hello and welcome to the CPC certification review training with Legacy this training is designed to assist you in passing the CPC certification examination this course is not designed for beginners you should have an understanding of the coding process prior to taking this review in this review we will discuss the CPT categories surgery guidelines hick picks level 2 and modifiers category 1 codes are the medical procedures evaluation and management Radiology Labs Etc Category 2 codes are located at the back of the CPT book behind the category 1 codes the category 2 codes are identified by the letter F at the end they are optional performance measurement tracking codes designed to facilitate data collection by the AMA and CMS regarding quality of care Category 3 codes are located behind the category 2 codes they are identified by the letter T at the end of each code they are temporary codes used for data collection in the Food and Drug Administration approval process regarding new and emerging technology services and procedures in the instructions for use of the CPT code book the second sentence explains that you do not select a CPT code that merely approximates the services provided instead an unlisted procedure code should be used CPT codes may be used by any qualified Healthcare professional the fifth paragraph of the introduction indicates the importance of reading the parenthetical instructions surrounding the CPT codes the parenthetical instructions are intended to prevent significant errors but are not all-inclusive the same paragraph in this section reminds us of the importance of accuracy and quality of coding by also referring to the parenthetical instruction related guidelines AMA CPT assistant and other coding resources this is an added reminder of how important it is to know and understand the guidelines this is all important information for you to remember as you venture into the world of coding guidelines appear throughout CPT and coders should be aware of them as referenced previously guidelines are found throughout CPT they are in the introduction of each section of the book and many of the subsections the guidelines provide specific information as to how to apply the codes in the section such as when to add Services together report Services separately when to use particular modifiers what makes a service complete versus limited and so on CPT convention refers to the guidelines and rules for using CPT codes correctly these conventions provide guidance on how to select the appropriate CPT code for a specific procedure or service the CPT convention includes rules for code selection code modifiers and code bundling CPT code symbols also known as iconography are used to provide additional information about the codes used to describe medical Surgical and diagnostic procedures and services these symbols are used to clarify the meaning of CPT codes to indicate that certain codes are related or to alert the user to a special circumstance for example the triangle symbol indicates that the code description has been revised or modified since the previous edition of the CPT manual the plus symbol is used to indicate that a code is an add-on code add-on codes are used to describe procedures or services that are performed in addition to the primary procedure or service understanding these symbols is essential for accurate and efficient CPT coding they can help to ensure that codes are applied correctly reducing the risk of errors and improving patient care CPT code set has been developed as Standalone descriptions of medical procedures however some of the procedures in the CPT code book are not printed in their entirety but refer back to a common portion of the procedure listed in the preceding entry this is evident when an entry is followed by one or more indentations this is done in an effort to conserve space there are a variety of icons or symbols used throughout CPT several of the different icons are shown on the screen take a moment to reference your book and find examples of these throughout CPT take a moment to familiarize yourself with all the iconography for example if you see a code with a circle next to it with a line through it that means that code is exempt from the use of modifier 51. category 1 CPT codes are five digit numerical codes such as one two three four five these are the codes that coders are commonly familiar with for reporting medical visits Services tests and procedures provided by physicians and other qualified Healthcare professionals to patients the codes are reviewed and updated annually by the AMA new codes begin use on January 1st it is mandatory to use category 1 CPT codes for reporting and reimbursement purposes each section has subsections subheadings and guidelines before the guidelines there are alternative coding suggestions available which will Aid the coder in finding correct codes the guidelines that appear below these suggestions provide valuable information about the correct coding of procedures in this section they will instruct coders about how to add Services together or when to report items separately when items are inclusive with other services what modifiers should be used and so on coders should spend time here familiarizing themselves with the guidelines take a moment to review the structure of the CPT book itself as you are coding review the documentation to determine what services were provided then review the CPT index to find the code or code range that would apply to the services codes can be