Current Procedural Coding Expert Sample

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© 2016 Optum360, LLC CPT © 2016 American Medical Association. All Rights Reserved. i

Contents

ContentsIntroduction ................................................................................... i

Getting Started with Current Procedural Coding Expert ................... iGuidelines ................................................................................................... iResequencing of CPT Codes ................................................................... iCode Ranges for Medicare Billing ........................................................ iiIcons ............................................................................................................ iiAppendixes ................................................................................................ v

Anatomical Illustrations ............................................................. viiBody Planes and Movements .............................................................. viiIntegumentary System ........................................................................ viiiMusculoskeletal System ........................................................................ ixMusculoskeletal System ......................................................................... xMusculoskeletal System ........................................................................ xiMusculoskeletal System ....................................................................... xiiMusculoskeletal System ...................................................................... xiiiMusculoskeletal System ...................................................................... xivRespiratory System ................................................................................ xvArterial System ...................................................................................... xviArterial System ..................................................................................... xviiArterial System ....................................................................................xviiiVenous System ...................................................................................... xixVenous System ....................................................................................... xxLymphatic System ................................................................................ xxiLymphatic System ............................................................................... xxiiDigestive System ................................................................................. xxiiiDigestive System ................................................................................. xxivGenitourinary System ......................................................................... xxvGenitourinary System ........................................................................ xxviEndocrine System ..............................................................................xxviiEndocrine System .............................................................................xxviiiNervous System ................................................................................... xxixNervous System .................................................................................... xxxEye .......................................................................................................... xxxiEar and Lacrimal System .................................................................. xxxii

Index ...................................................................................Index–1

Tabular ........................................................................................... 1Anesthesia .................................................................................................. 1Integumentary.........................................................................................12Musculoskeletal System ........................................................................33Respiratory System ................................................................................96Cardiovascular System ....................................................................... 110Digestive System.................................................................................. 157Urinary System...................................................................................... 200Genital System...................................................................................... 215Endocrine System ................................................................................ 235Nervous System.................................................................................... 237Eye and Ocular Adnexa....................................................................... 263Radiology ............................................................................................... 279Pathology and Laboratory................................................................. 314Medicine................................................................................................. 384Evaluation & Management................................................................ 446Category II Codes ................................................................................. 471Category III Codes ................................................................................ 487

Appendix A — Modifiers .......................................................... 499CPT Modifiers ........................................................................................499Modifiers Approved for Ambulatory Surgery Center

(ASC) Hospital Outpatient Use ..............................................501

Appendix B — New, Changed and Deleted Codes ................... 507New Codes .............................................................................................507Changed Codes ....................................................................................510Deleted Codes ......................................................................................513AMA Icon Changes ..............................................................................513

Appendix D — Crosswalk of Deleted Codes ............................ 515

Appendix E — Resequenced Codes ......................................... 517

Appendix F — Add-on Codes, Modifier 51 Exempt, Optum Modifier 51 Exempt, Modifier 63 Exempt, and Moderate Sedation Codes ................................................. 525

Add-on Codes .......................................................................................525AMA Modifer 51 Exempt Codes .......................................................525Modifier 63 Exempt Codes ................................................................525Moderate Sedation Codes .................................................................525Optum Modifier 51 Exempt Codes ..................................................526

Appendix G — Pub 100 References .......................................... 527Medicare IOM references ..................................................................527

Appendix H — Physician Quality Reporting System (PQRS) ........................................................................... 615

Appendix I — Medically Unlikely Edits (MUEs)

— Professional ........................631

Professional ...........................................................................................631OPPS ........................................................................................................653

Appendix J — Inpatient Only Procedures ................................ 675

Appendix K — Place of Service and Type of Service ................. 685

Appendix L — Multianalyte Assays with Algorithmic Analyses ................................................................................... 689

Appendix M — Glossary ............................................................ 691

Appendix N — Listing of Sensory, Motor, and Mixed Nerves . 703 Motor Nerves Assigned to Codes 95900 and 95907-95913 ......703 Sensory and Mixed Nerves Assigned to Codes 95907–95913...704

Appendix C — Evaluation and Management Extended Guidelines ................................................................................ 514

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Current Procedural Coding Expert Anatomical Illustrations

© 2016 Optum360, LLC CPT © 2016 American Medical Association. All Rights Reserved. xv

Anatom

ical Illustrations

Respiratory System

Nasal bones

Septal

cartilage

Septal

cartilage

Lateral

nasal

cartilages

Greater

alar

cartilageLateral

crus

Medial

crus

Nose

Nasopharynxregion

Oropharynxregion

Hypopharynxregion

Vocal cord

Larynx

Epiglottis

Auditory tube

Trachea

Nasalcavity

Pharynx

Upper

lobe

Lower

lobe

Lower

lobe

Diaphragm

Middle

lobe

Upper lobe

Right lung

(three lobes)

