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Medicare Correct Coding GD PDF
Medicare Correct Coding GD PDF
Coding Guide
Contents
Introduction ................................................................................................................................................................................................................................................... Introduction–1
Resource Based Relative Value System (RBRVS) Payment Computation ........................................................................................................................Introduction–1
Relative Value Units ...................................................................................................................................................................................................Introduction–1
PE-RVU Transition .......................................................................................................................................................................................................Introduction–1
Conversion Factor .......................................................................................................................................................................................................Introduction–1
Geographical Practice Cost Indices ............................................................................................................................................................................Introduction–1
General Formula for Calculating Payment ................................................................................................................................................................Introduction–2
Modifiers ...............................................................................................................................................................................................................................Introduction–2
Surgical Modifiers .......................................................................................................................................................................................................Introduction–2
Modifiers Affecting Correct Coding Edits ..................................................................................................................................................................Introduction–2
Other Payment Indicators ....................................................................................................................................................................................................Introduction–3
Status Indicator ...........................................................................................................................................................................................................Introduction–3
Global Period ..............................................................................................................................................................................................................Introduction–3
Physician Supervision Level ......................................................................................................................................................................................Introduction–3
Definitions ....................................................................................................................................................................................................................Introduction–3
Levels of Physician Supervision Diagnostic Tests.....................................................................................................................................................Introduction–3
Correct Coding Initiative (CCI) ..............................................................................................................................................................................................Introduction–4
The Commercial "Black Box" Edits ......................................................................................................................................................................................Introduction–4
Manual Organization ...........................................................................................................................................................................................................Introduction–5
How to Use ...........................................................................................................................................................................................................................Introduction–5
Step by Step Instructions ............................................................................................................................................................................................Introduction–5
Code Pair Additions ................................................................................................................................................................................................................. Summary of Changes–1
Code Pair Deletions ...............................................................................................................................................................................................................Summary of Changes–13
Modifier Revisions ................................................................................................................................................................................................................Summary of Changes–15
General Correct Coding Policies .....................................................................................................................................................................................................................General–1
A. Introduction ............................................................................................................................................................................................................................General–1
B. Coding Based on Standards of Medical/Surgical Practice ..................................................................................................................................................General–1
C. Medical/Surgical Package .....................................................................................................................................................................................................General–2
D. Evaluation and Management Services .................................................................................................................................................................................General–3
E. Standard Preparation/Monitoring Service ............................................................................................................................................................................General–3
F. Anesthesia Service Included in the Surgical Procedure .......................................................................................................................................................General–4
G. Coding Services Supplemental to a Principal Procedure (Add-on Codes) .........................................................................................................................General–4
H. Modifiers ................................................................................................................................................................................................................................General–4
I. HCPCS/CPT Procedure Code Definition .................................................................................................................................................................................General–5
J. HCPCS/CPT Coding Manual Instruction/Guideline ...............................................................................................................................................................General–5
K. Separate Procedures ..............................................................................................................................................................................................................General–6
L. Family of Codes ......................................................................................................................................................................................................................General–6
M. Most Extensive Procedures ..................................................................................................................................................................................................General–6
N. Sequential Procedures ..........................................................................................................................................................................................................General–6
O. Laboratory Panels ..................................................................................................................................................................................................................General–6
P. Misuse of Column 2 Code with Column 1 Code .................................................................................................................................................................General–6
Q. Mutually Exclusive Procedures..............................................................................................................................................................................................General–7
R. Gender-Specific Procedures (formerly Designation of Sex) .................................................................................................................................................General–7
S. Excluded Service .....................................................................................................................................................................................................................General–7
T. Unlisted Services or Procedures ...........................................................................................................................................................................................General–7
U. Modified, Deleted and Added Code Pairs, Edits
Surgery: Integumentary System (CPT Codes 10000–19999) ............................................................................................................................................ Integumentary–1
Correct Coding Policies ....................................................................................................................................................................................................Integumentary–1
A. Introduction .......................................................................................................................................................................................................Integumentary–1
B. Evaluation and Management ...........................................................................................................................................................................Integumentary–1
C. Anesthesia......................................................................................................................................................................................................... Integumentary–1
D. Incision and Drainage ......................................................................................................................................................................................Integumentary–1
E. Lesion Removal .................................................................................................................................................................................................Integumentary–2
F. Repair and Tissue Transfer ...............................................................................................................................................................................Integumentary–3
G. Grafts and Flaps ................................................................................................................................................................................................Integumentary–3
expansion of these ideas and concepts is planned for future refinement To reinforce the importance of following correct coding methodologies, the
years. final chapter presents an overview of fraud and abuse in the health care sys-
tem, including a summary of pertinent sections of the Health Insurance Port-
If you have any questions regarding the National Correct Coding Policy,
ability and Accountability Act of 1996.
please contact the provider relations staff of your Medicare carrier or submit
your comments in writing to: Finally, for your convenience, several reference appendices are supplied to
CMS Correct Coding Initiative provide you with supplementary information germane to reimbursement
AdminaStar Federal issues.
P.O. Box 50469
Indianapolis, IN 46250-0469 How to Use
Note: The following steps are based on data contained in the 2004 fee
The Commercial “Black Box” Edits schedule as posted on CMS’s Web site. At the time of printing there was leg-
Beginning October 1, 1998, CMS implemented the use of additional com- islation pending that may affect the conversion factor and GPCIs for 2004.
mercial edits in order to improve Medicare’s auditing system for detecting If changes are made to the conversion factor and the GPCI, you will be noti-
unbundling in procedure coding. These commercial edits (approximately fied via e-mail of the changes and given instructions as to where to locate
500) are also known as black box edits or commercial off-the shelf (COTS) the revised information on the Ingenix Web site.
edits. The new commercial procedure to procedure edits system will be
used concurrently with the National Correct Coding Initiative edits (approxi- Step by Step Instructions
mately 108,000). There will be no way of determining the source of the The steps to follow for successful use of the Medicare Correct Coding and
edits since, the same EOMB will apply for both sets of edits. Payment Manual for Procedures and Services are delineated below.
The new commercial edits were developed by a private commercial claims Step 1
auditing vendor and CMS intends to protect the proprietary rights attached Assign the initial code using the CPT manual. Locate the section of this
to these edits. No explicit Medicare policies require the disclosure of the manual containing the desired code series. Review the section information
specific edits, therefore, publishing the commercial edits will not be an concerning the correct coding policies.
option. Ingenix will continue to provide you with the most current version Example: You have assigned the CPT code 11450 using the source docu-
of the NCCI edits, but we are prohibited from including the new commercial ment and current CPT manual. Turn to section 10000-19999 in
edits. this manual. Review the introductory information.
Manual Organization Step 2
Medicare Correct Coding and Payment Manual was developed with the pro- Locate the specific CPT code. Review and verify the code description.
vider of services in mind. This manual presents the essential information 11450 Excision of skin and subcutaneous tissue for hidradenitis,
needed to submit claims correctly, completely and accurately every time in a axillary; with simple or intermediate repair
convenient, efficient format. With this information, you will experience more
proficient reimbursement, encounter fewer delays, denials and requests for Step 3
information, and avoid improper coding that may trigger an audit. Listed directly below the code and narrative are the relative value units for
The initial chapters contain an overview of the prominent legislative enact- this procedure. The formula for determining the payment amount under the
ments affecting the reimbursement system, a summary of the major compo- fee schedule is shown below.
nents of the Medicare physician fee schedule for services rendered, and [RVUw X GPCI work] + [PE-RVU X GPCIp]+ [RVUm X GPCIm] X CF =
general information concerning the general correct coding policies including Dollar Payment Amount
a quick reference section for the coding policy explanations.
Refer to Appendix A for component GPCIs, if calculating payment manually.
Following the introductory chapters, the manual provides a comprehensive
For this example, the clinic which provided the service is located in Ala-
summary of the reimbursement factors for each CPT code. Subsequent
bama.
chapters are arranged by code series arranged in ascending numerical order
noted on the individual tabs for quick location of a code or group of codes. Example:
Provided at the beginning of each of the code series are the coding policies
that apply specifically to that code series. Explicit examples of each of the RELATIVE VALUE UNITS
coding policies specific to each section is included in the section introduc- Work Malpractice PE–nf PE–f Total–nf Total–f
tion. Immediately following the coding policies and examples are the CPT 2.71 0.31 5.20 2.06 8.22 5.08
codes with full description, complete relative value units, payment indica-
tors, and the correct coding edits for the code. Some chapters provide fur- Work 2.71 X GPCIw 0.978 = 2.650
ther subdivision of the codes by body system. ADD
A chapter listing the above mentioned information for the HCPCS Level II Practice Expense 5.20 X GPCIp 0.870 = 4.524
codes for nonphysician services and supplies complements the previous ADD
CPT coding system information to complete the coding process for proce-
dures and services. Malpractice 0.31 X GPCIm 0.779 = 0.241
In order to implement the information presented in the first three sections of Subtotal = 7.415
this manual accurately, a chapter is devoted to completing the CMS-1500 Insert the RVUs for code 11450 into the formula for calculating payment.
form with line by line instructions.
5. “With” and “without” CPT codes are reported. The “without” proce- priate to report the separate component codes individually nor is it appropri-
dure is included in the “with” procedure. ate to report the component code (s) with the comprehensive code.