found in the CPT index in multiple ways condition procedure anatomical site and so on once you have identified the codes review those codes the code descriptions and all guidelines and instructions for reporting to select the code that represents the service provided behind the category 1 CPT codes are the category 2 CPT codes Category 2 codes are five character alphanumeric codes that end with the letter f f like fracture these coats are used for performance measurements and one method for reporting quality both to commercial insurance carriers as well as to Medicare for use with the quality payment program the category 2 codes were previously known as The Physician Quality Reporting System pqrs codes [Music] Category 3 codes are found behind the category 2 codes Category 3 codes are also five character alphanumeric codes but end with the letter t t like temporary category three codes are temporary codes used to report emerging technology services and procedures these codes can be reported alone remember the instructions for reporting CPT codes state to report the code that most accurately identifies the services performed this may be a category 3 temporary code rather than a category 1 CPT code there are several appendices in the back of the CPT book let's review a few of them now appendix a contains detailed descriptions of modifiers that are applicable to CPT anesthesia amblicatory surgery centers and some of the level 2 hick picks modifiers the clinical examples for CPT evaluation and Management Services were previously housed in appendix C however they have since been removed from the CPT code book as of 2023 for information or guidance on reporting e m services please refer to the e m guidelines the summary of CPT codes that include moderate sedation have been removed from the CPT code set and were previously housed in appendix G the codes that were previously included in the former appendix G have been revised with the removal of the moderate sedation symbol for information or guidance on reporting moderate sedation services with codes formally listed in appendix G please refer to the guidelines for codes 99151-99152-99153-99155-99156 and 99157 the alphabetical clinical topics listing formally appendix H has been removed from the CPT code book since this document is a dynamic and rapidly expanding source of information to link CPT Category 2 codes clinical conditions and measure abstracts the alphabetical listing is now solely accessed on the AMA CPT website in addition new codes for the publication cycle will continue to be located on the AMA CPT website prior to publication in the next edition of the CPT code book appendix N is a table of CPT codes that do not appear in numeric sequence in the listing of CPT codes and the code ranges with their corresponding locations rather than deleting and renumbering resequencing allows existing codes to be relocated to an appropriate location for the code concept regardless of the numeric sequence the codes listed in this table are identified in the CPT 2023 code set with a hash mark symbol for the location of the resequenced number within the family of related Concepts numerically placed references are used as a navigational alert to direct the user to the location of an out of sequence code procedures on the list for appendix P involve electronic communications using interactive equipment which include audio and video recording at a minimum ncci stands for National correct coding initiative per the CMS website CMS developed the national correct coding initiative to promote National correct coding methodologies and to control improper coding leading to inappropriate payment and Part B claims CMS owns the ncci detail and publishes it along with many other resources on its website many commercial carriers follow the CMS ncci edits as well while icd-10-cm codes are sequenced based on the ICD-10 guidelines and instructions found within the code book CPT codes are sequenced based on RB RBS RB RVs stands for resource-based relative value scale which is an estimation of physician work practice expense and medical malpractice RB RVs is found on the Medicare website once Services have been coded or identified they are sequenced using the highest relative value also known as rvu the highest rvu is ranked first followed by other codes in decreasing rvu order a CPT assistant is published reference material you will find references to it listed below codes in the CPT book CPT assistant offers articles answering everyday questions ncci bundling information e m billing guidance current code use and interpretation case studies demonstrating practical application of codes anatomic illustration charts and graphics for quick reference information for appealing an insurance denial and information to validate code usage when audited the CPT assistant is a subscription that is considered an official resource beginning of the surgery section in CPT you will find the surgery guidelines while payer policies may vary in general the global surgery package describes the set of services surrounding or applicable to surgical services the global surgery package describes pre-operative post-operative and intraoperative services that are included in the surgical service itself and are not separately billable the package applies to procedures and services in any location in the surgery guidelines the surgical package is detailed with six specific bullets please take a moment to review those the surgical Global period refers to the time period