Left lung

(two lobes)

Lungs

Ethmoid air

cells (sinus)

Maxillary

sinus

Eye

orbit

Inferior

turbinate

Middle

turbinate

Superior

turbinate

Mid frontal cutaway view

Nasal Turbinates

Sternum

Trachea

Aorta

T5

L1

Esophagus

Left main

bronchus

Abdominal

esophagus

Diaphragm

Pericardium

Respiratory

Trachea

Superior

lobe

bronchi

Middle

lobe

bronchi

Inferior

lobe

bronchi

Pulmonary

arterial

trunk

Bronchi

Paranasal Sinuses

Frontal

Ethmoid

Sphenoid

Maxillary

FrontalEthmoid

Sphenoid

Maxillary

Sample

Excision of skin and subcutaneous tissue for hidradenitis,inguinal; with simple or intermediate repair

11462

Tgec8FUD 0906 10.55 6.88

AMA: 2015,Jan,16; 2014,Jan,11; 2012,May,13; 2010,Apr,3-4

with complex repair11463Tgec8FUD 0906 14.05 9.35


Excision of skin and subcutaneous tissue for hidradenitis,perianal, perineal, or umbilical; with simple or intermediaterepair

11470

Tg8FUD 0906 11.65 8.02


with complex repair11471Tge8FUD 0906 14.35 9.89


11600-11646 Skin Lesion Removal: Malignant1 Biopsy on same lesion

Excision of additional margin at same operative sessionFull thickness removal including marginsLesion measurement before excision at largest diameter plus marginLocal anesthesiaSimple, nonlayered closure

2 Destruction (17260-17286)Excision of additional margin at subsequent operative session (11600-11646)

Code also complex closure (13100-13153)Code also each separate lesionCode also intermediate closure (12031-12057)Code also modifier 58 if re-excision is performed during postoperative periodCode also reconstruction (15002-15261, 15570-15770)Do not report with adjacent tissue transfer. Report only adjacent tissue transfer code.

(14000-14302)

Excision, malignant lesion including margins, trunk, arms, orlegs; excised diameter 0.5 cm or less

11600

Ts8tFUD 0106 5.435 3.42

AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2012,Jan,15-42; 2011,Jan,11;2010,Apr,3-4; 2010,Jan,3-5

excised diameter 0.6 to 1.0 cm11601Ts8tFUD 0106 6.455 4.26

AMA: 2015,Jan,16; 2014,Mar,12; 2014,Mar,4; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2012,Mar,4-7; 2010,Apr,3-4;2010,Jan,3-5


AMA: 2015,Jan,16; 2014,Mar,12; 2014,Mar,4; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5



excised diameter 3.1 to 4.0 cm11604Tg8tFUD 0106 8.895 6.17


excised diameter over 4.0 cm11606Tg8tFUD 0106 12.75 9.16


Excision, malignant lesion including margins, scalp, neck,hands, feet, genitalia; excised diameter 0.5 cm or less

11620

Ts8tFUD 0106 5.495 3.46



AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5





excised diameter 3.1 to 4.0 cm11624Tg8tFUD 0106 9.575 6.88


excised diameter over 4.0 cm11626Tg8tFUD 0106 11.55 8.47


Excision, malignant lesion including margins, face, ears,eyelids, nose, lips; excised diameter 0.5 cm or less

11640

2 Eyelid excision involving more than skin (67800-67808,67840-67850, 67961-67966)

Ts8tFUD 0106 5.655 3.58


excised diameter 0.6 to 1.0 cm116412 Eyelid excision involving more than skin (67800-67808,

67840-67850, 67961-67966)Ts8tFUD 0106 6.715 4.47



67840-67850, 67961-67966)Ts8tFUD 0106 7.655 5.27



67840-67850, 67961-67966)Ts8tFUD 0106 9.045 6.61



67840-67850, 67961-67966)Tg8tFUD 0106 11.15 8.17


excised diameter over 4.0 cm116462 Eyelid excision involving more than skin (67800-67808,

67840-67850, 67961-67966)Tg8tFUD 0106 14.65 11.3

AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2012,Jan,15-42; 2011,Jan,11; 2010,Apr,3-4;2010,Jan,3-5

11719-11765 Nails and Supporting StructuresCMS: 100-02,15,290 Foot Care2 Drainage of paronychia or onychia (10060-10061)

