Service and Procedural Coding: Current Procedural Terminology (CPT)
To use a tool, one must understand its language, format, and purpose. This chapter has been developed as a guide to help the coder achieve a better understanding of the various methods available in locating correct codes for maximum appropriate reimbursement. After completing this chapter, readers should be able to:
|Adjunct Codes||Codes used to record additional services.|
|AMA||American Medical Association.|
|Audit||A process to determine if the information sent to the insurance company is supported by the documentation in the medical record.|
|Biopsy||Removal of a small amount of tissue to determine the extent of a disease or to determine a diagnosis.|
|Bundling Services||Combining lesser services with a major service so that one charge will include the variety of services.|
|CCI||Correct Coding Initiative: Bundling edits created by CMS to combine various component items with a major service or procedure.|
|CMS||Centers for Medicare and Medicaid Services: The federal agency responsible for maintaining and monitoring the Medicare program, beneficiary services, and Medicaid and state operations (formerly Health Care Financing Administration [HCFA] until 2001).|
|Comorbidity||An ongoing condition that exists with another condition for which the patient is receiving treatment.|
|Component Billing||Billing for each item or service provided to a patient in accordance with insurance carriers’ policies.|
|CPT||Current Procedural Terminology. Nomenclature published by the AMA as a means to describe services rendered to a patient through the use of numerical codes.|
|CPT Code||Procedural description with a five-digit identifying code number.|
|Diagnostic Services||Services performed to determine or establish a patient’s diagnosis.|
|E&M Codes||Evaluation and Management codes used to report patient visits, consults, hospital care, and so on.|
|Endoscopic Procedure||A procedure performed through an existing orifice with an endoscope to visualize an abnormality or to determine the extent of a disease.|
|Global Period||Specific time frames assigned to a code by an insurance company before additional payment will be made following a surgical procedure (e.g., 10 days, 90 days).|
|Global Procedures||Major surgical procedures that typically have a follow-up period of 30, 60, 90, or 120 days before you may begin to bill the patient for services related to the original procedure.|
|HCPCS||Healthcare Common Procedure Coding System: A coding system designed by CMS to report patient services that uses codes from CPT and other sources of alphanumeric codes.|
|HIPAA||Health Insurance Portability and Accountability Act: An act passed in 1996 to set standards for electronic health care transactions and to protect the privacy and security of patients’ health information.|
|Major Procedure||A packaged procedure that includes the operation, local infiltration, digital blocks, and follow-up care for a specific number of days.|
|Medicare Part A||A national health insurance program for persons over the age of 65 years and qualified disabled or blind persons regardless of income, administered by CMS to cover the cost of hospitalizations and nursing facility charges.|
|Medicare Part B||An elective coverage program offered by CMS for aged and disabled patients to provide benefits for physician and other medical services as part of the Medicare program. This program has a monthly premium that must be paid by the beneficiary to keep the policy in good standing.|
|Minor Procedures||Services identified by AMA as a starred procedure. For Medicare, these include services with either 0 or 10 days of follow-up care.|
|Modality||Any physical agent applied to produce therapeutic changes to biological tissues (e.g., thermal, acoustic, mechanical).|
|POS Codes||Place service (e.g., office, hospital) codes: A complete list of these codes is found in the introduction section of the professional version of the CPT manual.|
|Ranking Codes||Listing services in their order of importance by dates of service and values. Codes are usually ranked by value from highest to lowest charges.|
|RVU||Relative value unit: A method to calculate fees for services. A unit is translated into a dollar value using a conversion factor or dollar multiplier. The assigned value is generally based on three factors: physician work component, overhead practice expense, and malpractice insurance.|
|Superbill||A form designed by a medical practice listing the most frequently used diagnosis and procedure codes.|
|Therapeutic Services||Services performed for treatment of a specific condition.|
|Unbundling Services||Listing services or procedures as separate billable components. Although this practice may generate more revenue, it is often an incorrect reporting technique that could result in an insurance company auditing a practice or asking for refunds of paid monies.|
|UPIN||Unique Personal Identification Number.|
This chapter provides an introduction to procedural coding. The more you know about coding, the better your chances for succeeding in your chosen field. In today’s world, more emphasis is placed on coding than ever before in the history of the medical profession. Practices are seeking trained coders to keep pace with the ever-changing rules and mandates. Therefore, the more informed the coder becomes, the more valuable his or her services will be.