0009T ....... 76940 32654 ....... 00529 33414........33310, 33315 33619 ....... 33310, 33315
0046T ....... 00400 32655 ....... 00529 33415........33310, 33315 33641 ....... 33310, 33315
0047T ....... 00400 32656 ....... 00529 33416........33310, 33315 33645 ....... 33310, 33315
0057T ....... 00520, 00740, 43235 32657........ 00529 33417........33310, 33315 33647 ....... 33310, 33315
0061T ....... 00400, 76000, 76001, 32658 ....... 00529 33420........33310, 33315 33660....... 33310, 33315
76003 32659 ....... 00529 33422........33310, 33315 33665....... 33310, 33315
10060....... 64449 32660 ....... 00529 33425........33310, 33315 33670 ....... 33310, 33315
10061 ....... 64449 32661 ....... 00529 33426........33310, 33315 33681....... 33310, 33315
11000 ....... 64449 32662 ....... 00529 33427........33310, 33315 33684....... 33310, 33315
11040....... 64449 32663 ....... 00529 33430........33310, 33315 33688....... 33310, 33315
11041 ....... 64449 32664 ....... 00529 33460........33310, 33315 33690....... 33310, 33315
11042 ....... 64449 32665 ....... 00529 33463........33310, 33315 33692....... 33310, 33315
11043 ....... 64449 33120 ....... 33310, 33315 33464........33310, 33315 33694....... 33310, 33315
11044 ....... 64449 33130 ....... 33310, 33315 33465........33310, 33315 33697 ....... 33310, 33315
20982....... 36000, 36410, 37202, 33206 ....... 36555, 36556, 36568, 33468........33310, 33315 33702 ....... 33310, 33315
62318, 62319, 64415, 36569 33470........33310, 33315 33710 ....... 33310, 33315
64416, 64417, 64450, 33207........ 36555, 36556, 36568, 33471........33310, 33315 33720 ....... 33310, 33315
64470, 64475, 69990, 36569 33472........33310, 33315 33722 ....... 33310, 33315
76360, 76362, 90780 33208 ....... 36555, 36556, 36568, 33474 ........33310, 33315 33730 ....... 33310, 33315
21116 ....... J1644 36569 33475........33310, 33315 33732 ....... 33310, 33315
21685 ....... 36000, 36410, 37202, 33210 ....... 36555, 36556, 36568, 33476........33310, 33315 33735 ....... 33310, 33315
62318, 62319, 64415, 36569
64416, 64417, 64450, 33478........33310, 33315 33736 ....... 33310, 33315
33211 ....... 36555, 36556, 36568, 33496........33310, 33315 33737 ....... 33310, 33315
64470, 64475, 69990, 36569
90780 33500........33310, 33315 33750 ....... 33310, 33315
33214 ....... 36555, 36556, 36568,
22325 ....... 22521 33501........33310, 33315 33755 ....... 33310, 33315
36569
22327 ....... 22520 33502........33310, 33315 33762 ....... 33310, 33315
33215 ....... 36555, 36556, 36568,
22520 ....... 20220, 20225, 20250, 36569 33503........33310, 33315 33764 ....... 33310, 33315
22305, 22310, 22315 33216 ....... 36555, 36556, 36568, 33504........33310, 33315 33766 ....... 33310, 33315
22521 ....... 20220, 20225, 20251, 36569 33505........33310, 33315 33767 ....... 33310, 33315
22305, 22310, 22315 33217 ....... 36555, 36556, 36568, 33506........33310, 33315 33770........ 33310, 33315
22532 ....... 36000, 36410, 37202, 36569 33508........33310, 33315 33771 ....... 33310, 33315
62310, 62318, 62319, 33218 ....... 36555, 36556, 36568, 33510........33310 33774........ 33310, 33315
64415, 64416, 64417, 36569 33511........33310 33775 ....... 33310, 33315
64450, 64470, 64475, 33220 ....... 36555, 36556, 36568, 33512........33310, 33315 33776........ 33310, 33315
64479, 69990, 90780 36569 33513........33310 33777........ 33310, 33315
22533 ....... 36000, 36410, 37202, 33226 ....... 75860 33514........33310 33778........ 33310, 33315
62311, 62318, 62319,
33234 ....... 36555, 36556, 36568, 33516........33310 33779........ 33310, 33315
64415, 64416, 64417,
36569 33517........33310, 33315 33780 ....... 33310, 33315
64450, 64470, 64475,
64483, 69990, 90780 33235 ....... 36555, 36556, 36568, 33518........33310, 33315 33781 ....... 33310, 33315
36569 33519........33310, 33315 33786 ....... 33310, 33315
24220 ....... J1644
33249 ....... 36555, 36556, 36568, 33521........33310, 33315 33788 ....... 33310, 33315
25246 ....... J1644
36569 33522........33310, 33315 33800....... 33310, 33315
27093 ....... J1644
33300 ....... 33310, 33315 33523........33310, 33315 33802....... 33310, 33315
27095 ....... J1644
33305 ....... 33310, 33315 33530........33310, 33315 33803....... 33310, 33315
27096 ....... J1644
33320 ....... 33310, 33315 33533........33310, 33315 33813 ....... 33310, 33315
27370 ....... J1644
33321 ....... 33310, 33315 33534........33310, 33315 33814 ....... 33310, 33315
27648 ....... J1644
33322 ....... 33310, 33315 33535........33310, 33315 33820 ....... 33310, 33315
31623 ....... 00529
33330 ....... 33310, 33315 33536........33310, 33315 33822 ....... 33310, 33315
31624 ....... 00529
33332 ....... 33310, 33315 33542........33310, 33315 33824 ....... 33310, 33315
31641 ....... 31640
33335 ....... 33310, 33315 33545........33310, 33315 33840....... 33310, 33315
31643 ....... 00529
33400 ....... 33310, 33315 33572........33310, 33315 33845 ....... 33310, 33315
32601 ....... 00529
33401 ....... 33310, 33315 33600........33310, 33315 33851 ....... 33310, 33315
32602 ....... 00529
33403 ....... 33310, 33315 33602........33310, 33315 33852 ....... 33310, 33315
32603 ....... 00529
33404 ....... 33310, 33315 33606........33310, 33315 33853 ....... 33310, 33315
32604....... 00529
33405 ....... 33310, 33315 33608........33310, 33315 33860....... 33310, 33315
32605 ....... 00529
33406 ....... 33310, 33315 33610........33310, 33315 33861....... 33310, 33315
32606....... 00529
33410 ....... 33310, 33315 33611........33310, 33315 33863....... 33310, 33315
32650 ....... 00529
33411 ....... 33310, 33315 33612........33310, 33315 33870 ....... 33310, 33315
32651 ....... 00529
33412 ....... 33310, 33315 33615........33310, 33315 33875 ....... 33310, 33315
32652 ....... 00529
33413 ....... 33310, 33315 33617........33310, 33315 33877 ....... 33310, 33315
32653 ....... 00529
47605 ....... 43752 49180 ....... 43752 57425 ........36000, 36410, 37202, 61735 ....... 61863
47610 ....... 43752 49200 ....... 43752 62318, 62319, 64415, 61750 ....... 61863
47612 ....... 43752 49201 ....... 43752 64416, 64417, 64450, 61751 ....... 61863
47620 ....... 43752 49215 ....... 43752 64470, 64475, 69990, 61760 ....... 61863
47630 ....... 43752 49220 ....... 43752 90780 61770 ....... 61863
47700........ 43752 49250 ....... 43752 58340........J1644 61791 ....... 61863
47701........ 43752 49255 ....... 43752 59070........36000, 36410, 37202, 61793 ....... 61863
62318, 62319, 64415,
47711 ....... 43752 49320 ....... 43752 61795 ....... 70557, 70558, 70559
64416, 64417, 64450,
47712 ....... 43752 49321 ....... 43752 64470, 64475, 69990, 61850 ....... 95961
47715 ....... 43752 49322 ....... 43752 76942, 76986, 90780 61860....... 61863, 95961
47716 ....... 43752 49323 ....... 43752 59072........36000, 36410, 37202, 61863 ....... 36000, 36410, 37202,
47720 ....... 43752 49400 ....... 43752 62318, 62319, 64415, 61790, 61795, 61850,
47721 ....... 43752 49419 ....... 43752, J1642 64416, 64417, 64450, 61880, 62318, 62319,
47740........ 43752 49420 ....... 43752 64470, 64475, 69990, 64415, 64416, 64417,
47741........ 43752 49421 ....... 43752 76942, 76986, 90780 64450, 64470, 64475,
59074........36000, 36410, 37202, 64550, 64553, 64555,
47760 ....... 43752 49422 ....... 43752
62318, 62319, 64415, 64560, 64565, 64573,
47765........ 43752 49423 ....... 43752 64575, 64577, 64580,
47780 ....... 43752 49424 ....... 43752 64416, 64417, 64450,
64470, 64475, 69990, 69990, 90780, 95925,
47785........ 43752 49425 ....... 43752 95926, 95927, 95961,
76942, 76986, 90780
47801 ....... 43752 49426 ....... 43752 G0173, G0242, G0243,
59076........36000, 36410, 37202,
47802 ....... 43752 49427 ....... 43752 G0251
62318, 62319, 64415,
47900 ....... 43752 49428 ....... 43752 64416, 64417, 64450, 61867 ....... 36000, 36410, 37202,
48000....... 43752 49429 ....... 43752 64470, 64475, 69990, 61720, 61735, 61750,
48001....... 43752 49560 ....... 43752 76942, 76986, 90780 61751, 61760, 61770,
48005....... 43752 49561 ....... 43752 61790, 61791, 61793,
59400........01958
61795, 61850, 61860,
48020....... 43752 49565 ....... 43752 59409........01958 61870, 61875, 61880,
48100 ....... 43752 49566 ....... 43752 59410........01958 62318, 62319, 64415,
48102 ....... 43752 49568 ....... 43752 59412........01958 64416, 64417, 64450,
48120 ....... 43752 49570........ 43752 59510........01958 64470, 64475, 64550,
48140....... 43752 49572........ 43752 59514........01958 64553, 64555, 64560,
48145 ....... 43752 49580 ....... 43752 59610........01958 64565, 64573, 64575,
48146....... 43752 49582 ....... 43752 59612........01958 64577, 64580, 69990,
48148....... 43752 49585 ....... 43752 59614........01958 90780, 95925, 95926,
48150....... 43752 49587........ 43752 59618........01958 95937, 95961, G0173,
48152 ....... 43752 49590 ....... 43752 G0242, G0243, G0251
59620........01958
48153 ....... 43752 49600 ....... 43752 61870 ....... 61863, 95961
59622........01958
48154 ....... 43752 49605 ....... 43752 61875 ....... 61863, 95961
59897........36000, 36410, 37202,
48155 ....... 43752 49606 ....... 43752 62318, 62319, 64415, 62350....... 95991
48180....... 43752 49610 ....... 43752 64416, 64417, 64450, 62351 ....... 95991
48400....... 43752 49611 ....... 43752 64470, 64475, 69990, 62360....... 95991
48500....... 43752 49905 ....... 43752 76942, 76986, 90780 62361....... 95991
48510 ....... 43752 49906 ....... 43752 61215........95991 62362....... 95991
48511 ....... 43752 50562 ....... 50557 61537........36000, 36410, 37202, 63001 ....... 20926
48520 ....... 43752 50684 ....... J1644 62318, 62319, 64415, 63003 ....... 20926
64416, 64417, 64450, 63011 ....... 20926
48540....... 43752 50690 ....... J1644
64470, 64475, 90780, 63015 ....... 20926
48545 ....... 43752 51605 ....... J1644 95829, 95920
48547 ....... 43752 52325 ....... 52005 63016 ....... 20926
61538........95829, 95920 63045....... 20926
48550....... 43752 52327 ....... 52005 61539........95829, 95920
48554 ....... 43752 52330 ....... 52005 63046....... 20926
61540........36000, 36410, 37202, 63101 ....... 36000, 36410, 37202,
48556....... 43752 52334 ....... 52005 62318, 62319, 64415, 62310, 62318, 62319,
49000 ....... 43752 52347........ 52010 64416, 64417, 64450, 64415, 64416, 64417,
49002 ....... 43752 52355 ....... 52354 64470, 64475, 90780, 64450, 64470, 64475,
49010 ....... 43752 53500 ....... 00910, 36000, 36410, 95829, 95920 90780
49020 ....... 43752 37202, 51701, 51702, 61566........36000, 36410, 37202, 63102 ....... 36000, 36410, 37202,
49021 ....... 43752 51703, 52000, 53660, 62318, 62319, 64415, 62311, 62318, 62319,
49040....... 43752 53661, 53665, 62318, 64416, 64417, 64450, 64415, 64416, 64417,
49041....... 43752 62319, 64415, 64416, 64470, 64475, 90780 64450, 64470, 64475,
64417, 64450, 64470, 61567........36000, 36410, 37202, 90780
49060....... 43752
64475, 69990, 90780 62318, 62319, 64415,
49061....... 43752 63170 ....... 20926
55873........ 76940 64416, 64417, 64450,
49062....... 43752 63172 ....... 20926
64470, 64475, 90780,
49080....... 43752 63173 ....... 20926
95829, 95920
49081....... 43752 63180 ....... 20926
61720........61863
49085....... 43752 63182 ....... 20926
0018T ....... 90871 46320 ....... 46080 90829........96155 99214 ....... 96155
0019T ....... 0020T, 76880, 76977, 46940 ....... 46080 90845........96155 99215 ....... 96155
76986, 76999 46942 ....... 46080 90846........90871, 96155 99217 ....... 90918, 90919, 90920,
0027T ....... 64470, 64479 58150 ....... 57280 90847........90871, 96155 90921, 96155
27093 ....... 62318, 64470, 64475 62263 ....... 62281, 62310, 62318, 90849........90871, 96155 99218 ....... 90918, 90919, 90920,