Trimming of nondystrophic nails, any number11719Zq8tFUD 0006 0.395 0.22

AMA: 2015,Jan,16; 2014,Jan,11

Debridement of nail(s) by any method(s); 1 to 511720Zq8tFUD 0006 0.915 0.42

AMA: 2015,Jan,16; 2014,Jan,11

6 or more11721Zq8tFUD 0006 1.265 0.70

AMA: 2015,Jan,16; 2014,Jan,11

; Female Only: Male Onlyc Bilateralg-w ASC Pmtb/f PC/TC Comp Onlyd/e Surg Assist Allowed / w/DocA-Y OPPSICMS: Pub 100AMA: CPT Asst

5 Facility RVU 6 Non-Facility RVU 4 Lab Crosswalk 3 Radiology Crosswalk

© 2016 Optum360, LLC (Blue Text)CPT © 2016 American Medical Association. All Rights Reserved. (Black Text)Medicare (Red Text)16

Integumentary System11462In

tegu

men

tary

Sys

tem

1146

2—

117

21

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© 2016 Optum360, LLC © 2016 American Medical Association. All Rights Reserved. 631

Appendix I —

Medically U

nlikely Edits (MU

Es) — Professional

Appendix I — Medically Unlikely Edits (MUEs) — Professional

The Centers for Medicare & Medicaid Services (CMS) began to publish many of the edits used in the medically unlikely edits (MUE) program for the first time effective October 2008. What follows below is a list of the published CPT codes that have MUEs assigned to them and the number of units allowed with each code. CMS publishes the updates on a quarterly basis. Not all MUEs will be published, however. MUEs intended to detect and discourage any questionable payments will not be published as the agency feels the efficacy of these edits would be compromised. CMS added another component to the MUEs—the MUE Adjudication Indicator (MAI). The appropriate MAI can be found in parentheses following the MUE in this table and specify the maximum units of service (UOS) for a CPT/HCPCS code for the service. The MAI designates whether the UOS edit is applied to the line or claim.

The three MAIs are defined as follows:

MAI 1 (Line Edit) This MAI will continue to be adjudicated as the line edit on the claim and is auto-adjudicated by the contractor.

MAI 2 (Date of Service Edit, Policy) This MAI is considered to be the “absolute date of service edit” and is based on policy. The total unit of services (UOS) for that CPT code and that date of service (DOS) are combined for this edit. Medicare contractors are required to review all claims for the same patient, same date of service, and same provider.

MAI 3 (Date of Service Edit: Clinical) This MAI is also a date-of-service edit but is based upon clinical standards. The review takes current and previously submitted claims for the same patient, same date of service, and same provider into account. When medical necessity is clearly documented, the edit may be bypassed or the claim resubmitted.

The quarterly updates are published on the CMS website at http://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp.

Professional

CPT MUE01996 1(2)0019T 1(1)0042T 1(1)0051T 1(2)0052T 1(2)0053T 1(2)0054T 2(1)0055T 2(1)0058T 1(1)0071T 1(2)0072T 1(2)0075T 1(2)0076T 2(1)0095T 1(1)0098T 1(1)0099T 2(2)0100T 2(2)0101T 1(1)0102T 2(2)0103T 1(1)0106T 4(2)0107T 4(2)0108T 4(2)0109T 4(2)0110T 4(2)0111T 1(1)0123T 2(2)0126T 1(1)0159T 2(2)0163T 2(1)0164T 4(2)0165T 4(2)0169T 1(1)0171T 1(2)0172T 3(1)0174T 1(1)0175T 1(1)0178T 1(1)0179T 1(1)0180T 1(1)

0182T 3(1)0184T 1(1)0190T 2(2)0191T 2(2)0195T 1(2)0196T 1(2)0198T 2(2)0200T 1(2)0201T 1(2)0202T 1(3)0206T 1(1)0207T 2(2)0208T 1(1)0209T 1(1)0210T 1(1)0211T 1(1)0212T 1(1)0213T 1(2)0214T 1(2)0215T 1(2)0216T 1(2)0217T 1(2)0218T 1(2)0219T 1(2)0220T 1(2)0221T 1(2)0222T 1(1)0223T 1(1)0224T 1(1)0225T 1(1)0228T 1(2)0230T 1(2)0232T 1(1)0233T 1(1)0234T 2(2)0235T 2(1)0236T 1(2)0237T 2(1)0240T 1(1)0241T 1(1)0243T 1(2)