during which all services related to a surgical procedure are included in the global surgery package the global period begins on the day of the surgery and ends either 10 days or 90 days after the surgery depending on the type of procedure preformed there are three types of surgical Global periods there is a zero-day global period which applies to surgical procedures that are considered minor and includes procedures such as biopsy and simple wound closures the 10-day Global period applies to surgical procedures that are considered intermediate and include procedures such as toenail removal the global period for these procedures is 10 days which means all the services related to the surgery are included in the global surgical package for a period of 10 days after the surgery the 90-day Global period applies to surgical procedures that are considered major and include procedures such as major organ transplant and complex Orthopedic surgeries the global period for these procedures is a little different it's actually a total of 92 days we count day one before the surgery the day of surgery and 90 days immediately following the day of surgery hick picks code include all services that are provided to the patients which are included in hick picks level one also known as CPT picks level 2 codes include ambulance drugs durable medical equipment and so on these codes are maintained by CMS and contain both permanent and temporary National codes the permanent codes are updated annually and go into effect January 1st the temporary codes are updated quarterly hick pick codes are five character alphanumeric codes that begin with an alpha letter for example a 9999 we will review a few of the hick pick sections now the a section includes the transportation services including ambulance medical and surgical supplies administrative and miscellaneous and investigational codes an example of an a code from hick picks is a 4253 take a moment to look this up in your hick pick books it is for a blood glucose test or Regent strips for home blood glucose monitoring per 50 strips this code refers to the supply of blood glucose test strips used for monitoring blood sugar levels in patients with diabetes the code specifies the quantity of 50 strips per unit and the code is used to bill for the cost of strips when they are provided to the patient for use at home the g-codes include professional service codes specifically applicable to Medicare patients and additional Quality Reporting codes note that there are some codes that are similar between CPT and hick picks look at codes g0412 through g0415 versus a 27215-27218 the g-codes are unilateral or bilateral the crosswalk below the G Codes note the appropriate CPT codes to reference for non-medicare patients however review of those CPT codes show that they are only unilateral when using the CPT codes modifier 50 would have to be appended if done bilaterally the codes in this section are drugs that are given subcutaneously intramuscularly intrathecally intravenously orally topically or inhaled the majority of J codes come with a specific dosage for a drug so be careful of the quantity reported also in the hick picks book appendix a lists a table of drugs and Biologicals which lists both generic and brand name drugs found throughout the hick picks book note the drug name units per code route of administration and hick picks code never code from this table always validate the code in the tabular list the L code section includes the orthotic procedures and services and prosthetic procedures the key coding concepts are the anatomic site number size and type of product or procedure the cue code section includes the temporary codes temporary codes can be added changed or deleted on a quarterly basis once established temporary codes are usually implemented within 90 days the time needed to prepare and issue implementation instructions and to enter the new code into CMS and the contractor's computer systems and initiate user education the key coding concepts are the anatomic site number size and type of procedure or product and the age of the patient the S code section includes the temporary National codes these are non-medicare codes the key coding concepts are the anatomic site number size type of procedure or product and the age of the patient there are appendices in the hick picks book we have already looked at appendix a example of other appendices typically include level 2 hicpix modifiers the modifier description definition explanation and tips for usage there are modifiers in this list that are billable with CPT codes as well as with the hick pick codes there are several other appendices in the hick picks book however note that each publisher may have a different set of appendices modifier 22 is appended to surgical CPT codes when the amount of work to perform the service was significantly greater than what is typically required to support the use of modifier 22 a copy of the operative report must be sent along with the claim the detail in the operative report must describe the additional work and the reasons for the additional work for example extra time difficulty the patient's condition or other complications modifier 24 is related to an evaluation and Management Service provided to a patient by the same physician During the post-operative period for a service completely unrelated to the surgery for example a patient has surgery on her right knee on day 32 of the post-operative period the patient injures their wrist and returns to