27096 ....... 62318, 64470, 64475 64470, 64475, 64479 90853........90871, 96155 90921, 96155
31640 ....... 31641 62264 ....... 62281, 62310, 62318, 90857........90871, 96155 99219 ....... 90918, 90919, 90920,
33510 ....... 93971 64470, 64475, 64479 90862 .......96155 90921, 96155
33511 ....... 93971 62281 ....... 62319, 64475 90865........96155 99220 ....... 90918, 90919, 90920,
33512 ....... 93971 62282 ....... 62318, 64470 90870........96155 90921, 96155
33513 ....... 93971 62290 ....... 62311, 64470, 64475, 90871........00104, 90801, 90802, 99221 ....... 96155
33514 ....... 93971 64483 90804, 90805, 90806, 99222 ....... 96155
33516 ....... 93971 62310 ....... 62319 90807, 90808, 90809, 99223 ....... 96155
33517 ....... 93971 62311 ....... 62318 90810, 90811, 90812, 99231 ....... 96155
33518 ....... 93971 62318 ....... 01996 90813, 90814, 90815, 99232 ....... 96155
33519 ....... 93971 62319 ....... 01996 90816, 90817, 90818, 99233 ....... 96155
75952 ....... 75966 90819, 90821, 90822, 99234 ....... 96155
33521 ....... 93971
75953 ....... 75966 90823, 90824, 90826, 99235 ....... 96155
33522 ....... 93971 90827, 90828, 90829,
33523 ....... 93971 75954 ....... 75966 99236....... 96155
90865, 90870, 90880,
34800....... 75966 76856 ....... 93975 99238....... 96155
96150, 96151, 96152,
34802....... 75966 77427........ 96155 96153, 96154, 96155, 99239....... 96155
34804....... 75966 77431........ 96155 97802, 97803, 97804, 99241 ....... 96155
34825 ....... 75966 77432........ 96155 G0270, G0271 99242 ....... 96155
34900 ....... 75966 77470 ........ 96155 90880 .......96155 99243 ....... 96155
35501 ....... 93971 90645 ....... 90748 90918........97802, 97803, 97804, 99244 ....... 96155
35506....... 93971 90646 ....... 90748 G0270, G0271 99245 ....... 96155
35507 ....... 93971 90647 ....... 90748 90919........90918, 97802, 97803, 99251 ....... 96155
35508....... 93971 90648 ....... 90748 97804, G0270, G0271 99252 ....... 96155
35509....... 93971 90720 ....... 90748 90920........90918, 90919, 97802, 99253 ....... 96155
90721 ....... 90748 97803, 97804, G0270, 99254 ....... 96155
35511 ....... 93971
90723 ....... 90636, 90700, 90701, G0271 99255 ....... 96155
35515 ....... 93971
90702, 90703, 90712, 90921........90918, 90919, 90920, 99261 ....... 96155
35516 ....... 93971 97802, 97803, 97804,
35518 ....... 93971 90713, 90718, 90719, 99262....... 96155
90720, 90721, 90748, G0181, G0270, G0271
35521 ....... 93971 99263 ....... 96155
90782 90922........90918, 90919, 90920,
35526 ....... 93971 99271 ....... 96155
90748........ 90636, 90782 90921
35531 ....... 93971 99272 ....... 96155
90801 ....... 96155 90923........90918, 90919, 90920,
35533 ....... 93971 90921 99273 ....... 96155
90802 ....... 96155 99274 ....... 96155
35536 ....... 93971 90924........90918, 90919, 90920,
90804 ....... 96155 99275 ....... 96155
35541 ....... 93971 90921
90805 ....... 96155 99281....... 96155
35546 ....... 93971 90925........90918, 90919, 90920,
90806 ....... 96155 99282....... 96155
35548 ....... 93971 90921
90807 ....... 96155 99283....... 96155
35549 ....... 93971 92002........96155
90808 ....... 96155 99284....... 96155
35551 ....... 93971 92004........96155
90809 ....... 96155 99285....... 96155
35556 ....... 93971 92012........96155
90810 ....... 96155 99291 ....... 96155
35558 ....... 93971 92014........96155
90811 ....... 96155 99292 ....... 96155
35560....... 93971 96150........96155
90812 ....... 96155 99293 ....... 90918, 90919, 90920,
35563 ....... 93971 96153........96155
90813 ....... 96155 90921, 96155
35565 ....... 93971 96155........96151, 96152, 96154
90814 ....... 96155 99294 ....... 90918, 90919, 90920,
35566....... 93971 97001 ........96155
90815 ....... 96155 90921, 96155
35571 ....... 93971 97002 ........96155
90816 ....... 96155 99295 ....... 90918, 90919, 90920,
35582 ....... 93971 97003 ........96155
90817 ....... 96155 90921, 96155
35583 ....... 93971 97004........96155
90818 ....... 96155 99296....... 90918, 90919, 90920,
35585 ....... 93971 99201........96155
90819 ....... 96155 90921, 96155
35587 ....... 93971 99202........96155
90821 ....... 96155 99298....... 90918, 90919, 90920,
43247 ....... 43450, 43453 99203........96155 90921, 96155
90822 ....... 96155
43450 ....... 43200 99204........96155 99299....... 90918, 90919, 90920,
90823 ....... 96155
45905....... 46080 99205........96155 90921, 96155
90824 ....... 96155
46030....... 46080 99211........96155 99301....... 96155
90826 ....... 96155
46050....... 46080 99212........96155 99302....... 96155
90827 ....... 96155
46221....... 46080 99213........96155 99303....... 96155
90828 ....... 96155
Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER
9.3 9.2 9.3 9.2 9.3 9.2 9.3 9.2
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
12001 - 12018 (Repair - simple) 3. Flap grafts (CPT codes 15570-15576) include excision of lesions at
12020 - 12021 (Treatment of wound dehiscence) the same site (CPT codes 11400-11646).
12031 - 12057 (Repair - intermediate) H. Breast (Incision, Excision, Introduction, Repair and
13100 - 13160 (Repair - complex) Reconstruction)
11719 - 11762 (Trimming, debridement and excision of nails) Because of the unique nature of procedures developed to address breast dis-
11770 - 11772 (Excision of pilonidal cysts) ease, a section of CPT (19000-19499) is set aside for such services.
11765 (Wedge excision) Fine needle aspiration biopsies, core biopsies, open incisional or excisional
biopsies, and related procedures performed to procure tissue from a lesion
F. Repair and Tissue Transfer for which an established diagnosis exists are not to be reported separately
When lesional excision is of such an extent that closure cannot be accom- at the time of a lesion excision unless performed on a different lesion or on
plished by simple, intermediate, or complex closure, other methodology the contralateral breast. However, if a diagnosis is not established, and the
must be employed. Frequently adjacent tissue transfer or tissue rearrange- decision to perform the excision or mastectomy is dependent on the results
ment is employed (Z-plasty, W-plasty, flaps, etc.). This family of codes, (CPT of the biopsy, then the biopsy is separately reported. The -58 modifier may
codes 14000-14350), involves excision with adjacent tissue transfer and be used appropriately to indicate that the biopsy and the excision or mastec-
correlates to excision codes. Excision CPT codes (11400-11646) and repair tomy are staged or planned procedures.
CPT codes (12001 – 13160) are not to be separately reported when CPT
codes 14000-14350 are reported. On the other hand, skin grafting per- Because excision of lesions occur in the course of performing a mastectomy,
formed in conjunction with these codes may be separately reported if it is breast excisions are not separately reported from a mastectomy unless per-
not included in the specific code definition. In the case of closure of trau- formed to establish the malignant diagnosis before proceeding to the mas-
matic wounds, these codes are appropriate only when the closure requires tectomy. Specifically CPT codes 19110-19126 (breast excision) are in
the surgeon to develop a specific adjacent tissue transfer; lacerations that general included in all mastectomy CPT codes 19140-19240 of the same
coincidentally are approximated using a tissue transfer technique (e.g. Z- side. However, if the excision is performed to obtain tissue to determine
plasty, W-plasty) should be reported with the more simple closure code. pathologic diagnosis of malignancy prior to proceeding to a mastectomy,
Debridement necessary to accomplish these tissue transfer procedures is the excision is separately reportable with the mastectomy. The –58 modi-
part of the column 1 procedure performed. Separate debridement CPT codes fier should be utilized in this situation.
(11000-11042) or repair CPT codes (12001-13160) would be inappropri-
Use of other integumentary codes for incision and closure are included in
ately reported with these CPT codes (14000-14350) for the same lesion/
the codes describing various breast excision or mastectomy codes. Because
injury. Procurement of cultures or tissue samples as a part of a closure are
of the frequent need to biopsy lymph nodes or remove muscle tissue in con-
included in the closure code and are not to be separately reported.
junction with mastectomies, these procedures have been included in the
G. Grafts and Flaps CPT coding for mastectomy. It would be inappropriate to separately bill for
Free skin grafts are coded by type (split or full), location, and size. For a spe- ipsilateral lymph node dissection in conjunction with the appropriate mas-
cific location, a primary code is defined and followed by a supplemental tectomy codes. In the circumstance where a breast lesion is identified and
code for additional coverage area. As a result of this coding scheme, for a treated and it is determined to be medically necessary to biopsy the con-
given area of involvement, the initial code is limited to one unit of service; tralateral nodes, use of the biopsy or lymph node dissection codes (using
the supplemental code may have multiple units of service depending on the the appropriate anatomic modifier, -LT or -RT for left or right, to indicate this)
area to be covered. Because, for a specific area, only one type of skin graft is would be acceptable. Additionally, breast reconstruction codes that include
typically applied, the primary free skin graft CPT codes (15100, 15120, the insertion of a prosthetic implant are not to be reported with CPT codes
15200, 15220, 15240, 15260) are mutually exclusive to one another. If that describe the insertion of a breast prosthesis only.
multiple areas require different grafts, a modifier indicating different sites
The CPT coding for breast procedures generally refers to unilateral proce-
should be used (anatomic or -59 modifier).
dures; when performed bilaterally, the -50 modifier would be appropriate.
Generally, debridement of non-intact skin (CPT codes 11000-11042) in This is identified parenthetically, where appropriate, in the CPT narrative.
anticipation of a skin graft is necessary prior to application of the skin graft
I. Add-on Codes
and is included in the skin graft (CPT codes 15050-15400). When skin is
There are a number of supplemental CPT codes defined in the CPT Manual.
intact, however, and the graft is being performed after excisional prepara-
The following is a listing of supplemental codes present in the integumen-
tion of intact skin, the CPT code 15000 (Excisional preparation) is sepa-
tary section of the CPT Manual. Although, not all-inclusive, the supplemen-
rately reported. CPT code 15000 is not to be used to describe debridement
tal code must be used in combination with the primary CPT code or the
of non-intact, necrotic or infected skin, nor is its use indicated with other
supplemental code cannot be reported.
lesion removal codes.
1. CPT codes 15350 (application of allograft) and 15400 (application
Primary CPT code Add-on CPT code
of xenograft) are part of all other graft codes and are not to be sepa-
rately reported with other grafts (CPT codes 15050 - 15261) for 11000 (Debridement up to 11001 (Each additional 10%)
graft placement on the same site. 10%)
2. The CPT code 67911 describes the “Correction of lid retraction;” a 11200 (Removal of skin tags, 11201 (Each additional 10
parenthetical notation is added advising that, if autogenous graft up to and including 15 lesions)
materials are used, tissue graft codes 20920, 20922 or 20926 can lesions)
be reported. Accordingly, all other procedures necessary to accom-
plish the service are included.
