co-existing conditions. The chief reason and the co-existing conditions must also be noted in the medical record. Co-existing conditions requiring specific tests or procedures should also be recorded on the claim form and in the medical record.

Billing the Highest Level

ICD-9 codes are composed of three-, four- and five-digit numeric and alphanumeric codes. ICD-9 codes classify groups of diseases and injuries by etiology and by organ system. These codes also classify symptoms.

Diagnosis codes must always be documented to the highest known level of specificity. If a three-digit code lists four- and five-digit codes as sub-codes, then the three-digit code becomes a category, not a billable code. Only those codes highlighted in bold in the example below are billable codes.

Samples of ICD-9 Levels
596  Other disorders of bladder

596.0  Bladder neck obstruction
596.1  Intestinovesical fistula
596.2  Vesical fistula, not elsewhere classified
596.3  Diverticulum of bladder
596.4  Atony of bladder
596.5  Other functional disorders of bladder

596.51  Hypertonicity of bladder
596.52  Low bladder compliance
596.53  Paralysis of bladder
596.54  Neurogenic bladder
596.55  Detrusor sphincter dyssynergia
596.59  Other functional disorder of bladder
596.6  Rupture of bladder, nontraumatic
596.7  Hemorrhage of bladder wall
596.8  Other specified disorders of bladder
596.9  Unspecified disorder of bladder

Using ICD-9 V Codes

When circumstances other than a disease or injury need to be recorded as a diagnosis, a V code must be used. Some examples are: a patient comes in for a prostate check-up because of family history; a patient is seen due to his desire to be an organ donor; or a problem is present that influences the patient’s health but is not, in itself, a current injury or illness.

V codes are now more commonly accepted by insurers for many conditions. Here are some examples of V codes used by urologists:

ICD-9 V Codes
V01.6 Contact with or exposure to communicable diseases, venereal disease
V10.46 Personal history of malignant neoplasm, prostate
V55.6 Attention to artificial openings, other artificial opening of urinary tract (nephrostomy, ureterostomy, urethrostomy)
V64.41 Laparoscopic surgical procedure converted to open procedure

HCPCS Coding System

The acronym HCPCS (pronounced “hick picks”) stands for Healthcare Common Procedure Coding System. This coding system is overseen by the Centers for Medicare & Medicaid Services (CMS). These are codes for such items as DME, supplies, drugs or other physician services. HCPCS is an alphanumeric system that includes on the CPT ® system. HCPCS Codes are broken down into the following sections:
A Medical and surgical supplies
B  Enteral and parenteral therapy
C  Outpatient prospective payment system
E  Durable medical equipment (DME)
G  Procedures/professional services (procedures not listed by CPT ®)
H  Rehabilitative services
J  Drugs administered other than oral method
J  Durable medical equipment (used by Medicare carrier)
L  Prosthetic implants
P  Pathology and laboratory services
Q  Q codes (temporary)
R  Diagnostic radiology services
S  Temporary national codes (non-Medicare)
T  National T codes established for State Medicaid Agencies

How to Use Them All Together

To report the patient’s condition, the services rendered and supplies for claims processing, you must use codes from all three coding systems. For example, here’s how to code for a collagen skin test and implant for incontinence (ICD-9-CM, CPT and HCPCS) when performed in the physician’s office.

Note: For Medicare, it is required that a skin test for collagen sensitivity be administered and evaluated over a four-week period prior to consideration of the implant. The skin test should be billed:

CPT ® code 95028, Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests

- as well as -

HCPCS Q3031 Collagen Skin Test (Although this code receives no reimbursemt it should be reported as supportive documentation)

On the day of the procedure, the physician’s service along with the cost of the implant would be billed:

CPT ® code 51715, Endoscopic injection of implant material into the sub-mucosal tissues of the urethra and/or bladder neck

HCPCS L8603 Collagen implant, urinary tract, per 2.5 cc syringe includes necessary supplies (specify number of injections in units on CMS 1500)

In addition, here are some ICD-9 diagnostic codes that the collagen implant might warrant to support medical necessity:
596.59  Other function disorder of bladder (detrusor instability)
596.8  Other specified disorders of the bladder
599.82  Intrinsic (urethral) sphincter deficiency [ISD]
625.6  Stress incontinence, female
753.9  Unspecified anomaly of urinary system
788.32  Stress incontinence, male
788.33  Mixed incontinence, (male or female) urge and stress
867.0  Injury to bladder and urethra, without mention of open wound into cavity
867.1  Injury to bladder and urethra, with open wound into cavity
V15.2  Other personal history presenting hazards to health, surgery to other major organs
V15.3  Other personal history presenting hazards to health, irradiation, previous exposure to therapeutic or other ionizing radiation

National Correct Coding Initiative (CCI)

The CCI edits were established to define correct coding practices and to control improper coding that leads to inappropriate reimbursement in Medicare Part B claims. In other words, this initiative’s purpose is to systematically define which services are bundled together and which may be billed separately. CCI edits are revised, published quarterly, and are broken into two sections:

(1) Correct Coding Edits for Column1/Column 2 (formerly Comprehensive/Component) CPT ® codes and (2) Mutually Exclusive CPT ® code combinations. Each of these sections is broken into two columns. The code in the second column is not payable with the code in the first column unless the edit allows the use of a modifier associated with CCI. The ability to use a modifier to “unbundle” a code is indicated by the CCI modifier number. The codes in the second column are suffixed with a CCI superscript modifier indicator number. A superscript 0 indicates that there are no circumstances in which a modifier would be appropriate to “unbundle” the codes presented. The services represented by the code combination will never be paid separately. A superscript 1 indicates that a modifier may be allowed in order to differentiate between the services provided. In other words, the Column 2 code (formerly the component code) will not be reimbursed if performed by the same provider on the same date of service as the Column 1 code (formerly the comprehensive code) unless a modifier -59, Distinct procedural service is appended to the component CPT ® code.

The AUA, in conjunction with AUA Coding Today, provides current quarterly edits from CCI for free. CCI edits can also be purchased from the National Technical Information Service (NTIS) by calling 800-363-2068 or can be downloaded from the CMS web site.

Example:

Column 1 Column 2
50590…………………………….. 360001 364101
372021 520001
520051 523201
523251 523301
523511 523521
623181 623191
644151 644161
644171 644501
644701 644751
699900 760001
760011 G03451
G03471 G03511
G03531 G03541
52332…………………………….. 009100 009160
360001 364101
372021 503941
506841 507151
517000 517010
517020 517030
520000 520011
520050 520071
522041 522810
523100 523150
536000 536010
536050 536200
536210 536600
536610 536650
623181 623191
644151 644161
644171 644501
644701 644751
699900 760001
760011 G03451
G03471 G03511
G03531 G03541
J20011 P96120

“Do’s and Don’ts” for Claims Submission

  • Do make sure the beneficiary’s name matches their ID card exactly.
  • Do use the right modifiers. Make sure you have used the appropriate modifier (-51 is the most problematic, carriers say).
  • Do list the Medicare identification number (UPIN) for the provider.
  • Do check your codes against the CCI list to determine which CPT ® codes can be billed together for Medicare. Some insurance carriers will follow Medicare’s determination of which CPT ® codes can be billed together.
  • Do use the correct diagnosis code for the service. This is a common problem and frequent reason for denials. Check that you haven’t submitted a three-digit code when a fourth- or fifth-digit code exists (remember, you must code to the highest degree of specificity), or made any typographical errors.
  • Do list your Clinical Laboratory Improvement Amendments (CLIA) identification number for claims containing laboratory tests performed in your office.
  • Do properly list purchased diagnostic tests. Those diagnostic services with a professional and technical component are subject to the “purchased diagnostic” provision of the Medicare program. Carriers may decide whether or not the physician performed both components (i.e., did not purchase one of the components from an outside source). To signify whether the test was both performed and interpreted in the physician’s office, some carriers require the use of locally assigned codes. Check with your carrier for local guidelines.
  • Don’t submit an operative report and a cover letter for claims filed with unlisted CPT codes or CPT codes with modifier 22, Unusual procedural service. Wait until the carrier sends a request for documentation. When the request comes in, then send your documentation to include the operative report and cover letter. Remember, the operative report is the documentation that describes the procedure performed for which there is no appropriate CPT code or explains what was unusual about the service to warrant additional payment to support modifer 22. The cover letter should detail the procedure performed, explain in layman’s terms why the procedure was different, took a longer amount of time or why a higher skill level was required, as the clerk who reviews your claim may not have extensive medical knowledge. This is a change due to the mandatory electronic claim submission implemented by Medicare in July 2005.
  • Don’t bill for a visit that is included in the global period for a surgery or procedure. This rule only applies to those codes with a global period. Remember, you cannot bill for a visit that is used to perform a surgical procedure. Only if the decision to perform the surgery was made during the visit (and modifier -57, Decision for Surgery, is used) can you bill for both the visit and the procedure.
  • Don’t re-submit returned or rejected claim forms. If your claim is returned or rejected for any reason, re-submit a completely new claim. Do not resend the old one and mark it “corrected.” This will only result in a second rejection.
  • Don’t bill for an unrelated visit during the postoperative period without modifier -24, Unrelated E&M Service by the Same Physician During a Postoperative Period. A visit during the postoperative period must be unrelated to the surgery to be billed and must include modifier -24. The diagnosis code for this visit should be for something completely unrelated.
  • Don’t automatically resubmit a claim. Remember, it takes roughly 13 days to process an electronic claim and 27 days to process a paper claim. Check the filing date on your original claim before resubmitting.
  • Don’t bill Medicare for routine physical exams and related services. Medicare does not pay for these services. These charges should be collected from the patient. A signed waiver is not required.
  • Don’t write “signature on file” for Item 31 (Signature of Physician or Supplier) of the CMS form 1500 for paper claims. It is appropriate to use “signature on file” and/or a computer-generated signature for electronic claims.