CPT Codes Defined and Demystified

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1 CPT Codes Defined and Demystified Office Visits, E&M, Evaluation and Management: Distinguish New or Established patient Must have a Diagnosis Charting reflects: Problem Focus, Complexity of History and Exam, Decision Making, and Time Spent with Patient (Exam always includes vital signs) 2009 CPT spiral bound code book pgs. 9 to 10 New Established Must have: Problem focused history 10 min 5 min Problem focused examination Straightforward medical decision making (Charting reflects CC + Brief HPI and Exam) Expanded problem focused history 20 min 10 min Expanded problem focused examination Straightforward medical decision making (Charting reflects CC + Brief HPI and Exam + Pertinent ROS) Detailed history 30 min 15 min Detailed examination Medical decision making of low complexity (Charting reflects CC + Detailed HPI and Exam + Additional ROS) Comprehensive history 45 min 25 min Comprehensive examination Medical decision making of moderate complexity (Charting reflects CC + Comprehensive HPI and Exam + Complete ROS) Comprehensive history 60 min 40 min Comprehensive examination Medical decision making of high complexity (Charting reflects CC + Comprehensive HPI and Exam + Complete ROS) Prolonged Office Visit (+) Coded in addition to an E&M Code (Office Visit) *Some feel these should only be used in unusual circumstances and that if used too often, it will trigger an audit CPT spiral bound code book pgs Direct (Face to Face): Reflects total time spent with patient that is beyond the time usually associated with the coded service. This reflects an Increase in time but not increase in complexity. This does not include time spent doing procedures, as those have their own time allotments.

2 minutes total time spent directly with patient minutes total time spent directly with patient (must be coded as the following: E&M Code ) Indirect (without Face to Face): Reflects total time spent before and after direct (face to face) time spent with the patient that was still related to patient care (eg. Review of extensive medical records or test results, communicating with other professionals/ family members) minutes total time spent indirectly regarding patient care minutes total time spent indirectly regarding patient care (must be coded as the following: E&M code ) Preventive Medicine Services Includes Well Child, Screening Gyn Exam, Screening Men s Health Exam, Screening Physical NO Diagnosis addressed at length other than need for screening Distinguish between New and Established patients If an abnormality is discovered requiring additional work perform the key components of an appropriate E&M visit, code for that E&M visit as well and use the 25 modifier to indicate this was done in addition to the screening exam. Not for Vaccine risk/benefit counseling and/or administration visits which are coded differently using Extent of focus depends on the age and sex of the patient Charting reflects: evaluation and management including age/gender appropriate history, exam, counseling/risk factor reduction interventions, ordering of lab/diagnostic procedures 2009 CPT spiral bound codebook pgs New Established Infant younger than 1 year Early Childhood age 1 4 years Late Childhood age 5 11 years Adolescent age years years years years Consultations Must be requested by another physician or other appropriate source (not initiated by patient or patient family) Physician has been requested to give opinion regarding evaluation or management of patient Chart notes must reflect communication back to original referral source via letter or phone call If mandated by third party use modifier 32 No distinguishing between New or Established patient

3 99241 Problem focused, 15 minutes Expanded problem focused, 30 minutes Detailed, 40 minutes Comprehensive, 60 minutes High comprehension, 80 minutes Telephone Services: Established patients only Not billed if office visit happened during previous 7 days Not billed if followed up with office visit within next 24 hours Count only the time related to medical discussion Must be supported by chart note detailing discussion and time spent on phone 2009 CPT code book pgs. 31 and 444 Physician Non Physician minutes minutes minutes On Line Medical Evaluation: Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network. (Do not report when using , for the same communication) Gynecology Procedures (other than screening annual exam) Screening annual exam coded as Preventive Medicine Services Coding depends on SPECIFIC AREA Examined and Treated 2009 CPT spiral bound code book pgs Colposcopy of vagina and cervix if present With biopsy of vagina or cervix modifier for each additional biopsy site Colposcopy of cervix and endocervix including upper/adjacent vagina With biopsy of cervix With biopsy of endometrial tissue (use in conjunction with 57420, 57421, ) Endometrial biopsy without colposcopy Escharotic treatment (verifying vagina chem. Tx or minor surgery chem. Application)

4 Diaphragm (or cervical cap) fitting and instructions IUD placement IUD removal Fitting and insertion of pessary or any other intravaginal support device IV Therapy All codes include time required to monitor vital signs and perform periodic patient assessment If Evaluation and Management of patient is performed outside of routine vital signs and monitoring during therapy, code for additional appropriate E&M service If hydration is incidental to administration of another fluid, it is not reported separately IV Push, 1 substance Additional push of new substances Additional push of same substance IV Infusion (chart should specify substance or drug) Up to first hour Each additional hour Additional sequential infusion up to 1 hour Concurrent infusion IV Hydration (do not report if under 30 minutes) 31 minutes to first hour Each additional hour Injectibles Given correct J Code according to content of IV Injection IM and Sub Q Single tendon Tendon/origin Trigger Point Injection 1 2 muscles muscles Arthrocentesis Small Joint (hand, wrist, foot, ankle, TMJ) Medium joint (elbow, shoulder, sacroiliac occasionally ankle) Large joint (knee, hip, occasionally shoulder or sacroiliac) Cervical/thoracic facet injection 64470

5 Cervical/thoracic facet injection, additional injection Lumbar facet injection Lumbar facet additional injection Hydrotherapy Code for the individual components of the specific hydrotherapy performed Constitutional Hydrotherapy: E/M as appropriate (99211) Hot/Cold (not measured in units) E stimulation (unattended, not measured in units) E stimulation (attended, measured in 15 minutes units) Hot Fomentation: E/M as appropriate (99211) Hot/Cold (not measured in units) Lymphatic drainage, manual therapy Russian Steam Bath: Contrast bath (by 15 minute units) Colonic Irrigation: Unlisted therapeutic procedure (by 15 minute units) (specify activity in chart) (More hydrotherapy procedures will be added as needed) Physical Medicine: 3 potential codes for any type of touch therapy Manual Therapy (highest reimbursement potential d/t highest level of training required): Includes joint mobilization, manipulation and lymphatic drainage, manual traction, myofascial release (billed by 15 minute increments, usually billed up to 4 units) Neuromuscular Re education Movement, balance coordination, kinesthetic sense, posture and/or proprioception (billed by 15 minute increments, usually billed up to 4 units) Massage Effleurage, petrissage and/or tapotement (billed by 15 minute increments, usually billed up to 4 units) Authors: Marnie Loomis and Karen Frangos 9/2/09, rev. 10/4/09

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