the orthopedic surgeon since the patient is already in a global period for the knee during which additional office visits are not billable if related to the surgery the orthopedic surgeon would append modifier 24 to the evaluation and management to indicate that this visit was related to something other than the knee surgery modifier 25 and modifier 57 are both modifiers used in medical billing to indicate that a service or procedure was performed during a separate encounter or visit than the one for which it was originally scheduled however there are some important differences between the two modifiers modifier 25 is used to indicate that a significant and separately identifiable evaluation and Management Service was provided by the same physician or other qualified health care provider on the same day as the procedure or other service this means that the physician provided a separate service in addition to the procedure that was necessary and distinct from the procedure itself this modifier is typically used when a patient comes in for a scheduled visit and also receives a separate service on the same day such as a vaccination or a minor procedure modifier 25 allows the physician to bill for both the e m service and the procedure without bundling them together modifier 57 is used to indicate that an e m service was provided on the same day as a major surgical procedure or a procedure with a global period of 90 days this modifier indicates that the evaluation and Management Service was the decision-making service that led to the performance of the major surgical procedure or procedure with a global period of 90 days this means that the physician provided a separate service that was necessary for the decision-making and management of the procedure itself modifier 57 allows the physician to bill for the E M service separately from the procedure without bundling them together in summary both modifier 25 and 57 are used to indicate that a service or procedure was performed during a separate encounter or visit than the one for which was originally scheduled however modifier 25 is used when a significant and separately identifiable e m service is provided on the same day as a procedure while modifier 57 is used with an e m service that is provided on the same day as a major surgical procedure or procedure with a global period of 90 days modifier 58 is used to indicate a staged or related procedure by the same physician During the post-operative period it can be a follow-up procedure that is more extensive than the original procedure it can also be used to indicate therapy performed during a surgical procedure for example a patient has a lesion removed that turns out to be malignant without clear margins the patient is brought back to the operating room seven days later the second more in-depth surgery to remove the cancer is submitted with modifier 58 to indicate that it is related to the primary or first procedure modifier 78 is used when there is an unplanned return to the operating room for a related procedure During the post-operative period for example a patient has gastric bypass surgery in January in March the patient is diagnosed with an incisional hernia at the location of the bypass incision the patient is taken back to the operating room in March for an incisional hernia repair the hernia repair is related to the bypass surgery and modifier 78 is used on the hernia repair code modifier 79 is used to report an unrelated procedure or service by the same physician or other qualified health care professional During the post-operative period for example a patient has an open reduction of an ankle fracture done in October in November the patient has an appendicitis and has an emergency appendectomy the appendectomy is unrelated to the ankle fracture repair and is coated with modifier 79 for the appendectomy modifier 50 can be appended to services that are done bilaterally check with your payer to determine if they want Services reported with modifier 50 or on separate lines with an RT and LT modifier on each one pay close attention to code descriptions as some will say unilateral or bilateral in those cases it would not be necessary to use modifier 50 as the code description is specific already modifier 51 is used when multiple procedures are performed during the same session by the same provider services are ordered in descending order based on the rvu modifier 52 is used to indicate reduced Services when a procedure is partially reduced ended early or eliminated at the provider's discretion append 52 to the code modifier 53 represents a discontinued procedure if a procedure is terminated due to extenuating circumstances or circumstances that threaten the well-being of the patient use this modifier with the procedure code modifier 59 is used to indicate that a service or procedure was distinct or separate from other services performed on the same day it is typically used to identify procedures that are not normally performed together but are necessary for the treatment of the patient's condition here's an example a patient undergoes a surgical procedure to remove a malignant tumor of the breast during the same encounter the surgeon also performs a sentinel lymph node biopsy which involves removing and examining the first lymph node that drains from the tumor to determine if the cancer has spread while the Sentinel lymph node biopsy is often performed during the same surgery as the tumor removal it is considered a separate and distinct service in this