Are you sometimes puzzled by the order in which you need to list your different CPT codes? Which goes first, which goes second, which ones maybe don't matter? Well, getting the sequence right is crucial for accurate medical coding, for proper reimbursement, uh, and for avoiding certain claim denials, not to mention passing some of those questions on your CPC exam. So, in today's video, I'm going to break down the essential CPT sequencing rules and provide you some of the knowledge and confidence to do this with precision. So, let's dive in. Today's video is sponsored by Select Coder, but more on them in just a minute. If you're new here, I'm Victoria. I'm a medical coder, auditor, educator, and content creator. And on my channel, I provide tips, tricks, and tutorials to help you be successful in a medical coding career, including things like how to sequence for CPT, career tips, how to advance in this career, but today I want to talk exclusively about sequencing and CPT. Now, I probably will make some other videos discussing ICD10 CM. That will be a longer video, so I thought it would be good to kind of separate them. So let's start out with a fundamental concept which is the hierarchy of coding. So CPT distinguishes between the main codes which are that primary procedure or primary service performed and then those add-on codes. And we should really think about add-on codes as those supporting players. They describe additional procedures that are always performed in conjunction with a main procedure. We cannot use an add-on code by itself. It has to be attached onto something. And you can easily identify these add-on codes in your CPT book because there's going to be that little plus symbol right next to them, actually right before them. So, if you look in your CPT book and you see a code and it has a plus and usually there's like a tiny little bit of an indentation sometimes next to them, um that will indicate to you that that is an add-on code. So, that can never be used alone. You have to add it on to something. So, if we look kind of at the example that we have listed here, the add-on code is for each additional. And sometimes you'll see that where we're adding on additional units or we're adding on additional components or parts. So, the main code is that laparoscopy, the interctomy, the resection of the small intestine. And then that add-on code that we're adding on there, that 44203 has to go with that main code. And it's for each additional small intestine resection. And it says list separately in addition to the code for the primary procedure. And of course I have to talk about bundling versus unbundling. So a lot of procedures they inherently include related services that there might be other CPT codes for and that's known as bundling. So when we take that whole package, we put it all together in one nice tight CPT code. That is a bundle. when we take that package and we build that package and then the other separate components that are included in that package as well that's unbundling. So when we are taking those services that should not be reported separately and reporting them separately. So we have to be really cautious about this. One of the comparisons I like to make is if you think of bundling like a cake when you when you purchase a cake you're purchasing everything that goes within that cake. the flour, the milk, the eggs, the butter, the sugar, the time it takes to bake that cake, the heat that's involved, the decorating fees. They just give you one nice package fee of the cake. So, you go to Walmart, you pick out a cake, and it's like, hey, here's the $25 for cake. They're not going to itemize it for you for, hey, it took this long to decorate and and eggs and milk and butter. So, in most cases, you're just buying that cake. It wouldn't make sense if we were if we were billing you the cake and flour and eggs and sugar. Now, are there some particular instances where you might be buying a cake and also buying butter? Yeah, I mean, technically, you could go to the Walmart checkout and buy a cake and and buy butter, but that's kind of a an an unusual instance. It's not that we're going to buy the cake usually and all of the ingredients that go out in the cake. So, there may be some instances, and we may see that in medical coding, too, where we see, hey, here's this nice bundled package. Oh, yeah. I know this is a component of it, but this compo, this part, this extra little add-on was actually totally separate. So, we see that in medical coding and in CPT coding as well. So, usually we have that nice tight package of everything that's included even with surgeries like our pre-operative care, our post-operative care. So, if you get like a laceration repair, that suture removal with that same provider is typically included, but we there are nuances. we might build that out separately if it's something like uh maybe a different provider did it or there was something else going on that wasn't typical. So, just wanted to kind of bring that in there cuz we're going to talk about modifiers and kind of how those come into the sequencing uh considerations as well. Separate procedures. So, you'll notice that some CPT codes are labeled as a separate procedure. You'll see it highlighted here on the slide, the separate procedure. And that means that under normal circumstances that procedure is considered part of a more comprehensive service. But again, there are instances where that separate procedure could be reported on its own. So for example, if it truly truly is the only procedure performed or if it's clearly distinct and unrelated from the other main procedure, maybe if there's like an anatomical kind of difference. Maybe one whole procedure was performed on a right side and then we have the separate procedure that maybe was done on a separate location. So in those cases we might need to append a modifier like modifier 59 to indicate its distinct nature. Now when a patient undergoes multiple procedures in the same day the general