11101 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs;
simple closure), unless otherwise listed; each separate/additional lesion lesion diameter 0.6 to 1.0 cm
(List separately in addition to code for primary procedure) RELATIVE VALUE UNITS
RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P 0.85 0.05 1.13 0.38 2.03 1.28 0
0.41 0.02 0.34 0.19 0.77 0.62 INC MODIFIERS INDICATORS
MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status 2 4 NPD NPD DOC 09 A
2 NA NPD NPD NPD 09 A CORRECT CODING EDITS
CORRECT CODING EDITS 01995●, ¥<1> 1100✚, ¥<1> 1900■, ¥<1> 1901■, ¥<1> 2001✚, ¥<1> 2002✚, ¥<1> 2004✚, ¥<1> 2005✚, ¥<1> 2006✚,
NA ¥ <1
> 2007✚, ¥<1
> 2011✚, ¥<1
> 2013✚, ¥<1
> 2014✚, ¥<1
> 2015✚, ¥<1
> 2016✚, ¥<1
> 2017✚, ¥<1
> 2018✚, ¥<1
> 7250✚,
¥ <3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■,
¥ <6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9> 0780❆, ¥<G
> 0168❆
11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and
including 15 lesions
RELATIVE VALUE UNITS
11302 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs;
lesion diameter 1.1 to 2.0 cm
Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS
0.77 0.05 1.07 0.78 1.89 1.60 10 Work MP PE–nf PE–f Total–nf Total–f Global P
MODIFIERS INDICATORS 1.04 0.06 1.32 0.47 2.42 1.57 0
-50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS
2 4 NPD NPD NPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status
CORRECT CODING EDITS 2 4 NPD NPD DOC 09 A
01995●, ¥<10060
> ❆, ¥<10061
> ❆, ¥<11057
> ✓, ¥<11100
> ✚, ¥<11301
> ✓, ¥<11302
> ✓, ¥<11303
> ✓, ¥<11306
> ✓, CORRECT CODING EDITS
¥<11307
> ✓, ¥<11308
> ✓, ¥<11310
> ✓, ¥<11311
> ✓, ¥<11312
> ✓, ¥<11313
> ✓, ¥<11400
> ✓, ¥<11401
> ✓, ¥<11402
> ✓,
¥<11403
> ✓, ¥<11404
> ✓, ¥<11406
> ✓, ¥<11420
> ✓, ¥<11421
> ✓, ¥<11422
> ✓, ¥<11423
> ✓, ¥<11424
> ✓, ¥<11426
> ✓, 01995●, ¥<1> 1900■, ¥<1> 1901■, ¥<1> 2001✚, ¥<1> 2002✚, ¥<1> 2004✚, ¥<1> 2005✚, ¥<1> 2006✚, ¥<1> 2007✚,
¥<11440
> ✓, ¥<11441
> ✓, ¥<11442
> ✓, ¥<11443
> ✓, ¥<11444
> ✓, ¥<11446
> ✓, ¥<11450
> ✓, ¥<11451
> ✓, ¥<11462
> ✓, ¥ <1
> 2011✚, ¥<1
> 2013✚, ¥<1
> 2014✚, ¥<1
> 2015✚, ¥<1
> 2016✚, ¥<1
> 2017✚, ¥<1
> 2018✚, ¥<1
> 7250✚, ¥<3
> 6000❆,
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 A
10080 Incision and drainage of pilonidal cyst; simple
RELATIVE VALUE UNITS
CORRECT CODING EDITS
Work MP PE–nf PE–f Total–nf Total–f Global P
¥<10021
> ▼, ¥<19290
> ■, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■,
¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, ¥<90780
> ❆ 1.16 0.11 3.19 1.16 4.46 2.43 10
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
10040 Acne surgery (eg, marsupialization, opening or removal of multiple milia,
2 4 NPD NPD NPD 09 A
comedones, cysts, pustules)
RELATIVE VALUE UNITS CORRECT CODING EDITS
Work MP PE–nf PE–f Total–nf Total–f Global P 01995●, ¥<2> 0500❍, ¥<3> 6000❆, ¥<3> 6410❆, ¥<3> 7202■, ¥<6> 2318■, ¥<6> 2319■, ¥<6> 4415■, ¥<6> 4416■,
¥ <6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■,
69990■, ¥<9> 0780❆
1.17 0.06 1.02 0.68 2.25 1.91 10
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status 10081 Incision and drainage of pilonidal cyst; complicated
2 4 NPD NPD NPD 09 A RELATIVE VALUE UNITS
CORRECT CODING EDITS Work MP PE–nf PE–f Total–nf Total–f Global P
01995●, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, 2.44 0.23 4.16 1.53 6.83 4.20 10
¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, 2 4 NPD NPD NPD 09 A
cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); sim- CORRECT CODING EDITS
ple or single
01995●, ¥<1> 0080▼, ¥<2> 0500❍, ¥<3> 6000❆, ¥<3> 6410❆, ¥<3> 7202■, ¥<6> 2318■, ¥<6> 2319■, ¥<6> 4415■,
RELATIVE VALUE UNITS ¥ <6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■,
69990■, ¥<9> 0780❆
Work MP PE–nf PE–f Total–nf Total–f Global P
1.16 0.10 1.22 0.95 2.48 2.21 10
MODIFIERS INDICATORS 10120 Incision and removal of foreign body, subcutaneous tissues; simple
-50 -51 -62 -66 -80, -82 Suprv Status RELATIVE VALUE UNITS
2 4 NPD NPD NPD 09 A Work MP PE–nf PE–f Total–nf Total–f Global P
CORRECT CODING EDITS 1.21 0.12 1.48 0.42 2.81 1.75 10
01995●, ¥<11055 > ▼, ¥<11056 > ❆, ¥<11057 > ❆, ¥<11401
> ✓, ¥<11402
> ✓, ¥<11403
> ✓, ¥<11404
> ✓, ¥<11406
> ✓, MODIFIERS INDICATORS
¥<11421
> ✓, ¥<11422 > ✓, ¥<11423
> ✓, ¥<11424
> ✓, ¥<11426
> ✓, ¥<11441
> ✓, ¥<11442 > ✓, ¥<11443
> ✓, ¥<11444
> ✓, -50 -51 -62 -66 -80, -82 Suprv Status
¥<11446
> ✓, ¥<11450 > ✓, ¥<11451 > ✓, ¥<11462 > ✓, ¥<11463 > ✓, ¥<11470 > ✓, ¥<11471> ✓, ¥<11600
> ✓, ¥<11601
> ✓,
¥<11602> ✓, ¥<11603
> ✓, ¥<11604
> ✓, ¥<11606
> ✓, ¥<11620 > ✓, ¥<11621 > ✓, ¥<11622
> ✓, ¥<11623
> ✓, ¥<11624
> ✓, 2 4 NPD NPD NPD 09 A
¥<11626 > ✓, ¥<11640 > ✓, ¥<11641 > ✓, ¥<11642 > ✓, ¥<11643 > ✓, ¥<11644 > ✓, ¥<1> 1646✓, ¥ <1
> 1719❆, ¥<1
> 1720❆, CORRECT CODING EDITS
¥ <1 > 1721❆, ¥<1 > 1730▼, ¥<1 > 1740❆, ¥<1
> 1765❆, ¥<2 > 0000✓, ¥<2 > 0005✓, ¥<2 > 0500❍, ¥ <3
> 0000✓, ¥<3
> 6000❆,
01995●, ¥<1> 1055▼, ¥<1> 1056❆, ¥<1> 1057❆, ¥<1> 1719❆, ¥<1> 1720❆, ¥<1> 1721❆, ¥<3> 6000❆, ¥<3> 6410❆,
¥ <3 > 6410❆, ¥<3 > 7202■, ¥<6 > 2318■, ¥<6 > 2319■, ¥<6 > 4400●, ¥<6 > 4402●, ¥<6 > 4405●, ¥ <6
> 4408●, ¥<6
> 4410●,
¥ <3
> 7202■, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■,
¥ <6 > 4412●, ¥<6 > 4413●, ¥<6 > 4415●, ¥<6 > 4416●, ¥<6 > 4417●, ¥<6 > 4418●, ¥<6 > 4420●, ¥ <6
> 4421●, ¥<6
> 4425●,
69990■, ¥<9> 0780❆, ¥<G
> 0127❆
¥ <6 > 4430●, ¥<6 > 4435●, ¥<6 > 4445●, ¥<6 > 4446●, ¥<6 > 4447●, ¥<6 > 4448●, ¥<6 > 4449●, ¥ <6
> 4450●, ¥<6
> 4470■,
¥ <6 > 4475●, ¥<6
> 4479●, ¥<6 > 4483●, 69990■, ¥<9 > 0780❆, ¥<9 > 7601❆, ¥<G > 0127❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Integumentary–5
CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Musculoskeletal System (CPT Codes 20000–29999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
E. General Policy Statements sue due to the fracture should be separately reported using the CPT
1. When a tissue transfer procedure (e.g. graft) is described in the prin- codes 11010-11012.
cipal procedure code, a separate service is not reported for perform-
ing the tissue transfer service necessary to complete the procedure. 6. Grafts, such as CPT codes 20900-20924, are only to be separately
reported if the major procedure code description does not include
2. In situations where monitoring of interstitial fluid pressure is rou- graft in its definition.
tinely performed as part of the postoperative care (e.g. distal lower
extremity procedures with risk of anterior compartment compres- 7. The CPT code 20926 is a general code for tissue grafting (e.g.
sion), a separate code for monitoring of interstitial fluid pressure paratenon, fat, dermis) to be used when the primary procedure does
(e.g. CPT code 20950) should not be reported. not include grafting and when another graft code does not more
accurately describe the nature of the grafting procedure being per-
3. When electrical stimulation is used to aid bone healing, the appro- formed. Accordingly, it should not be used with codes in which the
priate bone stimulation codes (CPT codes 20974-20975) should be graft is already listed as a part of the procedure or with other graft-
reported; the codes for nerve stimulation (CPT codes 64550- ing codes (see Chapter III for other graft codes).
64595) are inappropriate for this service. If a neurostimulator is
medically necessary for other indications (e.g. pain control), a sepa- 8. CPT codes 29874 (Surgical knee arthroscopy for removal of loose
rate service is reported, however, the -59 modifier should be body or foreign body) and 29877 (Surgical knee arthroscopy for
attached indicating that this service is distinct in that it represents debridement/shaving of articular cartilage) should not be reported
treatment of different symptoms; accordingly the medical record with other knee arthroscopy codes (29871-29889). Report G0289
should reflect the indication for the nerve stimulator. In addition, (Surgical knee arthroscopy for removal of loose body, foreign body,
CPT codes 97014 and 97032 (physical medicine for electrical stim- debridement/shaving of articular cartilage at the time of other surgi-
ulation) are not to be reported in conjunction with the above listed cal knee arthroscopy in a different compartment of the same knee).
codes by the surgeon.
9. Medicare Global Surgery Rules prevent separate payment for post-
4. Routinely, exploration of the surgical field is performed during a operative pain management when provided by the physician per-
surgical session; codes describing independent exploratory services forming an operative procedure. CPT codes 36000, 36410,
are not to be reported when a more comprehensive procedure is 37202, 62318-62319, 64415-64417, 64450, 64470, 64475
being performed in the same area. Specifically, an exploration code and 90780 describe services that may be utilized for postoperative
such as CPT code 22830 (exploration of spinal fusion) is not pain management. The services described by these codes may be
reported with other procedures involving the spine unless per- reported only if performed for purposes unrelated to the postopera-
formed at a different site/different incision from the other procedure tive pain management.
(s). If, for example, a cervical spine procedure was being performed,
10. Medicare Anesthesia Rules prevent separate payment for anesthesia
and, at the same operative session, a lumbar fusion was explored
when provided by the physician performing a medical or surgical
through a separate incision, the CPT code 22830-59 could be
service. The physician should not report CPT codes 00100-01999.
reported assuming the requirement for medical necessity was satis-
Additionally, the physician should not unbundle the anesthesia pro-
fied.
cedure and report component codes individually. For example,
5. Debridements (CPT codes 11040-11042, and 11720-11721) are introduction of a needle or intracatheter into a vein (CPT code
included in the surgical procedures conducted on the musculoskele- 36000), venipuncture (CPT code 36410), or intravenous infusion
tal system when debridement of tissue is in the immediate surgical (CPT code 90780) should not be reported when these services are
field of other than fractures and dislocations. If, however, tissue related to the delivery of an anesthetic agent.