The Health Insurance Portability and Accountability Act (HIPAA) national standard code set for procedures is the Current Procedural Terminology, more commonly referred to as CPT. This code set was established in 1966 by the American Medical Association (AMA) to serve as a uniform language describing services and procedures performed by physicians and other health care professionals. CPT serves as a guide that helps the coder accurately report medical, surgical, or diagnostic services rendered to a patient. It is composed of five-digit numerical codes with descriptive explanations. CPT serves as a dependable, nationally mandated communication tool used by physicians, insurance companies, and patients.
The purpose of this book is to teach you convention and guideline applications as they pertain to AMA guidelines for coding applications. The purpose of CPT coding is to provide a means to report services to the patient. CPT codes often serve as a time use chart to track patient encounters or services. The patient’s medical record is the source for procedure codes that comply with regulations.
The care provided to a patient is documented in his or her medical record in terms of the services rendered. This documentation is a legal record of both the diagnoses and the procedures for a patient. The medical office documents every meeting with a patient by documenting the patient’s name, the encounter date and reason, the physician’s examination results, tests that were ordered, the diagnosis, the plan of care or notes on treatments that were performed, and the instructions given to the patient.
It is important for the coder to remember that using a CPT code does not guarantee that the provider will receive payment from the insurance company. It is often said, “If it is not documented, it did not happen,” meaning that Medicare and commercial carriers examine the medical necessity of services before payment. Therefore, if the physician performed a service, it must be documented in the medical record. If a carrier doubts that there is adequate medical necessity, it may conduct an audit of the documentation. In such a review, the carrier examines the medical record to ensure that the diagnosis and procedure codes are correctly linked and that services were provided at the correct level. If the service is not documented, the carrier will deny payment for the service even if a correct CPT code is used.
Many coders, after gaining basic experience on the job, seek certification as a coder. Certification is granted after the coder passes a national test of coding knowledge, and it increases the coder’s value to the practice. Two organizations offer coding certification.
CPT was established in 1966 by the AMA to serve as a uniform language describing the services and procedures performed by physicians and other health care professionals. CPT serves as a guide to accurate reporting of medical, surgical, or diagnostic services rendered to a patient. It consists of five-digit numerical codes with descriptive explanations. CPT serves as a dependable, nationally accepted communication tool used by physicians, insurance companies, and patients. CPT is the HIPAA standard code set for reporting procedures.
CPT is updated and published every November to meet the constantly changing demands of the medical industry. As new codes are added, the older, obsolete codes are revised or deleted from the manual. Several factors must be considered before determining if a code should or should not be included in the updated edition of the CPT manual. Two key factors are as follows:
Note that the inclusion or exclusion of a code or description from CPT does not necessarily affect reimbursement for the procedure. Reimbursement policies are determined by individual third-party payers based on contract agreements and special clauses.
Code descriptions may be changed or added to CPT when a physician writes to the AMA asking that a new code be entered into the manual or an older code be expanded based on new methods and terminology. The inclusion or deletion of a code is a lengthy process involving the cooperation of the AMA, physicians, and medical societies.