rule is to list the most significant or sometimes people will say the most complex procedure first. How do we determine that significance? Well, in most cases, it's RVU order. So, the procedure with the highest RVU or what we call relative value unit. And this is this magic number that is made up that goes, "Oh, yeah. This is like the complexity level of these procedures. How much work goes into them." Using a simple example, um, if you're having open heart surgery, that's going to be a lot of relative value units. It might be like 30 or 40 relative value units, but if you're doing something like a mole removal on your arm, that might be like 1.2 RVU, right? So the higher the RVU, usually the higher the reimbursement is. Typically the reason that we have that higher RVU first listed on the claim, we want to sequence that first is because of reimbursement. A lot of insuranceances will reimburse based off of RVU, but then within we have multiple procedures, they reduce those fees. So we want that very first highest RVU one that they're probably going to pay the most for sequenced first, followed by the ones that are lower RVUs. So, let's say um we have an insurance that they say, "Hey, the first one listed, we'll pay 100% of that." Maybe the second one though, they're only going to pay 70% or 50%. And then some they're like, "Hey, anything after like the third line, we're not even going to pay anything." So, we want to make sure that things are sequenced appropriately so that we get reimbursed the most amount cuz any any excuse the insurance has to not have to pay us as much, they'll do that. So, if we have a $2 procedure on line one and a $500 procedure on line two, they're going to pay us 100% of the $2 procedure and then maybe half of that that lesser procedure that costs more. Now, one of the things I will tell you though, uh, is that it's very easy with certain tools to figure out the sequencing. Now, you may not have access to this for the CPC exam, and I'll talk about that though in a minute. But if you want to be able to do these great sequencings like I do, let me tell you about how I was able to just easily plug these in and find out all of the bundling, find out all of the RV use, what order to put them in, what modifiers I might want to put on them by using this great tool called Select Coder. Select Coder is an online coding resource that provides all the decision-making information you need to quickly and accurately code these claims. And a lot of people love it because it is so easy to use and find what you need. Actually, 97% of users say that it helps them code more accurately and reduce those annoying denials. And it's powered by the official coding guidelines. So, you'll receive access to weekly part B news publications and specialty coding articles along with thousands of coding and billing tips and the plain English descriptions of procedures and diagnoses. So you can search modifiers, you can search ICD10 CM, you can search CPT, hickpix codes in a single search field and it provides easy to navigate results. Select coder streamlines your coding workflow. So the CCI validation tool reveals clear bundling results which might identify conflicts or alert you to modifiers that could allow unbundling or reveal medically unlikely edits. And the NCD and LCD policies enable you to verify medical necessity with the most current part A, part B, and DME coverage results based on your location. The integrated code lists and links to the Medicare policies will make it more efficient and accurate. Plus, Select Coder has an ENM audit tool that lets you compare timebased and medical decisionmaking selections for office and outpatient visits in one swift process. And the results for both selections are calculated side by side so you can quickly see what is the best to report your claims. And if you are looking for CEUs, you can earn up to 24 APC and 12 AHEA CEUs per year through the decision health articles and quizzes. And you can try Select Coder for yourself by signing up for a 14-day free trial at the link in the description. Now, I talked a little bit about modifiers and how those can play into sequencing. And one of the most common modifiers related to sequencing is the 51 modifier. And that signifies that multiple procedures were performed during the same surgical sec session. And generally, you'll append this to the secondary. So, it could be line 2 3 4 5 etc. those procedures. However, it's really important to remember that payer rules can vary. So, always check the specific guidelines when if if they require the 51 modifier. I will tell you that a lot of the Medicare information that's out there, what they say is like that's an internal modifier. Please don't put that on because that's for us to kind of worry about. And honestly, when you put a 51 modifier on it, it's almost like it triggers to the insurance company like, "Hey, don't forget to reduce our payment." So, we practice it when we're doing our certification exams. But what I'll say is what you may experience real world is a lot of the insurance companies don't even want you to bother with the 51s. They know what procedures to pay you less on. You don't have to alert them. But when you're looking as far as official coding guidelines when we're when we're coding for the CPC exam, make sure you're looking for those 51 modifiers. Unless it has one of those little busters that says it's modifier 51 exempt, and you don't have to put the 51 modifier on it. and add-on codes do not get the 51 modifier as well. Now, modifier 59 is a pretty significant one as well. And that one tells you that this procedure was distinct or independent from other services that were performed on the same day. And that distinction can arise for several reasons. It could be because the procedure was performed during different sessions. They were done because they were different surgeries. they were on different anatomical sites or organ systems. They required separate incisions or different excisions. Uh