CPT coding system - -Descriptive terms Stand-alone code - -includes complete
and identifying codes for reporting description of
medical services and procedures procedure or service
Provides uniform language that describes
medical,
surgical, and diagnostic services Indented code - -appears below stand-
Published by the American Medical Association alone code,
(AMA) requiring coder to refer back to common portion
of
code description located before semicolon
CPT codes - -Five digits in length
Descriptions reflect health care services and
procedures CPT Category II Codes - -Tracking codes
performed in modern medical practice. used for performance
Reviewed by AMA to update codes and measurement in compliance with PQRS
descriptions Assigned for certain services or test results
annually that support performance measures
Alphanumeric and consist of four digits
followed by alpha character F
Category I CPT codes - -Five-digit CPT Reporting is optional.
code and descriptor nomenclature
Organized in six sections
CPT Category III Codes - -Allow for
utilization tracking of emerging:
Category II CPT codes - -Reported to track Technology
performance measurements Procedures
Use is optional. Services
Facilitate data collection/assessment about
new services/procedures during FDA
Category III CPT codes - -Contains approval process
"emerging technology" temporary codes Alphanumeric and consist of four digits
Assigned for data purposes followed by the alpha character T
Archived after five years unless accepted for
placement
CPT Appendices - -Appendix A—CPT
modifiers/descriptions
CPT Category I Sections - -Evaluation and Appendix B—Added/deleted/revised codes
Management (E/M) Appendix C—E/M clinical examples
Anesthesia Appendix D—Summary list of add-on codes
Surgery
Radiology
Pathology and Laboratory Guidelines - -define and explain
Medicine assignment
of codes, procedures, and services in a
particular CPT section
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, CPT Coding Study Review with Verified Answers Graded A
Subterms
Unlisted Procedures/Services - -Assigned may also be followed by
for procedure or service for which additional subterms that are indented
there is no CPT code
Special report (e.g., copy of procedure
report) is attached to claim to describe: Single Codes
Nature and Code Ranges - -Index code numbers
Extent are represented by:
Need for procedure or service Single code number
Time, effort, and equipment necessary Range of codes, separated by:
Dash
Series of codes separated by commas
Notes - -Instructional notes—appear Combination of single codes and ranges of codes
throughout Note: Review all listed codes before assigning a
CPT to clarify assignment of codes code
Blocked unindented note—located below for the procedure or service.
subsection
title and contains instructions that apply to all
codes in Boldface type - -Main terms in the CPT
that subsection index are printed in boldface type.
Indented parenthetical note—located below Note: CPT categories, subcategories,
subsection headings, and code numbers are also printed in
title, code description, or a code description that boldface type.
contains an example
Cross-reference term See - -Directs coders
Descriptive Qualifiers - -Terms that clarify to index entry under which code is listed
assignment of CPT code Italicized type is used for cross-reference term
Can occur in middle of main clause or after See.
the semicolon
May or may not be enclosed in parentheses
Inferred words - -used to save space when
referencing subterms
CPT Index - -Organized by alphabetical
main terms
Main terms represent: CPT Modifiers - -Modifiers indicate that
Procedures or services description of
Organs or anatomic sites service or procedure performed has been
Conditions altered.
Synonyms, eponyms, and abbreviations Clarify services and procedures performed
by providers.
CPT code and description remain
Modifying Terms - -Main term unchanged.
may be followed by subterms
that modify main term and/or terms they
follow. CPT Modifiers - -Reported as two-digit
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