The CPT manual contains six categories that are listed in numerical order, with the exception of the Evaluation and Management (E&M) codes. Because all practices use these E&M codes, the AMA has placed them in the front of the book for easy access.
|Introduction Category||Code Sections|
|Category I Codes|
|Evaluation and Management||99201 to 99499|
|Anesthesia||00100 to 01999|
|99100 to 99140|
|Surgery||10021 to 69990|
|Radiology||70010 to 79999|
|Pathology and Laboratory||80048-89356|
|Medicine||90281 to 99199|
|99500 to 99602|
|Category II||0001F TO 7025F|
|Category III||0019T TO 0259T|
A CPT code is a five-digit numerical code used to describe the professional services of a physician or other caregiver. Professional services may include medical, surgical, radiology, pathology or laboratory, anesthesiology, or evaluation and management services.
Information contained in the introduction explains the intent of the coding system while providing insight into the formats and terminologies used. Additional definitions are provided for CPT update requests, guidelines, modifier applications, and unlisted services or procedures.
The CPT coding system is a means of communicating to third-party payers exactly what the physician did to or for a patient. Correct use of the codes will help the practice receive, in a timely manner, the full reimbursement allowed for work performed by the physician.
E&M codes are listed first in the manual, as a matter of convenience, because they are the codes most commonly used by all medical practices. These codes are based on levels of service or treatment and the location in which the service was provided. A few examples of applications for E&M codes are office visits, hospital visits, and consultations.
The anesthesia codes were developed to report the administration of anesthesia. These codes include local, general, and regional anesthesia; the administration of fluids and blood as related to anesthesia; and other supportive services, such as preoperative and postoperative visits.
Pathology and laboratory codes are used to report services provided by physicians, pathologists, or technologists under the responsible supervision of a physician. These codes are used for diagnostic studies, tests, consultations, toxicology, hematology, immunology, and anatomical or surgical pathology.
Codes in this section are supplemental tracking codes that can be used for measuring performance. The purpose of these codes is to reduce the need for record abstraction and chart review, thereby minimizing the administrative burden on health care providers and professionals. These codes facilitate data collection about the quality of care by coding certain measures that have been agreed upon as contributions to good patient care.
The use of these codes is optional. The codes are not required for correct coding, and they may not be used as a substitute for Category I codes. Note that because these codes describe components that are typically included in an E&M service or test results that are part of a laboratory procedure, there is no reimbursement value associated with them.
Because of advances in technology and procedure development, the AMA has created another code series, the Category III codes. These codes are listed in the back of the CPT manual before Appendix A. These codes are temporary codes used for emerging technology, services, and procedures. Category III codes were established to more accurately capture information lacking in established codes and to eliminate overuse of the unlisted codes.
Unlike Category I codes, which are revised only once a year, Category II and III codes are updated semiannually in January and July. Updates can be obtained via the AMA/CPT web site (www.ama-assn.org/go/cpt).
In the following exercise, you will become familiar with the various sections of CPT. With time and experience, the coder is able to identify a particular code section by the first two digits of the procedure code.
Medicare did not adopt CPT coding until 1986. In 1986, CMS (formerly HCFA) developed a multilevel coding system to describe services and procedures. CMS named this coding system the Healthcare Common Procedure Coding System, more commonly referred to as HCPCS (sometimes pronounced “hick pix”).
This section, referred to as National Use Codes, contains codes created by Medicare as a supplement to the CPT manual. This publication lists more than 2000 codes for reporting supplies, services, or procedures that are not contained in the CPT manual developed by the AMA.
Level II codes differ from CPT in that they are alphanumeric codes. These codes begin with letters of the alphabet (A to V) followed by four numbers (e.g., A0001). Level II codes are generally accepted for reporting services nationwide because they were designed with set descriptions and guidelines for use.
Because level II HCPCS is a national coding set for Medicare carriers, copies may be purchased from the same companies that sell ICD-9-CM and CPT coding manuals. Unlike the CPT manuals, HCPCS level II codes are updated throughout the year. The updated or revised codes are published in the Medicare newsletters for your state and are available on the Internet.