debridement is necessary for a more extensive area (e.g. concurrent
soft tissue damage due to trauma), the debridement codes can be
reported. In open fractures and/or dislocations, debridement of tis-
29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondro- 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)
plasty where necessary) or multiple drilling or microfracture
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
10.99 1.59 9.00 9.00 21.58 21.58 90
7.99 1.35 7.05 7.05 16.39 16.39 90
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
1 5 NPD NPD DOC 09 A
1 5 NPD NPD DOC 09 A
CORRECT CODING EDITS
CORRECT CODING EDITS
01995●, ¥<2> 0610❆, ¥<2> 7347▼, ¥<2> 7570❆, ¥<2> 9870❍, 29874■, ¥<2> 9875❍, 29877■, ¥<2> 9882◆,
01995●, ¥<20610
> ❆, ¥<27570
> ❆, ¥<29870
> ❍, 29874■, ¥<29875
> ❍, 29877■, ¥<29883
> ✓, ¥<29884
> ❍, ¥ <2
> 9884❍, ¥<3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■,
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥ <6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9> 0780❆
¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without
manipulation (separate procedure)
including any meniscal shaving)
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
7.29 1.23 6.63 6.63 15.15 15.15 90
8.45 1.43 7.29 7.29 17.17 17.17 90
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
1 5 DOC DOC 8 09 A
1 5 DOC DOC DOC 09 A
CORRECT CODING EDITS
CORRECT CODING EDITS
01995●, ¥<2> 7570❆, ¥<2> 9870❍, 29874■, ¥<2> 9875❍, 29877■, ¥<3> 6000❆, ¥<3> 6410❆, ¥<3> 7202■,
01995●, ¥<20610
> ❆, ¥<27347
> ▼, ¥<27570
> ❆, ¥<29870
> ❍, ¥<29871
> ▼, 29874■, ¥<29875
> ❍, 29877■, ¥ <6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■,
69990■,
¥<29881
> ◆, ¥<29882
> ✓, ¥<29883
> ✓, ¥<29884
> ❍, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥ <9
> 0780❆
¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with
bone grafting, with or without internal fixation (including debridement of
including any meniscal shaving)
base of lesion)
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
7.72 1.31 6.89 6.89 15.92 15.92 90
9.04 1.52 7.89 7.89 18.45 18.45 90
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
1 5 NPD NPD DOC 09 A
1 5 DOC DOC 8 09 A
CORRECT CODING EDITS
CORRECT CODING EDITS
01995●, ¥<20610
> ❆, ¥<27347
> ▼, ¥<27570
> ❆, ¥<29870
> ❍, ¥<29871
> ▼, 29874■, ¥<29875
> ▼, 29877■,
¥ <0
> 012T▼, ¥<0
> 013T▼, 01995●, ¥<2> 0610❆, ¥<2> 7570❆, ¥<2> 9870❍, 29874■, ¥<2> 9875❍, ¥<2> 9876▼,
¥<29882
> ✓, ¥<29883
> ✓, ¥<29884
> ❍, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■,
29877■, ¥<2> 9879▼, ¥<2> 9884❍, ¥<2> 9886◆, ¥<2> 9887◆, ¥<3> 6000❆, ¥<3> 6410❆, ¥<3> 7202■, ¥<6> 2318■,
¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
¥ <6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9> 0780❆
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
1 4 NPD NPD 8 09 A
20150 Excision of epiphyseal bar, with or without autogenous soft tissue graft
obtained through same fascial incision
CORRECT CODING EDITS RELATIVE VALUE UNITS
¥<11000
> ✚, ¥<11011
> ❆, ¥<11012
> ❆, ¥<11040
> ✚, ¥<11041
> ✚, ¥<11042
> ✚, ¥<11043
> ✚, ¥<11044
> ✚, ¥<12001
> ✚, Work MP PE–nf PE–f Total–nf Total–f Global P
¥<12002
> ✚, ¥<12004
> ✚, ¥<12005
> ✚, ¥<12006
> ✚, ¥<12020
> ✚, ¥<12021
> ✚, ¥<12041
> ✚, ¥<12042
> ✚, ¥<12044
> ✚,
¥<12045
> ✚, ¥<12046
> ✚, ¥<12047
> ✚, ¥<13102
> ✚, ¥<13122
> ✚, ¥<13131
> ✚, ¥<13132
> ✚, ¥<13133
> ✚, ¥<13152
> ❆, 13.61 1.15 7.30 7.30 22.06 22.06 90
¥<13153
> ✚, ¥<13160
> ✚, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<37615
> ❆, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, MODIFIERS INDICATORS
¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆, ¥<97601
> ❆, ¥<G0168
> ❆
-50 -51 -62 -66 -80, -82 Suprv Status
1 4 DOC DOC 8 09 A
20101 Exploration of penetrating wound (separate procedure); chest CORRECT CODING EDITS
¥ <1
> 1900■, ¥<1
> 1901■, ¥<1
> 2001❆, ¥<1
> 2002❆, ¥<1
> 2004❆, ¥<1
> 2005❆, ¥<1
> 2006❆, ¥<1
> 2007❆, ¥<1
> 2011❆,
RELATIVE VALUE UNITS
¥ <1
> 2013❆, ¥<1
> 2014❆, ¥<1
> 2015❆, ¥<1
> 2016❆, ¥<1
> 2017❆, ¥<1
> 2018❆, ¥<1
> 2020❆, ¥<1
> 2021❆, ¥<1
> 2031❆,
Work MP PE–nf PE–f Total–nf Total–f Global P ¥ <1
> 2032❆, ¥<1
> 2034❆, ¥<1
> 2035❆, ¥<1
> 2036❆, ¥<1
> 2037❆, ¥<1
> 2041❆, ¥<1
> 2042❆, ¥<1
> 2044❆, ¥<1
> 2045❆,
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Musculoskeletal–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Respiratory, Cardiovascular, Hemic, Lymphatic, Mediastinum
and Diaphragm (CPT Codes 30000–39999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
etc. followed by a similar open procedure such as thromboendarter- CPT codes are available describing the separate services (CPT codes
ectomy), only the service for the successful procedure, which is usu- 34001 - 34203) and describing these services with thromboendar-
ally the most extensive, open procedure is reported (see sequential terectomy (CPT codes 35301 - 35381). Only the most comprehen-
procedure policy, Chapter I, Section N). In the case where a percuta- sive code describing the services performed for a given site can be
neous procedure is performed at the site of one lesion, and an open reported; therefore, for a given site, a code from both of the above
procedure is performed at a separate lesion, the services for the per- groups cannot be reported together. Additionally, in accordance
cutaneous procedure should be reported with the -59 modifier only with the sequential procedure policy, if a balloon thrombectomy
if the lesions are in distinct anatomical vessels. fails, and requires a performance of an open thromboendarterec-
tomy, only the more comprehensive service that was performed
7. The HCPCS/CPT codes 36000, 36406, 36410, 90784, etc. repre- (generally the open procedure) is reported.
sent very common procedures performed to gain venous access for
phlebotomy, prophylactic intravenous access, infusion therapy, che- 13. When percutaneous angioplasty of a vascular lesion is followed at
motherapy, drug administration, among others. When intravenous the same session by a percutaneous or open atherectomy, generally
access is routinely obtained in the course of performing other medi- due to insufficient improvement in vascular flow with angioplasty
cal/diagnostic/surgical procedures, or is necessary to accomplish alone, only the column 1 atherectomy procedure that was per-
the procedure (e.g. infusion therapy, chemotherapy), it is inappropri- formed (generally the open procedure) is reported (see sequential
ate to bill separately for the venous access services. The work of procedure policy, Chapter I, Section N).
gaining routine vascular access is integral to and therefore included
in the work value of the procedure. When the service is performed 14. CPT codes 35800-35860 are to be used when a return to the oper-
alone or a service does not routinely require vascular access, these ating room is necessary for exploration for postoperative hemor-
codes may be separately reported. While this represents a general rhage; accordingly, these codes are not to be coded for bleeding that
policy statement, specific policy statements are written for further occurs during the initial operative session. Generally, when these
clarification elsewhere. When transcatheter therapy services are codes are used, they are to be reported with the -78 modifier indi-
performed, the placement of the needle and catheter are included in cating that the service represents a return to the operating room for
the primary service. a related procedure during the postoperative period.
8. When (non-coronary) transluminal angioplasty or other translumi- D. Hemic and Lymphatic Systems
nal procedure is performed at the same session/site as angiogra- When bone marrow aspiration is performed alone, the appropriate code to
phy, only one selective catheter placement code for the involved site report is CPT code 38220. When a bone marrow biopsy is performed, the
should be reported. If the angiogram and the angioplasty or other appropriate code is CPT code 38221 (bone marrow biopsy); this code can-
transluminal procedure are not performed in immediate sequence not be reported with CPT code 20220 (bone biopsy). CPT codes 38220
and the catheters are left in place during the interim, a second selec- and 38221 may only be reported together if the two procedures are per-
tive catheter placement or access code should not be reported. Addi- formed at separate sites or at separate patient encounters. Separate sites
tionally, dye injections to position the catheter should not be include bone marrow aspiration and biopsy in different bones or two sepa-
reported as a second angiography procedure. rate skin incisions over the same bone. When both a bone marrow biopsy
(CPT code 38221) and bone marrow aspiration (CPT code 38220) are per-
9. When a median sternotomy is performed to accomplish cardiotho- formed at the same site through the same skin incision, only the bone mar-
racic procedures, the repair of the sternal incision is part of the pri- row biopsy (CPT 38221) should be reported.
mary procedure. The CPT codes 21820-21825 (treatment of
sternum fracture) are not separately reported nor should the E. General Policy Statements
removal of embedded wires be reported if a repeat procedure or 1. Medicare Global Surgery Rules prevent separate payment for post-
return to the operating room (e.g. postoperative hemorrhage on the operative pain management when provided by the physician per-
day of surgery) is necessary. forming an operative procedure. CPT codes 36000, 36410,
37202, 62318-62319, 64415-64417, 64450, 64470, 64475
10. When existing vascular access lines or selectively placed catheters and 90780 describe services that may be utilized for postoperative
are used to procure arterial or venous samples, billing for the sam- pain management. The services described by these codes may be
ple collection separately is inappropriate. reported only if performed for purposes unrelated to the postopera-
tive pain management.
11. Peripheral vascular bypass CPT codes describe bypass procedures
using venous grafts (CPT codes 35501-35587) and using other 2. Medicare Anesthesia Rules prevent separate payment for anesthesia
types of bypass procedures (arterial reconstruction, composite). when provided by the physician performing a medical or surgical
Because, at a given site of obstruction, only one type of bypass is service. The physician should not report CPT codes 00100-01999.
performed, these groups of codes are mutually exclusive. When dif- Additionally, the physician should not unbundle the anesthesia pro-
ferent sites are treated with different bypass procedures in the same cedure and report component codes individually. For example,
operative session, the different bypass procedures may be sepa- introduction of a needle or intracatheter into a vein (CPT code
rately reported, using an anatomic modifier or the -59 modifier. 36000), venipuncture (CPT code 36410), or intravenous infusion
(CPT code 90780) should not be reported when these services are
12. Vascular obstruction may be caused by thrombosis, embolism and/ related to the delivery of an anesthetic agent.
or atherosclerosis as well as other conditions. Treatment may,
therefore, include thrombectomy, embolectomy and/or endarterec-
tomy; these procedures may be performed alone or in combination.
39010 Mediastinotomy with exploration, drainage, removal of foreign body, or 39501 Repair, laceration of diaphragm, any approach
biopsy; transthoracic approach, including either transthoracic or median RELATIVE VALUE UNITS
sternotomy Work MP PE–nf PE–f Total–nf Total–f Global P
RELATIVE VALUE UNITS 13.11 1.65 6.53 6.53 21.29 21.29 90
Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS
11.72 1.75 6.43 6.43 19.90 19.90 90 -50 -51 -62 -66 -80, -82 Suprv Status
MODIFIERS INDICATORS 2 4 DOC DOC 8 09 A
-50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS
2 4 DOC DOC 8 09 A ¥<32002
> ❍, ¥<32020
> ❍, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202■,
> ¥ <3
> 9560▼, 44005❍, ¥<4> 4200❍, 44850❍,
CORRECT CODING EDITS 44950✚, 49000❍, ¥<4> 9002❆, 49010❍, 49255❍, 49570❍, ¥<6> 2318■, ¥<6> 2319■, ¥<6> 4415■,
¥ <6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9
> 0780❆
¥<32002
> ❍, ¥<32020
> ❍, ¥<35820
> ❆, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, 38530▼, ¥<62318
> ■, ¥<62319
> ■,
¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
39220 Excision of mediastinal tumor 39503 Repair, neonatal diaphragmatic hernia, with or without chest tube inser-
tion and with or without creation of ventral hernia
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
17.32 2.52 8.31 8.31 28.15 28.15 90 94.46 4.22 33.85 33.85 132.53 132.53 90
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 4 DOC DOC 8 09 A 2 4 DOC DOC 8 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<32002
> ❍, ¥<32020
> ❍, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, 60520❍, 60522❍, ¥<62318
> ■, ¥<62319
> ■, ¥ <3
> 2002❍, ¥<3
> 2020❍, ¥<3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, ¥<3
> 9560▼, ¥<3
> 9561▼, 44005❍, ¥<4> 4200❍,
¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■,
69990■, ¥<90780
> ❆ 44820❍, 44850❍, 44950✚, 49000❍, ¥<4> 9002❆, 49010❍, 49255❍, 49570❍, ¥<6> 2318■,
¥ <6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9
> 0780❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Respiratory–5
CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Digestive System (CPT Codes 40000–49999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
tion of treating bleeding induced by the procedure); these services 3. In accordance with the sequential procedure policy, only one code
would be reimbursed under the multiple endoscopic payment rules for hemorrhoidectomy is reported; the most extensive procedure
for gastrointestinal endoscopy. necessary to successfully accomplish the hemorrhoidectomy would
be appropriate. Additionally, if, in the course of a hemorrhoidec-
10. When a transabdominal colonoscopy (via colotomy)(CPT code tomy, an abscess is identified and drained, a separate procedure
45355) and/or standard sigmoidoscopy or colonoscopy is per- code is not reported for the incision and drainage, as this was per-
formed as a necessary part of an open procedure (e.g. colectomy), formed in the course of the hemorrhoidectomy. If the incision and
the endoscopic procedure(s) is (are) not separately reported. On the drainage of the abscess occurred at a different site than the hemor-
other hand, if either endoscopic procedure is performed as a diag- rhoidectomy, then this procedure could appropriately be reported
nostic procedure upon which the decision to perform the open pro- with a -59 modifier.