and it simply just was a distinct service. It was it was totally separate and not something that's normally included in that in that other code. So let's say for example a patient has a fall and they injure their wrist and during the fall they also scrape their knee. So they need a fracture repair of the wrist and a laceration repair of the knee. Well, typically closures are included in surgeries, but in this case, it would be a separate area. So, it wasn't the same as the closure that maybe they're going to do on this wrist repair. It's going to be a totally separate area. So, in that case, we might be doing a modifier differentiation like a modifier 59 or one of the X modifiers for Medicare that says, hey, this is separate and it should be reimbursed separately because this isn't the same area. Now, while modifier 51 and 59 are pretty uh important for general sequencing, there's some other modifiers that might come into play. 50 that's for our bilateral procedure. So, we're performing that same CPT code on the right and left sides. We have 25 significant separately identifiable ENM on the same day as a procedure or service. And that's used when we have an ENM service with other minor procedures. uh to a lesser extent we have 76 and 77. So that's when we're doing some some repeat procedures. But we also kind of have to consider if we are doing an ENM service on the same day as a minor procedure. So if we have an ENM um and that ENM is significant and it's separately identifiable from the usual pre-operative and post-operative care, we can report it in addition to the procedure code. So in that case that 25 modifier goes on that ENM service. So it would be like 99213 with the 25 modifier or 99222 with the 25 modifier. So the 25 always goes on the ENM service. It's also a good idea but not necessarily a requirement to have different diagnoses. Let's say for example we have this patient. They're coming in for treatment of their diabetes and their hypertension and they meet all of the criteria for a 99214, but while they're there, they are like, "Hey, I have some skin tags. Can you remove them for me?" So, we're going to have this 99214 and then we're also going to have this 112000 for the skin tags. So, we're going to attach that diabetes and the hypertension diagnosis codes to the ENM service attach the 25 modifier. And then we're going to have that skin tag removal CPT code. and we should assign these skin tag diagnosis to that CPT code. So, making sure that we're assigning the right diagnosis to the right procedure. It's not necessarily required that you have to do that, but it does make things a little bit more cut and dry and it looks a lot better to insurance to say, hey, you know, we're not double dipping here cuz they're totally separate diagnosis. So, some tips and best practices. Remember, the foundation of accurate coding is through detailed documentation. And so your medical record has to have all of these supporting information, the rationale. So if you're adding on that 59 modifier or 25 modifier for those additional services that we're reporting on the on lines two or three or four, um, make sure that all that documentation is there saying, hey, this was a separate area. Hey, this was a this was not included in the normal pre-operative or post-operative care. Everything has to be there. I've even seen some practices that they'll put in requirements that say if we're going to bill out an office visit with something else on the same day that maybe they want two separate notes or if they're or even billing like an annual wellness visit and in in ENM service on the same day they kind of want two different notes or two different sections something very distinct. So it looks like they're very like we're definitely not double dipping here. Um you know no one likes no one likes getting their money taken back after the fact. And then of course we also have those payer specific rules and sometimes they can impact how you sequence the codes, how you're applying modifiers. Again, some of them want those 51s. Most of them are like, "Hey, don't bother." And some of them are going to reimburse differently depending on what's on line one or two and what their reimbursement structure is. So, make sure that you're consulting your specific policies of the insurance companies that you're working with and that you're leveraging reliable resources like your CPT book, your coding software, things like select coder and you know talk to your professional organizations, not just the coding organizations, specialty society associations as well. So, staying up to date with their guidelines and their updates and their philosophies to ensure accurate coding. really be mindful of some of those errors like the unbundling or making sure that you're you're putting things in RVU order and that uh you keep an a breast of those guideline changes. But yeah, there you have it. A breakdown of the essential CPT sequencing rules. Remember the hierarchy of the codes. We have to have those add-on codes. They can't be in line one. They have to be attached onto something else. Make sure that we're prioritizing those prior RVU ones in the line order. As far as the CPC exam, they're not going to be like so nuanced that one procedure and the other procedure, they're going to give you options of like, okay, is it going to be this uh selection? Is it going to be option A or D, and this one's going to be like two procedures that you're like, oh, I don't know which one is, you know, the higher complexity of that. They're going to give you ones that are a little bit more straightforward. By understanding some of these principles, it'll help you understand the sequencing and the complexity of what's going to go first versus what's going to go second. If you have any specific questions or specific uh scenarios that you would like me to cover in the future, definitely let me know in the comments below. Otherwise, I will see you guys in the next video. And until then, just keep on coding