It is important to understand how to use CPT correctly. The introduction to CPT provides instructions for using the manual. The introduction explains the format, the definitions of levels of service, and the symbols used; it also provides general instructions about using the manual. Each section also includes explanations pertinent to a particular chapter or subchapter that should be read before coding from that section.
|Section||Identifies the service and code range (e.g., Surgery)|
|Subsection||Identifies the type of service (e.g., Integumentary)|
|Heading||Identifies anatomical setting (e.g., Skin, subcutaneous and accessory structures)|
|Subheading||Identifies the service (e.g., Incision and drainage)|
Codes that immediately follow the code with the semicolon share the common language portion of the definition. The code shares the common portion of the definition. The codes immediately following are indented so you can easily see that they count as the wording to the right of the semicolon.
Coders unfamiliar with this format could double-bill the service by listing the base code and the indented code. Had the documentation stated “Fine-needle aspiration; with imaging guidance,” you would have listed CPT code 10022 on the claim form.
To draw the coder’s attention to important information, CPT provides additional coding information in the form of statements in parentheses. Within a parenthetical statement, the coder might be directed to another code or to information that an additional code might be used to report the service.
CPT uses symbols to alert the coder to changes or special aspects of a code. The circle, triangle, and inverted triangles are used to highlight text only for a specific publication. In the next edition of CPT, these symbols will be used to highlight different coding information that has been updated or newly created.
|A circle or dot identifies a new code.|
|A triangle identifies a revised code.|
|▶ ◀||Highlights new and revised text other than the procedure descriptors for ease in comparing the older data with the new or updated information.|
|+||Indicates an add-on code (e.g., +15787 . . . Abrasion; each additional four lesions or less).|
|Used to identify codes exempt from modifier -51 (e.g., 20660, Application of cranial tongs, caliper, or stereotactic frame, including removal [separate procedure]).|
|;||A semicolon is used to save space (e.g., 20670, Removal of implant; superficial [e.g., buried wire, pin, or rod] [separate procedure]).|
|Bull’s-eye: This bull’s-eye symbol was added to indicate those procedures in which the provision of moderate sedation services is considered to be inherent and, therefore, not separately reported by the same physician performing the primary service.|
|Lightning bolt: This convention was added to highlight products that are awaiting U.S. Food and Drug Administration (FDA) approval (e.g., 90661, Influenza virus vaccine, derived from cell cultures).|
|Number sign is used to identify codes listed out of numerical sequence. See Appendix N.|
Add-on codes are for procedures that are always performed during the same operative session as another surgery and are never performed separately. These codes are inherently secondary codes. The CPT manual highlights these codes by listing a plus (+) sign before the code and adding the phrase “each additional” or “list separately in addition to primary procedure.”
Within each section and subsection, codes are provided to use when a description or code does not completely or accurately describe the service or procedure provided by the physician. These codes are unlisted procedures codes. They are easy to identify because they are listed as the last code in each section and usually end with the digits “99” or “9.” A complete list of unlisted procedure codes for each of the major six categories is provided in the notes or guidelines at the beginning of each category.
Coders must exercise particular care when using these codes, because reimbursement may be lower than anticipated. To provide a third-party payer with sufficient information to determine reimbursement, operative notes or any other supporting documentation should accompany these codes.
|A||Complete listing of CPT modifiers with detailed descriptions.|
|B||Summary of additions, deletions, and revisions for the current year.|
|C||Clinical examples of E&M codes.|
|D||Summary of CPT add-on codes, which are identified by a + symbol.|
|E||Summary of CPT codes exempt from Modifier -51 reporting rules. These codes are identified by a Ø symbol.|
|F||Summary of CPT codes exempt from Modifier 63, Procedures performed on infants weighing less than 4 kg.|
|G||Summary of CPT codes that include Moderate (Conscious) Sedation. These codes are identified by the bull’s-eye symbol ().|
|H||Alphabetical Index of Performance Measures by Clinical Condition or Topic.|
|I||Genetic Testing Code Modifiers.|
|J||Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves.|
|K||Products pending FDA approval. These codes are identified by a lightning bolt symbol ().|
|L||Vascular Families. The addition of this appendix is to assist coders in the selection of first, second, third, and beyond third-order branch arteries using the aorta as the entry point.|
|M||Cross-walk to deleted CPT codes. This appendix is provided as a summary of deleted codes for 2006 that have been cross-walked to the 2007 CPT codes.|
|N||Summary of resequenced CPT codes.|
The AMA developed modifiers to be used with codes to explain various aspects of coding. Modifiers help clarify codes and may maximize reimbursement. A complete list of CPT modifiers is found in Appendix A of the CPT manual.