cedure is made, the procedure(s) may be reported separately. The
-58 modifier may be used to indicate that the diagnostic endoscopy 4. A number of groups of codes describe surgical procedures of a pro-
and the open procedure are staged or planned services. gressively more comprehensive nature or with different approaches
to accomplish similar services. In general, these groups of codes
C. Abdominal Procedures are not to be reported together (see mutually exclusive policy).
When any open abdominal procedure is performed, an exploration of the While a number of these groups of codes exist in CPT, several spe-
surgical field is routinely performed to identify anatomic structures or any cific examples include CPT codes 45110-45123 for proctectomies,
anomalies that may be present. Accordingly, an exploratory laparotomy CPT codes 44140-44160 for colectomies, CPT codes 43620-
(CPT code 49000) is not separately reported with any open abdominal pro- 43639 for gastrectomies, and CPT codes 48140-48180 for pan-
cedure. If routine exploration of the abdomen during an open abdominal createctomies.
procedure identifies abnormalities requiring a more extensive surgical field
that makes the procedure unusual, the -22 modifier may be reported with 5. When it is necessary to create or revise an enterostomy, or remove
supporting documentation in the medical record, indicating that an unusual or excise a section of bowel due to fistula formation, a separate
procedural service was performed. enterostomy closure code or fistula closure code is not reported. In
the case of creating or revising an enterostomy, the closure is mutu-
When, in the course of a hepatectomy, a cholecystectomy is necessary in ally exclusive and in the case of fistula excision, the closure is
order to successfully perform the hepatectomy, a separate procedure code is included in the excision procedure.
not coded for the cholecystectomy; component column 2 procedures neces-
sary to perform a more comprehensive column 1 procedure are included in 6. Because the digestive tract is bordered by a mucocutaneous margin,
the column 1 code describing the more comprehensive service. several CPT codes may define services involving biopsy, destruc-
tion, excision, removal, etc. of lesions of this margin. When a lesion
Appendectomies are commonly performed incidentally during many
involving this margin is identified and it is medically necessary to
abdominal procedures. The appendectomy is only to be reported separately
remove, only one code which most accurately describes the service
if it is medically necessary. If done incidental to another procedure, the
performed should be submitted, generally either from the CPT sec-
appendectomy would be included in the major procedure performed.
tion describing integumentary services (10040-19499) or diges-
When, in the course of an open abdominal procedure, a hernia repair is per- tive services (40490-49999). For example, if a patient presents
formed, a service is reported only if the hernia repair is medically necessary with a benign lip lesion, and it is removed with a wedge excision, it
at a different incisional site. Incidental hernia repair in the course of an would be acceptable to bill the CPT code 40510 (excision of lip) or
abdominal procedure that is not medically necessary should not be the appropriate code from CPT codes 11440-11446 (excision of
reported. The medical record should document the medical necessity of the lesions); billing a code from both sections would be inappropriate.
service if it is reported.
7. Laparoscopic procedures performed in place of an open procedure
When a recurrent hernia requires repair, the appropriate recurrent hernia are subject to the standard surgical practice guidelines.
repair code is reported. A code for incisional hernia repair is not to be
reported in addition to the recurrent hernia repair unless a medically neces- 8. Medicare Global Surgery Rules prevent separate payment for post-
sary incisional hernia repair is performed at a different site. In this case, the operative pain management when provided by the physician per-
-59 modifier should be attached to the incisional hernia repair code. forming an operative procedure. CPT codes 36000, 36410,
37202, 62318-62319, 64415-64417, 64450, 64470, 64475
D. General Policy Statements and 90780 describe services that may be utilized for postoperative
1. When a vagotomy is performed in conjunction with esophageal or pain management. The services described by these codes may be
gastric surgery, the appropriate CPT code describing the compre- reported only if performed for purposes unrelated to the postopera-
hensive column 1 coded service is reported. The range of CPT codes tive pain management.
64752-64760 includes services described by the vagotomy codes
performed as separate procedures and are not reported in addition 9. Medicare Anesthesia Rules prevent separate payment for anesthesia
to esophageal or gastric surgical CPT codes (e.g. 43635-43641) when provided by the physician performing a medical or surgical
which include vagotomy as part of the service. service. The physician should not report CPT codes 00100-01999.
Additionally, the physician should not unbundle the anesthesia pro-
2. When a closure of an enterostomy or enterovesical fistula requires cedure and report component codes individually. For example,
the resection and anastomosis of a segment of bowel, the CPT introduction of a needle or intracatheter into a vein (CPT code
codes 44626 and 44661, include the anastomosis or the enteric 36000), venipuncture (CPT code 36410), or intravenous infusion
resection. Accordingly, additional enteric resection codes are not to (CPT code 90780) should not be reported when these services are
be reported. related to the delivery of an anesthetic agent.
-50 -51 -62 -66 -80, -82 Suprv Status RELATIVE VALUE UNITS
2 4 NPD NPD NPD 09 A Work MP PE–nf PE–f Total–nf Total–f Global P
CORRECT CODING EDITS 5.37 0.56 6.65 5.25 12.58 11.18 90
00170●, ¥<11440
> ▼, ¥<11441
> ▼, ¥<11442
> ▼, ¥<11443
> ▼, ¥<11444
> ▼, ¥<11446
> ▼, ¥<11640
> ▼, ¥<11641
> ▼, MODIFIERS INDICATORS
¥<11642
> ▼, ¥<11643
> ▼, ¥<11644
> ▼, ¥<11646
> ▼, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<40500
> ▼, ¥<62318
> ■, -50 -51 -62 -66 -80, -82 Suprv Status
¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780 > ❆,
2 4 NPD NPD NPD 09 A
¥<92502
> ❆
CORRECT CODING EDITS
00170●, ¥<3> 6000❆, ¥<3> 6410❆, ¥<3> 7202■, ¥<6> 2318■, ¥<6> 2319■, ¥<6> 4415■, ¥<6> 4416■, ¥<6> 4417■,
40520 Excision of lip; V-excision with primary direct linear closure ¥ <6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■,
69990■, ¥<9> 0780❆, ¥<9> 2502❆
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P 40650 Repair lip, full thickness; vermilion only
4.64 0.50 7.41 5.09 12.55 10.23 90
RELATIVE VALUE UNITS
MODIFIERS INDICATORS
Work MP PE–nf PE–f Total–nf Total–f Global P
-50 -51 -62 -66 -80, -82 Suprv Status
3.62 0.37 5.62 3.86 9.61 7.85 90
2 4 NPD NPD NPD 09 A
MODIFIERS INDICATORS
CORRECT CODING EDITS
-50 -51 -62 -66 -80, -82 Suprv Status
00170●, ¥<11440
> ▼, ¥<11441
> ▼, ¥<11442
> ▼, ¥<11443
> ▼, ¥<11444
> ▼, ¥<11446
> ▼, ¥<11640
> ▼, ¥<11641
> ▼,
2 4 NPD NPD DOC 09 A
¥<11642
> ▼, ¥<11643> ▼, ¥<11644 > ▼, ¥<11646
> ▼, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<40500
> ▼, ¥<40510
> ▼,
¥<40525
> ✓, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416■,
> ¥ <6
> 4417■, ¥<6 > 4450■, ¥<6 > 4470■, ¥<6 > 4475■, CORRECT CODING EDITS
69990■, ¥<9> 0780❆, ¥<9> 2502❆ 00170●, ¥<1> 3150✓, ¥<1> 3151✓, ¥<1> 3152✓, ¥<3> 6000❆, ¥<3> 6410❆, ¥<3> 7202■, ¥<4> 0652✓, ¥<4> 0654✓,
¥ <6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■,
¥ <9
> 0780❆, ¥<9
> 2502❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Digestive–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI Version 10.0)
43264 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- 43269 Endoscopic retrograde cholangiopancreatography (ERCP); with endo-
scopic retrograde removal of calculus/calculi from biliary and/or pancre- scopic retrograde removal of foreign body and/or change of tube or stent
atic ducts RELATIVE VALUE UNITS
RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P 8.16 0.34 3.13 3.13 11.63 11.63 0
8.85 0.49 3.37 3.37 12.71 12.71 0 MODIFIERS INDICATORS
MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status 2 5 NPD NPD NPD 09 A
2 5 NPD NPD NPD 09 A CORRECT CODING EDITS
CORRECT CODING EDITS 00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥<3> 6000❆, ¥<3> 6005❆, ¥ <3
> 6010❆,
00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥<36000 > ❆, ¥<36005
> ❆, ¥<36010
> ❆, ¥ <3
> 6011❆, ¥<3
> 6012❆, ¥<3
> 6013❆, ¥<3
> 6014❆, ¥<3
> 6015❆, ¥<3
> 6410❍, ¥<3
> 7202■,43200❍, ¥ <4
> 3215▼,
¥<36011
> ❆, ¥<36012
> ❆, ¥<36013
> ❆, ¥<36014
> ❆, ¥<36015
> ❆, ¥<36410
> ❍, ¥<37202
> ■, 43200❍, ¥<43215
> ▼, 43234❍, ¥<4> 3235❍, 43260❍, ¥<4> 3268✓, 44360❍, 44376❍, ¥<6> 2318■, ¥<6> 2319■, ¥ <6
> 4415■,
43234❍, ¥<43235> ❍, 43260❍, 44360❍, 44376❍, ¥<62318 > ■, ¥<62319> ■, ¥<64415
> ■, ¥<64416
> ■, ¥ <6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<7 > 6000✚, ¥<7
> 6001✚, ¥ <9
> 0780❆,
¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<76000 > ✚, ¥<76001
> ✚, ¥<90780
> ❆, ¥<90781
> ❆, ¥ <9> 0781❆, 90782❆, 90783❆, 90784❆, 92511❍, ¥<9 > 4760❆, ¥<9
> 4761❆
90782❆, 90783❆, 90784❆, 92511❍, ¥<94760 > ❆, ¥<94761
> ❆
43267 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- 43272 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation
scopic retrograde insertion of nasobiliary or nasopancreatic drainage tube of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot
RELATIVE VALUE UNITS biopsy forceps, bipolar cautery or snare technique
Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS
7.35 0.41 2.84 2.84 10.60 10.60 0 Work MP PE–nf PE–f Total–nf Total–f Global P
MODIFIERS INDICATORS 7.35 0.41 2.84 2.84 10.60 10.60 0
-50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS
2 5 NPD NPD NPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status
CORRECT CODING EDITS 2 5 NPD NPD DOC 09 A
00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥<36000 > ❆, ¥<36005
> ❆, ¥<36010
> ❆, CORRECT CODING EDITS
¥<36011
> ❆, ¥<36012
> ❆, ¥<36013
> ❆, ¥<36014
> ❆, ¥<36015
> ❆, ¥<36410
> ❍, ¥<3> 7202■, 43200❍, ¥ <4
> 3219▼, 00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥<3> 6000❆, ¥<3> 6005❆, ¥<3> 6010❆,
43234❍, ¥<4> 3235❍, 43260❍, 44360❍, 44376❍, ¥<6> 2318■, ¥<6> 2319■, ¥<6> 4415■, ¥ <6
> 4416■, ¥ <3
> 6011❆, ¥<3
> 6012❆, ¥<3
> 6013❆, ¥<3
> 6014❆, ¥<3
> 6015❆, ¥<3
> 6410❍, ¥<3
> 7202■,43200❍, ¥<4> 3228▼,
¥ <6 > 4417■, ¥<6 > 4450■, ¥<6 > 4470■, ¥<6 > 4475■, 69990■, ¥<7 > 6000✚, ¥<7 > 6001✚, ¥<9 > 0780❆, ¥ <9
> 0781❆, 43234❍, ¥<4> 3235❍, ¥<4> 3258▼, 43260❍, 44360❍, 44376❍, ¥<6> 2318■, ¥<6> 2319■, ¥<6> 4415■,
90782❆, 90783❆, 90784❆, 92511❍, ¥<9> 4760❆, ¥<9> 4761❆ ¥ <6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<7 > 6000✚, ¥<7
> 6001✚, ¥<9
> 0780❆,
¥ <9> 0781❆, 90782❆, 90783❆, 90784❆, 92511❍, ¥<9 > 4760❆, ¥<9
> 4761❆
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
the urinary system, the bladder irrigation (CPT code 51700) is not plish similar services. In general, these groups of codes are not to
to be reported. This code is to be used for irrigation with therapeu- be reported together (see mutually exclusive policy). While a num-
tic agents or for irrigation as an independent therapeutic service. ber of these groups of codes exist in CPT, a specific example
includes the series of codes describing prostate procedures (CPT
9. When electromyography (EMG) is performed as part of a biofeed- codes 55801-55845). In addition, all prostatectomy procedures
back session, neither CPT code 51784 nor 51785 is to be reported (e.g. CPT codes 52601-52648 and 55801-55845) are also mutu-
unless a significant, separately identifiable diagnostic EMG service ally exclusive of one another.