example the surgeon would report the breast tumor removal with the appropriate CPT code and then append modifier 59 to the CPT code for the Sentinel lymph node biopsy this would allow the surgeon to bill for both procedures separately and avoid any bundling issues it is important to note that the use of modifier 59 should always be well documented in the patient's medical record to support the need for the separate and distinct service the documentation should clearly explain why the additional service was necessary and how it was different from the original service provided the CMS subset of modifier 59 is a list of specific codes that should be used in place of the modifier when billing for certain Services the subset was created to help clarify the use of modifier 59 and reduce the incidence of incorrect billing practices there are four different subsets of modifier 59 XE XS XP and XU the use of the CMS subset of modifier 59 is intended to be more specific and descriptive than simply appending modifier 59 to a code by using the appropriate X subset providers can more accurately convey the reason for the separate and distinct service and help reduce the risk of claim denials and audits however it is important to note that the use of these subsets is not mandatory and providers can still use modifier 59 when appropriate modifier 62 is used when two surgeons work together as primary surgeons on a single surgical procedure this is sometimes referred to as co-surgery both surgeons must have performed distinct and separate portions of the same procedure and both must have taken an active role in the surgery modifier 62 is typically used when the two surgeons have complementary skills or expertise that are needed for the procedure for example in a complex spine surgery one surgeon may be responsible for the anterior portion of the procedure while another surgeon may be responsible for the posterior portion in this case both surgeons would be considered primary surgeons and would use modifier 62 to indicate that they both played an active role in the surgery modifier 66 is used to indicate that a surgical procedure was performed by a team of two or more surgeons working together with one surgeon acting as the primary surgeon and the others acting in an assisting role this type of surgery is sometimes referred to as team surgery unlike modifier 62 which is used when two surgeons work together as primary surgeons on a single procedure modifier 66 is used when one surgeon is the primary surgeon and the others are assisting in some way the assisting surgeons May perform tasks such as providing exposure retracting tissue or holding instruments but they do not perform a distinct and separate portion of the procedure modifier 66 is typically used in situations where a procedure is complex and the assistance of another surgeon is necessary to ensure its successful completion it may also be used when a more experienced surgeon is guiding a less experienced surgeon through a procedure to help train them it is important to note that the use of modifier 66 requires careful documentation in the medical record to support the need for the assisting surgeons and their specific roles in the procedure this documentation should include the reason why the assisting surgeons were needed the specific tasks they performed and how their involvement contributed to the success of the procedure this documentation is important to ensure that the use of modifier 66 is appropriate and to avoid any potential billing issues or audits modifier 80 is used to indicate that an assistant surgeon was present and involved in the surgical procedure an assistant surgeon is a qualified physician who assists the primary surgeon in performing a surgical procedure modifier 80 is typically used when two or more surgeons work together with one surgeon serving as the primary and the other as the assistant in this case the assistant surgeon is responsible for performing specific portions of the surgical procedure such as preparing the patient for surgery closing incisions or providing other technical assistance to the primary surgeon modifier 80 is added to the surgical procedure code to indicate that the assistant surgeon Services were necessary and performed during the procedure the use of this modifier allows for separate payment to the assistant surgeon for their services it is important to note that not all surgical procedures require an assistant surgeon and the decision to involve an assistant surgeon is typically made on the basis of complexity of the procedure the patient's condition and the surgeon's preference ancillary modifiers are specific to radiology and some laboratory services some services are combination of professional and Technical components the professional component identifies the work of the physician to perform read interpret and supervise the service the technical component identifies the costs associated with owning the equipment employing the technicians the supplies the equipment overhead Etc when services are billed without the modifier they are considered to be Global or inclusive of both Technical and professional components to separate out the technical and Professional Services the modifier TC or 26 are applied to the CPT code TC is for the technical component and 26 for the professional thank you for joining us for this review if you would like more details about our intensive CPC training or any of our other training programs please visit our website at Medical billco.com