In the HCPCS code list, Medicare has also developed level II modifiers to be used in addition to the CPT modifiers. The national modifier codes are AA thru ZZ. Two or more modifiers may be used with one code to give the most accurate description possible for that service. The modifier that has the greatest impact on reimbursement should be listed immediately after the CPT code.
|All of the modifiers are listed with examples of correct coding applications.|
|Unusual Procedural Services|
|When the service provided is greater than the time or service usually required for the procedure.|
Example:A surgical procedure that usually takes 1 hour took 3 hours. A report or summary should accompany the claim to explain the reason for the increase in charges.
|Correct Coding:||58180-22||(Supracervical abdominal hysterectomy)|
|Occasionally, a procedure that usually requires either no anesthesia or local anesthesia must be done under general anesthesia because of unusual circumstances. This circumstance is reported by adding modifier -23 to the procedure code of the basic service.|
Example:During a sigmoidoscopic procedure, the patient required general anesthesia.
|Correct Coding:||45330||Sigmoidoscopy, flexible|
|45330-23||General anesthesia applied|
|Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period|
|Use this modifier when the physician needs to indicate that an E&M service was performed during a postoperative period for a reason (or reasons) unrelated to the original procedure.|
Example:A patient had gallbladder surgery but came to the office because of a cold 3 weeks following the procedure (same physician). By using this modifier, the coder alerts the carrier that the office visit was not related to the surgical procedure. The physician will then be paid for the visit pertaining to the cold.
|Correct Coding:||99213-24||(Established patient office visit)|
|Significant, Separately Identifiable E&M Service by the Same Physician on the Day of a Procedure|
|This modifier indicates that on the day a procedure or other service was performed, the patient’s condition required a significant, separately identifiable E&M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.|
Example:A patient was seen for a sore throat and the removal of a wart. Both services (the office visit and the procedure) should be coded, because the reason for the office visit (sore throat) was unrelated to the reason for the surgery.
|Correct Coding:||17110||Wart removal|
|Certain procedures are a combination of a physician component and a technical component. To report only the physician component, add this modifier to the CPT code number.|
Example:The patient has had a chest x-ray, and the physician is only interpreting the film.
|Correct Coding:||71010||Radiology examination, chest, single|
|This modifier applies to services related to mandated treatments or testing (e.g., third-party payer, governmental, legislative, or regulatory requirement).|
|Correct Coding:||99243-32||Outpatient consultation, mandated|
|Anesthesia by Surgeon|
|Use this modifier to code for the services of regional or general anesthesia when this service is provided by the surgeon. Do not use it to code local anesthesia.|
Example:The surgeon who drained the patient’s cyst also administered a regional anesthetic.
|Correct Coding:||40801-47||Drainage of abscess, cyst, hematoma, vestibule of mouth; with application of anesthesia by the surgeon|
|When the same procedure is performed on both sides of the body, use this modifier to indicate that service. The modifier is appended to the second procedure.|
Example:The patient had two hernias, one in the right groin and one in the left groin that were repaired at the same operative session.
|Correct Coding:||49520||Repair recurrent inguinal hernia, right side|
|49520-50||Repair recurrent inguinal hernia, left side|
|When multiple procedures other than E&M services are performed on the same day or during the same operative session by the same provider. The services are reported as follows:|
Example:The surgeon removed the patient’s uterus and also cut an opening into the bladder to drain it.