is provided. If either the CPT code 51784 or the CPT code 51785 is
to be used for a diagnostic electromyogram, a separate report must D. Female Genital System
be available in the medical record to indicate this service was per- 1. When a pelvic examination is performed in conjunction with a
formed for diagnostic purposes. gynecologic procedure, either as a necessary part of the procedure
or as a confirmatory examination, the pelvic examination is not sep-
10. When endoscopic visualization of the urinary system involves sev- arately reported. A diagnostic pelvic examination may be per-
eral regions (e.g. kidney, renal pelvis, calyx, and ureter), the appro- formed for the purposes of deciding to perform a procedure;
priate CPT code is defined by the approach (e.g. nephrostomy, however, this examination is included in the evaluation and man-
pyelostomy, ureterostomy, etc.) as indicated in the CPT descriptor. agement service at the time the decision to perform the procedure is
When multiple endoscopic approaches are simultaneously neces- made.
sary to accomplish a medically necessary service (e.g. renal endos-
copy through a nephrostomy and cystourethroscopy performed at 2. All surgical laparoscopic, hysteroscopic or peritoneoscopic proce-
the same session), they may be separately coded with the multiple dures include diagnostic procedures. Therefore, CPT code 49320 is
procedure modifier -51 on the less extensive codes. When multiple included in 38120, 38570-38572, 43280, 43651-43653,
endoscopic approaches are necessary to accomplish the same pro- 44200-44202, 44970, 47560-47570, 49321-49323, 49650-
cedure, the successful endoscopic approach should be reported. 49651, 54690-54692, 55550, 58545-58554, 58660-58673,
60650; and 58555 is included in 58558-58563.
11. When urethral catheterization or urethral dilation (e.g. CPT codes
51701-51703) is necessary to accomplish a more extensive proce- 3. Lysis of adhesions (CPT code 58660) is not to be reported sepa-
dure, the urethral catheterization/dilation is not to be separately rately when done in conjunction with other surgical laparoscopic
reported. procedures.
12. Multiple ureteral anastomosis procedures are defined by CPT codes 4. Pelvic exam under anesthesia indicated by CPT code 57410, is
50740-50810, and 50860. In general, they represent mutually included in all major and most minor gynecological procedures and
exclusive procedures and are not to be reported together. If one is not to be reported separately. This procedure represents routine
anastomosis is performed on one ureter, and a different anastomo- evaluation of the surgical field.
sis is performed on a contralateral ureter, the appropriate modifier
(e.g. -LT, -RT) is used with the appropriate CPT code to describe the 5. Dilation of vagina or cervix (CPT codes 57400 or 57800), when
service performed on the respective ureter. done in conjunction with vaginal approach procedures, is not to be
reported separately unless the CPT code manual description states
13. CPT code 50860 (ureterostomy, transplantation of ureter to skin) is "without cervical dilation."
mutually exclusive of CPT codes 50800-50830 (e.g. ureterostomy,
ureterocolon conduit, urinary undiversion) unless performed at dif- 6. Administration of anesthesia, when necessary, is included in every
ferent locations in which case an anatomic modifier should be used. surgical procedure code, when performed by the surgeon.
14. The CPT codes 53502-53515 describe urethral repair codes for 7. Colposcopy (CPT codes 56820, 57420, 57452) should not be
urethral wounds or injuries (urethrorrhaphy). When a urethroplasty reported separately when performed as a “scout” procedure to con-
is performed, codes for urethrorrhaphy should not be reported in firm the lesion or to assess the surgical field prior to a surgical pro-
addition since “suture to repair wound or injury” is included in the cedure. A diagnostic colposcopy resulting in the decision to perform
urethroplasty service. a non-colposcopic procedure may be reported with modifier -58.
Diagnostic colposcopies (56820, 57420, 57452) are not separately
C. Male Genital System reported with other colposcopic procedures.
1. Transurethral drainage of a prostatic abscess (e.g. CPT code 52700)
is included in male transurethral prostatic procedures and is not E. Maternity Care and Delivery
reported separately. The majority of procedures in this section (CPT codes 59000-59899)
include only what is described by the code in the CPT definition. Additional
2. Urethral catheterization (e.g. CPT codes 51701, 51702, and procedures performed on the same day would be reported separately. The
51703), when medically necessary to successfully accomplish a few exceptions to this rule consist of:
procedure, should not be separately reported.
■ CPT codes 59050 and 59051(fetal monitoring during labor),
3. The puncture aspiration of a hydrocele (e.g. CPT code 55000) is 59300 (episiotomy) and 59414 (delivery of placenta) are includ-
included in services involving the tunica vaginalis and proximate ed in CPT codes 59400 (routine obstetric care, vaginal delivery),
anatomy (scrotum, vas deferens) and in inguinal hernia repairs. 59409 (vaginal delivery only), 59410 (vaginal delivery and post-
partum care), 59510 (routine obstetric care, cesarean delivery),
4. A number of codes describe surgical procedures of a progressively 59514 (cesarean delivery only), 59515 (cesarean delivery and
more comprehensive nature or with different approaches to accom- postpartum care), 59610 (routine obstetric care, vaginal delivery,
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Urinary–45
CPT only ©2003 American Medical Association. All Rights Reserved.
Urinary System
50010 Renal exploration, not necessitating other specific procedures 50045 Nephrotomy, with exploration
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
10.92 0.95 5.48 5.48 17.35 17.35 90 15.37 1.27 6.88 6.88 23.52 23.52 90
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 4 DOC DOC 8 09 A 2 4 DOC DOC 8 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, 44950✚, 49000❍, ¥<49002
> ❆, 49010❍, ¥<50100
> ❍, ¥<60540
> ❍, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, 44950✚, 49000❍, ¥<49002
> ❆, 49010❍, ¥<5> 0010❆, ¥<5> 0020▼,
¥<60545
> ❍, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, ¥ <5
> 0541▼, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■,
69990■, ¥<90780
> ❆ 69990■, ¥<9> 0780❆
50020 Drainage of perirenal or renal abscess; open 50060 Nephrolithotomy; removal of calculus
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
14.58 0.96 8.90 8.90 24.44 24.44 90 19.19 1.37 8.13 8.13 28.69 28.69 90
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 4 DOC DOC NPD 09 A 2 4 DOC DOC 8 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, 44950✚, 49000❍, ¥<49002
> ❆, 49010❍, ¥<49020
> ✓, ¥<50010
> ❆, ¥ <3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, 44950✚, 49000❍, ¥<4> 9002❆, 49010❍, ¥<5> 0020▼, ¥<5> 0040▼,
¥<50205
> ▼, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, ¥ <5
> 0045▼, ¥<5
> 0065✓, ¥<5
> 0070✓, ¥<5
> 0075✓, ¥<5
> 0500❆, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■,
69990■, ¥<90780
> ❆ ¥ <6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9> 0780❆
50021 Drainage of perirenal or renal abscess; percutaneous 50065 Nephrolithotomy; secondary surgical operation for calculus
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
3.36 0.18 1.11 1.11 4.65 4.65 0 20.67 1.35 6.38 6.38 28.40 28.40 90
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 4 NPD NPD 8 09 A 2 4 NPD NPD 8 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<49061
> ✓, ¥<49424
> ❍, ¥<50020
> ✓, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥ <3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, 44950✚, 49000❍, ¥<4> 9002❆, 49010❍, ¥<5> 0020▼, ¥<5> 0040▼,
¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆ ¥ <5
> 0045▼, ¥<5
> 0075✓, ¥<5
> 0500❆, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■,
¥ <6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9> 0780❆
14.85 0.98 8.51 8.51 24.34 24.34 90 Work MP PE–nf PE–f Total–nf Total–f Global P
-50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS
2 4 DOC DOC NPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Urinary–5
CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, Auditory
Systems (CPT Codes 60000–69999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
In addition, taps, punctures or burr holes accompanied by drainage 6. When a spinal puncture is performed, the local anesthesia neces-
procedures (e.g. hematoma, abscess, cyst, etc.) followed by other sary to perform the spinal puncture is included in the procedure
procedures, are not separately reported unless performed as staged itself. The submission of nerve block or facet block codes for local
procedures. The -58 modifier may be used to indicate staged or anesthesia for a diagnostic or therapeutic lumbar puncture is inap-
planned services. Many intracranial procedures include bone grafts propriate when there is no independent medical necessity of the
by CPT definition and these grafts should not be reported sepa- administration of local anesthetic except for the lumbar puncture.
rately. Separate codes are not to be reported. In comparison, if, in the
course of a nerve or other anesthetic block procedure, cerebrospinal
2. Biopsies performed in the course of Central Nervous System (CNS) fluid is withdrawn, it is inappropriate to bill for a diagnostic lumbar
surgery should not be reported as separate procedures. puncture; only the nerve (or other) block should be reported; the
CSF procurement is not for diagnostic purposes.
3. Craniotomies and craniectomies always include a general explora-
tion of the accessible field; accordingly it is not appropriate to code 7. The appropriate code for the open treatment of median nerve com-
an exploratory surgery (e.g. CPT codes 61304, 61305) when pression at the wrist (carpal tunnel syndrome) is CPT code 64721;
another procedure is performed at the same session. according to CPT Manual definition, this includes the open release
of the transverse carpal ligament. Additionally, if an arthroscopic
4. When services are performed at the same session, but represent dif- procedure (CPT code 29848) fails and must be followed by an open
ferent types of services or are being performed at different sites (see procedure (CPT code 64721), only the open, or successful, proce-
example below), the -59 modifier should be added. This modifier dure can be reported, if necessary, with a -22 modifier.
indicates that this service was a distinct, separate service and
should not be included in the column 1 code. 8. Nerve repairs by suture or neurorrhaphies (CPT codes 64831-
64876) include suture and anastomosis of nerves when performed
to correct traumatic injury to or anastomosis of nerves which are without other evidence for glaucoma, is not to be separately
proximally associated (e.g. facial-spinal, facial-hypoglossal, etc.). reported.
When neurorrhaphy is performed in conjunction with a nerve graft
(CPT codes 64885-64907), a neuroplasty, transection, excision, 3. The various approaches to removing a cataract are mutually exclu-
neurectomy, excision of neuroma, etc., a separate service is not sive of one another when performed on the same eye.
reported for the primary nerve suture.