CPT MUE0244T 1(2)0249T 1(2)0253T 1(1)0254T 2(2)0255T 2(2)0262T 1(1)0263T 1(1)0264T 1(1)0265T 1(1)0266T 1(1)0267T 1(1)0268T 1(1)0269T 1(1)0270T 1(1)0271T 1(1)0272T 1(1)0273T 1(1)0274T 1(2)0275T 1(2)0278T 1(1)0281T 1(2)0282T 1(3)0283T 1(3)0284T 1(1)0285T 1(1)0286T 1(2)0287T 2(1)0288T 1(2)0289T 2(2)0290T 1(1)0291T 1(2)0292T 1(1)0293T 1(2)0294T 1(1)0295T 1(2)0296T 1(2)0297T 1(2)0298T 1(2)0299T 1(2)0300T 1(1)0301T 1(1)

CPT MUE0302T 1(1)0303T 1(1)0304T 1(1)0305T 1(1)0306T 1(1)0307T 1(1)0308T 1(1)0309T 1(1)0310T 1(1)0311T 1(1)0312T 1(1)0313T 1(1)0314T 1(1)0315T 1(1)0316T 1(1)0317T 1(1)0329T 1(2)0330T 1(2)0331T 1(3)0332T 1(3)0333T 1(2)0335T 2(2)0336T 1(3)0337T 1(3)0338T 1(2)0339T 1(2)0347T 1(3)0348T 1(3)0349T 1(3)0350T 1(3)0351T 5(3)0352T 5(3)0353T 2(3)0354T 2(3)0355T 1(2)0356T 4(2)0357T 1(2)0358T 1(2)0359T 1(2)0360T 1(2)0361T 3(3)

CPT MUE0362T 1(2)0363T 3(3)0364T 1(2)0366T 1(2)0368T 1(2)0370T 1(3)0371T 1(3)0372T 1(3)0373T 1(2)0375T 1(2)0376T 2(3)0377T 1(2)0378T 1(2)0379T 1(2)0380T 1(2)0381T 1(2)0382T 1(2)0383T 1(2)0384T 1(2)0385T 1(2)0386T 1(2)0387T 1(3)0388T 1(3)0389T 1(3)0390T 1(3)0391T 1(3)0001M 1(1)0002M 1(1)0003M 1(1)0006M 1(2)0007M 1(2)0008M 1(3)10021 4(3)10022 4(3)10030 2(3)10040 1(2)10060 1(2)10061 1(2)10080 1(3)10081 1(3)10120 3(3)

CPT MUE10121 2(3)10140 2(3)10160 3(3)10180 2(3)11000 1(2)11001 1(3)11004 1(2)11005 1(2)11006 1(2)11008 1(2)11010 2(3)11011 2(3)11012 2(3)11042 1(2)11043 1(2)11044 1(2)11055 1(2)11056 1(2)11057 1(2)11100 1(2)11101 6(3)11200 1(2)11201 0(3)11300 5(3)11301 6(3)11302 4(3)11303 3(3)11305 4(3)11306 4(3)11307 3(3)11308 4(3)11310 4(3)11311 4(3)11312 3(3)11313 3(3)11400 3(3)11401 3(3)11402 3(3)11403 2(3)11404 2(3)11406 2(3)

CPT MUE11420 3(3)11421 3(3)11422 3(3)11423 2(3)11424 2(3)11426 2(3)11440 4(3)11441 3(3)11442 3(3)11443 2(3)11444 2(3)11446 2(3)11450 1(2)11451 1(2)11462 1(2)11463 1(2)11470 3(2)11471 2(3)11600 2(3)11601 2(3)11602 3(3)11603 2(3)11604 2(3)11606 2(3)11620 2(3)11621 2(3)11622 2(3)11623 2(3)11624 2(3)11626 2(3)11640 2(3)11641 2(3)11642 3(3)11643 2(3)11644 2(3)11646 2(3)11719 1(2)11720 1(2)11721 1(2)11730 1(2)11732 9(3)

CPT MUE11740 3(3)11750 6(3)11752 3(3)11755 4(3)11760 4(3)11762 2(3)11765 4(3)11770 1(3)11771 1(3)11772 1(3)11900 1(2)11901 1(2)11920 1(2)11921 1(2)11922 1(3)11950 1(2)11951 1(2)11952 1(2)11954 1(3)11960 2(3)11970 2(3)11971 2(3)11976 1(2)11980 1(2)11981 1(3)11982 1(3)11983 1(3)12001 1(2)12002 1(2)12004 1(2)12005 1(2)12006 1(2)12007 1(2)12011 1(2)12013 1(2)12014 1(2)12015 1(2)12016 1(2)12017 1(2)12018 1(2)12020 2(3)

CPT MUE

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