|Correct Coding:||Primary procedure: 58150||Supracervical abdominal hysterectomy|
|Secondary procedure: 51040-51||Cystostomy with drainage|
|Under certain circumstances, a service or procedure is partially completed. This modifier alerts the carrier that a reason exists for a lower than usual charge. The reduced services modifier will protect the charge data for the practice.|
Example:93923, Noninvasive physiological studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood). The study was performed on a patient with a history of amputation of the extremity.
|Correct Coding:||93923-52||Noninvasive physiological studies of upper or lower extremity arteries|
|The physician may elect to terminate a procedure due to extenuating circumstances or because it threatens the well-being of the patient. Note: This modifier is not used to report the elective cancellation of a procedure before the patient’s anesthesia induction and/or surgical preparation in the operating suite.|
Example:The physician began a colonoscopy but had to discontinue the procedure because the patient had not been properly prepped.
|Correct Coding:||45378-53||Colonoscopy, discontinued|
|Surgical Care Only|
|This modifier indicates that one physician performed a surgical procedure and another physician provided preoperative and/or postoperative management.|
Example:The physician performed only the laminectomy.
|Correct Coding:||63250-54||Laminectomy, surgical procedure only|
|Postoperative Management Only|
|This modifier indicates that a physician other than the surgeon provided the postoperative care.|
Example:A physician other than the surgeon provided the postoperative management of the laminectomy.
|Correct Coding:||63250-55||Laminectomy, postoperative management|
|Preoperative Management Only|
|This modifier indicates that a physician other than the surgeon provided the preoperative evaluation of the patient.|
Example:A physician, other than the surgeon, performed the preoperative evaluation before the patient was admitted for a laminectomy.
|Correct Coding:||63250-56||Laminectomy, preoperative management|
|Decision for Surgery|
|Use this modifier for an E&M service that results in the initial decision to perform surgery. It applies only to major procedures (i.e., those with a 90-day global period) when surgery is performed within 24 hours of the decision for the surgery.|
Example:During the encounter with the surgeon, the decision was made to perform surgery the next day.
|Correct Coding:||99203-57||Initial office visit with decision for surgery made at the time of the visit|
|Staged or Related Procedure or Service by the Same Physician during the Postoperative Period|
|This modifier is used when the physician needs to indicate that a procedure or service performed during the postoperative period was planned prospectively at the time of the original procedure (staged), was more extensive than the original procedure, or was performed for therapy following a diagnostic surgical procedure.Example:The patient had a breast biopsy. The results indicated a need for a partial mastectomy. The service was scheduled within the 10-day global period of the biopsy.|
|Correct Coding:||19160-58||Mastectomy, partial|
|Distinct Procedural Service|
|This modifier indicates that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures or services that are not normally reported together but are appropriate under the circumstances. This may represent a different patient encounter, different site or organ system, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician.|
Example:Removal of a lesion from the arm and another from the back.
|Correct Coding:||11601||Excision, malignant lesion (first lesion)|
|11601-59||Excision, malignant lesion (second lesion)|
|Under certain circumstances, two surgeons (usually with different skills) may be required to manage a surgical procedure.|
Example:A laminectomy was performed by a neurosurgeon and an orthopedic surgeon. Each bills the same CPT code with modifier -62.
|Correct Coding:||63250-62||Laminectomy, two surgeons|
|Procedure Performed on an Infant Weighing Less Than 4 kg|
|In some cases, the small size of a neonate or infant significantly increases the complexity and physician work components required for a procedure. This modifier is used only for procedures on patients in this circumstance.|
Example:The patient is a 3-kg infant who requires an enterectomy, resection of small intestine.
|Correct Coding:||44120-63||Enterectomy, resection of small intestine; single resection and anastomosis|
|Use this modifier when highly complex procedures (i.e., those requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the “surgical team” concept.|
Example:A heart transplantation required the skills of a highly trained cardiovascular team.
