Yes, it’s true. There are so many books and so little time, I haven’t even had time to blog for the last two weeks because I had my nose in two of them. Thank God for smartphones and long waits at the car wash, or who knows how much longer it would been before I posted again!
In my first post of this series, I gave one of my favorite quotes: “ICD is from Mars, HCPCS is from Venus.” So let’s move on to Venus for a bit. Don’t worry, we’ll be back to Mars, but I like to talk about the present before I talk about the future (ICD-10), so let’s get on with it. I apologize for the length of this post, but I have a lot to say today!
Three Levels of HCPCS
The Healthcare Common Procedure Coding System (HCPCS) has three different levels and just to make things more interesting, Level I is not usually called HCPCS, it’s called CPT. The Current Procedural Terminology (CPT) was developed and is maintained by the American Medical Association (AMA).
By Physicians for Physicians
What makes CPT so unique is that it is the only coding system in the HIPAA-approved code sets that is developed by physicians for physicians. The codes you see in the CPT code book are the result of various medical and surgical societies coming together with the AMA to decide which procedures deserve their very own CPT codes. Every year at the AMA’s CPT Symposium, coders from around the country gather in Chicago to listen to these physicians present the coding updates for the coming year. It’s an expensive but valuable conference that I think every coder should experience at least once. 
CPT codes are primarily used by physicians to report procedures and services performed in every possible setting where a physician – or qualified health practitioner – may see a patient: his office, the hospital, a clinic, a nursing home, etc. But it doesn’t stop there. CPT is also used to report hospital outpatient procedures. Of course, since there are still a lot of procedures that are performed solely as inpatient, hospital coders use a small number of CPT codes in comparison to pro-fee (physician) coders.
Three within Three
So now that we know that CPT is one of three levels of HCPCS, let’s delve a little deeper into this major code set. CPT has three categories of codes and this is still a pretty new concept for me because when I was learning, there were no categories, just CPT codes.
Category I Codes
Category I codes are the original CPT codes they’re what I like to call “grown-up” CPT codes. In order to get a grown-up CPT code, a procedure has to meet some pretty stringent criteria:
- The procedure must have FDA approval
- The procedure must be commonly performed by practitioners nationwide
- The procedure must have proven efficacy
Once these criteria are met, a five-digit numeric code is assigned to the procedure and unlike ICD (different planet, remember?), these codes do not have decimal points. The codes are arranged in sections by type of procedure or service:
- Evaluation and Management (E/M) (codes beginning with 9)
- Anesthesia (codes beginning with 0)
- Surgery (codes beginning with 1-6)
- Radiology (codes beginning with 7)
- Pathology and Laboratory
- Medicine (the rest of the codes beginning with 9)
The Surgery codes are divided by specialty, for example, the cardiovascular codes begin with 3 and neuro codes begin with 6. After coding for a while, you should be able to look at a CPT code and have a general idea of what it is. A common newbie mistake is to look for the E/M codes in the back of the book. After all, they begin with 9! But remember that CPT is a coding system that was developed by physicians for physicians and since physicians use E/M codes more than any others, they are in the front of the book for quick reference.
Here are a few examples of Category I CPT codes:
- 99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity
- 12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6cm to 7.5cm
- 75625, Aortography, abdominal, by serialography, radiological supervision and interpretation
Category II CPT Codes
Category II CPT codes are located behind the Category I CPT codes in the book. These are the only CPT codes that are optional. They are used by physicians for tracking performance measures. The purpose of these codes is to decrease administrative burden on providers while collecting information on the quality of patient care. Category II codes are five-digit alphanumeric codes that end in “F.” Here are some examples:
- 1040F, DSM-5 criteria for major depressive disorder documented at the initial evaluation (MDD, MDD ADOL)1
- 3775F, Adenoma(s) or other neoplasm detected during screening colonoscopy (SCADR)12
Category II CPT codes are implemented throughout the year and may be implemented before they actually appear in the CPT book. Code updates can be accessed on the AMA’s website.
Category III CPT Codes
Category III CPT codes, or “baby codes,” as I like to call them, are for emerging technologies that do not meet the criteria of a grown-up Category I CPT code. The Category III codes are found behind the Category II codes in the CPT book. For procedures that are not commonly performed, lack FDA-approval, or don’t yet have proven efficacy, Category III codes are assigned. These are temporary codes for a period of 5 years. It has become common practice to see Category III codes reach Category I status with each annual update. For 2015, one of those procedures that was moved was transcatheter mitral valve repair with a prosthesis. The MitraClip uses this relatively new technology to treat mitral regurgitation and it received FDA approval in 2013.
These are five-digit alphanumeric codes that end in “T.” The codes are added throughout the year and may be implemented before they are published in the CPT book. Here are some examples of some Category III codes:
- 0387T, Transcatheter insertion or replacement of permanent lead less pacemaker, ventricular
- 0274T, Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic
Updates to Category III codes can also be found on the AMA’s website throughout the year.
Staying Updated
Back in the day, it was important just to make sure that you had the most recent year’s CPT book to ensure you were using valid codes. However, with the Internet, now it’s also important to monitor the CPT updates and errata on a regular basis since changes are made throughout the calendar year. I find it easiest to put a reminder on my calendar the first of each month to check the AMA’s website for updates to the errata, which is a list of corrected errors in the CPT code book, as well as changes in Category III codes. Since I don’t use Category II codes, I forego that update, but if you are coding them, be sure to look for those updates too.