|Correct Coding:||33945-66||Heart transplant, with or without recipient cardiectomy|
|Repeat Procedure by Same Physician|
|Use this modifier when a physician needs to indicate that a procedure or service was repeated subsequent to the original service on the same day.|
Example:The patient had an ECG (93000) in the morning with a repeat ECG in the afternoon.
|Correct Coding:||93000-76||ECG, repeat procedure|
|Repeat Procedure by Another Physician|
|This modifier indicates that a procedure had been performed by another physician on the same day and was repeated by a different physician.|
Example:The patient had an ECG (93000) at the primary care physician’s office and was sent to a cardiologist who repeated the ECG on the same day.
|Correct Coding:||93000-77||ECG, repeat procedure|
|Return to the Operating Room for a Related Procedure|
|This modifier indicates that another procedure, related to the first procedure, was performed during the initial procedure’s postoperative period and required a return to the operating room.|
Example:The patient had abdominal surgery. Three days after surgery an infection occurs in the wound site, requiring the patient to return to the operating room for debridement of the wound site.
|Correct Coding:||11000-78||Debridement of necrotic tissue, related procedure|
|Unrelated Procedure or Service in a Postoperative Period|
|When a patient is seen by the same physician for an unrelated problem or condition during the postoperative period, use this modifier.|
Example:A patient has a Maze procedure for the treatment of atrial fibrillation (33253) and goes home. The wound site is healing well. Two weeks later, the patient is seen by the same physician for pericardiotomy for removal of a foreign body (33020). Because the second procedure is within the global period for the original surgery, attach modifier -79 to the second procedure.
|This modifier identifies the services of another physician who acts as a second pair of hands for a surgical procedure.|
Example:A patient undergoes intestinal fistula closure (44640), requiring the assistance of another physician to complete. The primary surgeon would report the service as 44640. To report the services of the assistant, add modifier -80 to the same code.
|Correct Coding:||44640-80||Closure of intestinal fistula (Surgical assisting coding only)|
|Minimum Assistant Surgeon|
|Use this modifier for a procedure that does not normally require a surgical assistant but because of extenuating circumstances requires the services of another physician for a short time.Note: Many commercial insurance companies allow this modifier to be used when assistance is provided by personnel other than an MD or DO. For Medicare carriers, you must use modifier -AS to report services provided by an assistant who is not an MD or DO.|
Example:A patient treated for gingivitis requiring a gingivectomy (41820, excision gingiva, each quadrant) required the assistance of another physician for a short period of time. Note: This modifier may also be used to report surgical assistance of a nurse practitioner or physician assistant based on insurance company policies.
|Correct Coding:||41820-81||Gingivectomy, excision gingiva, each quadrant|
|Use this modifier when a qualified resident surgeon is not available. This modifier is typically reserved for teaching hospitals and teaching physician services.|
Example:A teaching physician required assistance to close an intestinal fistula. At the time of the procedure, a resident was not available to provide assistance. Another teaching physician had to assist with the procedure.
|Correct Coding:||44640-82||Closure of intestinal fistula|
|Reference (Outside) Laboratory|
|This modifier is used when laboratory procedures are performed by a party other than the treating or reporting physician. Use this modifier with only the 80000 code series.|
Example:A patient with Conn’s disease is scheduled for aldosterone studies in the morning and in the afternoon to compare the results of electrolyte excretion by the kidneys.
|Repeat Clinical Diagnostic Laboratory Test|
|Use this modifier to indicate a repeat of the same laboratory test on the same day to obtain subsequent (multiple) test results.|
Note: This modifier may not be used when tests are performed to confirm initial results; when specimen testing problems or equipment failure occur; or for any other reason when a normal, one-time, reportable is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance testing, evocative/suppression testing).
|Alternate Laboratory Platform Testing|
|Use this modifier when laboratory testing is performed using a kit or transportable instrument.|