By the way, the errata is on the list of approved materials for the AAPC exams. The year I took the CIRCC exam (Certified Interventional Radiology and Cardiology Coder), there were a lot of errors in the electrophysiology code notes and the errata was something I really needed. Be sure to check it out!
By the way, the errata is on the list of approved materials for the AAPC exams. The year I took the CIRCC exam (Certified Interventional Radiology and Cardiology Coder), there were a lot of errors in the electrophysiology code notes and the errata was something I really needed. Be sure to check it out!
Modifiers
HCPCS codes have a concept specific to HCPCS codes only: modifiers. Think of modifiers like moons that are specific to a planet (and please forget for a moment that Venus doesn’t have any moons!). Modifiers apply to HCPCS codes only, not ICD-9-CM codes. They are added to HCPCS codes to provide additional information, such as a bilateral procedure or an unusual service or to indicate that a procedure was discontinued. CPT modifiers are two numeric digits that are appended to a HCPCS code with a dash (e.g., 75710-59).
All CPT Coders are not Created Equal
The people who assign CPT codes are just as complex as the coding system. Since hospital coders code only a subset of CPT codes, they don’t have the same skill set that a pro-fee coder has. Remember that hospital inpatient coders use volume 3 of ICD-9-CM to code procedures. Hospital outpatient coders assign CPT codes for procedures that are found in the outpatient setting. So while the pro-fee coder coding for the cardiologist will code everything from a clinic visit in the physician’s office to an angioplasty in the hospital cardiac cath lab to a full blown coronary bypass in the hospital’s OR (all using CPT, of course), the outpatient hospital coder would only use CPT to code the angioplasty. Hospitals don’t follow conventional E/M rules and coronary bypass is an inpatient procedure that gets coded using ICD-9. In addition, many of the modifiers used by hospitals are different than those used by physicians.
These differences are one of the reasons it’s so difficult to make the crossover from hospital to pro-fee coding and vice versa. I personally hate E/M coding but I know people who love it. So if you find that one area of coding is not really your cup of tea, fear not! You may find another area very rewarding.
I also really can’t talk about CPT without bringing up a little tiny thing from the hospital side called a charge description master (CDM), or as it’s more commonly called, the charge master. It’s as masterful as it sounds: a line-item listing of everything a hospital department charges for. Each line item has a description of the charge, charge amount, and sometimes a CPT code. One of the most difficult transitions I see in pro-fee coders crossing over to the hospital side is not understanding that the coder doesn’t code everything. There are many codes that are assigned automatically by the charge master when a charge is applied to the bill. This is the case when the CPT code doesn’t require a lot of subjective reasoning (e.g., lab test or x-ray). For those procedures and services, such as operative procedures, that require subjective reasoning, a real-live coder will assign the code. It may sound counter intuitive, but this actually increases the amount of coding-related jobs in a hospital. The charge master analyst requires coding knowledge as he/she works with hospital departments to set up charges, research appropriate CPT codes for the procedure or service, and determine if it will be hard coded (by the charge master) or soft coded (by a person in coding).
CPT Made (Too?) Simple
This posting really oversimplifies the CPT code set (that’s right, it gets more complex!), but it’s a start if you’re still finding your way in the coding field. I have a love-hate relationship with CPT because I find it both challenging (love!) but also frustrating when I hear conflicting coding advice between CMS, the AMA, and medical/surgical societies (hate!). If you find that you love all aspects of CPT, then you can have a very lucrative career in either the pro-fee or facility coding arenas.
Stay tuned to this series… Next up is HCPCS Level II.
I also really can’t talk about CPT without bringing up a little tiny thing from the hospital side called a charge description master (CDM), or as it’s more commonly called, the charge master. It’s as masterful as it sounds: a line-item listing of everything a hospital department charges for. Each line item has a description of the charge, charge amount, and sometimes a CPT code. One of the most difficult transitions I see in pro-fee coders crossing over to the hospital side is not understanding that the coder doesn’t code everything. There are many codes that are assigned automatically by the charge master when a charge is applied to the bill. This is the case when the CPT code doesn’t require a lot of subjective reasoning (e.g., lab test or x-ray). For those procedures and services, such as operative procedures, that require subjective reasoning, a real-live coder will assign the code. It may sound counter intuitive, but this actually increases the amount of coding-related jobs in a hospital. The charge master analyst requires coding knowledge as he/she works with hospital departments to set up charges, research appropriate CPT codes for the procedure or service, and determine if it will be hard coded (by the charge master) or soft coded (by a person in coding).
CPT Made (Too?) Simple
This posting really oversimplifies the CPT code set (that’s right, it gets more complex!), but it’s a start if you’re still finding your way in the coding field. I have a love-hate relationship with CPT because I find it both challenging (love!) but also frustrating when I hear conflicting coding advice between CMS, the AMA, and medical/surgical societies (hate!). If you find that you love all aspects of CPT, then you can have a very lucrative career in either the pro-fee or facility coding arenas.
Stay tuned to this series… Next up is HCPCS Level II.