4. Some retinal detachment repair procedures include some vitreous
9. In the same area of the cortex, neurostimulator electrodes can be procedures (e.g. CPT code 67108 includes 67015, 67025, 67028,
implanted in only one fashion; accordingly, the CPT code 61850 67031, 67036, 67039, and 67040). Certain retinal detachment
(burr hole) is included in the CPT code 61860 (craniectomy). Codes repairs are mutually exclusive to anterior procedures such as focal
describing craniotomy procedures (e.g. CPT codes 62100-62121) endolaser photocoagulation (e.g. CPT codes 67110 and 67112 are
are generally bundled into craniectomy codes (e.g. CPT codes mutually exclusive to CPT code 67108).
61860-61875).
5. CPT codes 68020-68200 (incision, drainage, excision of the con-
10. Because procedures necessary to accomplish a column 1 procedure junctiva) are included in all conjunctivoplasties (CPT codes 68320-
are included in the column 1 procedure, CPT codes such as 62310- 68362).
62311, 62318-62319 (injection of diagnostic or therapeutic sub-
stances) are included in the codes describing more invasive back 6. CPT code 67950 (canthoplasty) is included in repair procedures
procedures. Additionally, at the same site, codes describing lamino- such as blepharoplasties (CPT codes 67917, 67924, 67961,
tomy procedures are included in laminectomy codes. CPT codes 67966).
22100-22116 (partial excision of vertebral components) represent
7. Correction of lid retraction (CPT code 67911) includes full thickness
distinct procedures, and, accordingly, are not reported with laminot-
graft (e.g. CPT code 15260) as part of the total service performed.
omy/laminectomy procedures unless the services are performed as
described in the codes. 8. In the circumstance that it is medically necessary and reasonable to
inject sclerosing agents in the same session as surgery to correct
11. CPT codes describing the performance of a tracheostomy are not to
glaucoma, the service is included in the glaucoma surgery. Accord-
be reported with the CPT code 61576 (transoral approach to skull
ingly, codes such as CPT codes 67500, 67515, and 68200 for
base including tracheostomy) as this service is included in the
injection of sclerosing agents (e.g. 5-FU, HCPCS/CPT code J9190)
descriptor for the code.
should not be reported with other pressure- reducing or glaucoma
C. Ophthalmology procedures.
1. When a subconjunctival injection (e.g. CPT code 68200) with a D. Auditory System
local anesthetic is performed as part of a more extensive anesthetic
1. When a mastoidectomy is included in the description of an auditory
procedure (e.g. peribulbar or retrobulbar block), a separate service
procedure (e.g. CPT codes 69530, 69802, 69910), separate codes
for this procedure is not to be reported. This is a routine part of the
describing mastoidectomy are not reported.
anesthetic procedure and does not represent a separate service.
2. Myringotomies (e.g. CPT codes 69420 and 69421) are included in
2. Iridectomy, trabeculectomy, and anterior vitrectomy may be per-
tympanoplasties and tympanostomies.
formed in conjunction with cataract removal. When an iridectomy is
performed in order to accomplish the cataract extraction, it is an E. General Policy Statements
integral part of the procedure; it does not represent a separate ser- 1. Medicare Global Surgery Rules prevent separate payment for post-
vice, and is not separately reported. Similarly, the minimal vitreous operative pain management when provided by the physician per-
loss occurring during routine cataract extraction does not represent forming an operative procedure. CPT codes 36000, 36410,
a vitrectomy and is not to be separately reported unless it is medi- 37202, 62318-62319, 64415-64417, 64450, 64470, 64475
cally necessary for a different diagnosis. While a trabeculectomy is and 90780 describe services that may be utilized for postoperative
not performed as a part of a cataract extraction, it may be performed pain management. The services described by these codes may be
to control glaucoma at the same time as a cataract extraction. If the reported only if performed for purposes unrelated to the postopera-
procedure is medically necessary at the same time as a cataract tive pain management.
extraction, it can be reported under a different diagnosis (e.g. glau-
coma). The codes describing iridectomies, trabeculectomies, and 2. Medicare Anesthesia Rules prevent separate payment for anesthesia
anterior vitrectomies, when performed with a cataract extraction when provided by the physician performing a medical or surgical
under a separate diagnosis, must be reported with the -59 modifier. service. The physician should not report CPT codes 00100-01999.
This indicates that the procedure was performed as a different ser- Additionally, the physician should not unbundle the anesthesia pro-
vice for a separate situation. The medical record should reflect the cedure and report component codes individually. For example,
medical necessity of the service if separately reported. For example, introduction of a needle or intracatheter into a vein (CPT code
if a patient presents with a cataract and has evidence of glaucoma, 36000), venipuncture (CPT code 36410), or intravenous infusion
(i.e. elevated intraocular pressure preoperatively) and a trabeculec- (CPT code 90780) should not be reported when these services are
tomy represents the appropriate treatment for the glaucoma, a sepa- related to the delivery of an anesthetic agent.
rate service for the trabeculectomy would be separately reported.
Performance of a trabeculectomy as a preventative service for an
expected transient increase in intraocular pressure postoperatively,
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Endocrine–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Nervous System
61000 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; 61050 Cisternal or lateral cervical (C1-C2) puncture; without injection (separate
initial procedure)
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
1.57 0.16 0.97 0.97 2.70 2.70 0 1.50 0.16 1.28 1.28 2.94 2.94 0
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 4 NPD NPD NPD 09 A 2 4 NPD NPD DOC 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■,
¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆ ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
61001 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; 61055 Cisternal or lateral cervical (C1-C2) puncture; with injection of medication
subsequent taps or other substance for diagnosis or treatment (eg, C1-C2)
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
1.48 0.18 1.08 1.08 2.74 2.74 0 2.09 0.16 1.44 1.44 3.69 3.69 0
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 4 NPD NPD NPD 09 A 2 NA NPD NPD NPD 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<61000
> ✓, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, 01905●, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<61050
> ◆, ¥<62310
> ●, ¥<6> 2318●, ¥<6> 2319■, ¥<6> 4415■,
¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆ ¥ <6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, ¥<6
> 4479●,
69990■, ¥<9> 0780❆
61020 Ventricular puncture through previous burr hole, fontanelle, suture, or 61070 Puncture of shunt tubing or reservoir for aspiration or injection procedure
implanted ventricular catheter/reservoir; without injection
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
0.88 0.11 1.05 1.05 2.04 2.04 0
1.50 0.31 1.38 1.38 3.19 3.19 0
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
2 4 NPD NPD NPD 09 A
2 4 NPD NPD NPD 09 A
CORRECT CODING EDITS
CORRECT CODING EDITS
¥ <3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■, ¥<6
> 4450■,
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<61000
> ❆, ¥<61001
> ❆, ¥<61070
> ❆, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥ <6
> 4470■, ¥<6
> 4475■, 69990■, ¥<9> 0780❆
¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
61026 Ventricular puncture through previous burr hole, fontanelle, suture, or 61105 Twist drill hole for subdural or ventricular puncture;
implanted ventricular catheter/reservoir; with injection of medication or RELATIVE VALUE UNITS
other substance for diagnosis or treatment Work MP PE–nf PE–f Total–nf Total–f Global P
RELATIVE VALUE UNITS 5.11 1.26 4.01 4.01 10.38 10.38 90
Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS
1.68 0.25 1.45 1.45 3.38 3.38 0 -50 -51 -62 -66 -80, -82 Suprv Status
MODIFIERS INDICATORS 2 4 NPD NPD DOC 09 A
-50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS
2 4 NPD NPD NPD 09 A ¥ <3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, ¥<6
> 1793❆, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■, ¥<6
> 4417■,
CORRECT CODING EDITS ¥ <6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, ¥<6
> 9990■, ¥<9
> 0780❆, ¥<G
> 0173❆, ¥<G
> 0242❆, ¥<G
> 0243❆
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ■, ¥<61000
> ❆, ¥<61001
> ❆, ¥<61020
> ◆, ¥<61070
> ❆, ¥<62318
> ■, ¥<62319
> ■,
¥<64415
> ■, ¥<64416
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■, ¥<64475
> ■, 69990■, ¥<90780
> ❆
61107 Twist drill hole for subdural or ventricular puncture; for implanting ven-
tricular catheter or pressure recording device
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
4.97 1.22 3.36 3.36 9.55 9.55 0
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD NPD 09 A
CORRECT CODING EDITS
¥ <3
> 6000❆, ¥<3
> 6410❆, ¥<3
> 7202■, ¥<6
> 1105◆, ¥<6
> 1793❆, ¥<6
> 2318■, ¥<6
> 2319■, ¥<6
> 4415■, ¥<6
> 4416■,
¥ <6
> 4417■, ¥<6
> 4450■, ¥<6
> 4470■, ¥<6
> 4475■, ¥<6
> 9990■, ¥<9
> 0780❆, ¥<G
> 0173❆, ¥<G
> 0242❆, ¥<G
> 0243❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Endocrine–7
CPT only ©2003 American Medical Association. All Rights Reserved.
Radiology Services (CPT Codes 70000–79999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
tion of informed consent, discussion of follow-up, and the review of the 5. CPT code 76970 (ultrasound study, follow-up) cannot be reported
medical record. In this setting, a separate evaluation and management ser- with any other echocardiographic or ultrasound guidance proce-
vice is not reported. As a rule, if the medical decision making that evolves dures because it represents a follow-up procedure on the same day.
from the procurement of the information from the patient is limited to
whether or not the procedure should be performed, whether comorbidity 6. CPT code 77790 (supervision, handling, loading of radiation
may impact the procedure, or involves discussion and education with the source) is not to be reported with any of the remote afterloading
patient, an evaluation/management code is not reported separately. If a sig- brachytherapy codes (e.g. CPT codes 77781-77784) since these
nificant, separately identifiable service is rendered, involving taking a his- procedures inherently include the supervision of the radioelement.
tory, performing an exam, and making medical decisions distinct from the
procedure, the appropriate evaluation and management service can be 7. Bone studies such as CPT codes 76020-76065 require a series of
reported. The appropriate evaluation and management service code is cho- radiographs; billing separately for bone studies and individual
sen based on the type of service rendered which satisfies the Evaluation and radiographs obtained in the course of the bone study is inappropri-
Management guidelines developed by the AMA and CMS. ate.
In radiation oncology, evaluation and management services would not be 8. Radiologic supervision and interpretation codes for specific proce-
separately reported with the exception of an initial consultation at which dures include all the radiologic services necessary for that proce-
time a decision is made whether to proceed with the treatment. Radiation dure. For example, do not additionally report fluoroscopy (e.g., CPT
oncology includes clinical treatment planning, simulation, medical radiation codes 76000, 76001, 76003, 76005) or ultrasound guidance
physics, dosimetry treatment devices, special services, and clinical treat- (e.g., CPT codes 76942, 76986).
ment management procedures in teletherapy and brachytherapy.
The categories of procedures in this subsection are well-defined according to
levels of intensity for clinical treatment planning, devices, delivery and man-
agement.
E. Nuclear Medicine
The general policies promulgated above apply to nuclear medicine as well
as standard diagnostic imaging. Several issues specific to the practice of
nuclear medicine require comment.
The injection of the radionuclide is included as part of the procedure; sepa-
rate injection codes (e.g. 36000, 90783) should not be reported.
Single photon emission computed tomography (SPECT) studies represent
an enhanced methodology over standard planar nuclear imaging. When a
limited anatomic area is studied, there is no additional information procured
by obtaining both planar and SPECT studies. While both represent medi-
cally acceptable imaging studies, when a SPECT study of a limited area is
performed, a planar study is not to be separately reported. When vascular
flow studies are obtained using planar technology in addition to SPECT
studies, the appropriate CPT code for the vascular flow study should be
reported, not the flow, planar and SPECT studies. In cases where planar
images must be procured because of the extent of the scanned area (e.g.
bone imaging), both planar and SPECT scans may be necessary and
reported separately.
F. General Policy Statements
1. Any abdominal radiology procedure that has a radiological supervi-
sion and interpretation code (e.g. CPT code 75625 for abdominal
aortogram), would also include abdominal x-rays (e.g. CPT codes
74000-74022) as part of the total service.
79100 Radiopharmaceutical therapy, polycythemia vera, chronic leukemia, 79300 Interstitial radioactive colloid therapy
each treatment by intravenous injection
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA
1.31 0.20 3.07 3.07 4.58 4.58 NA
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 C
2 NA NPD NPD DOC 09 A
CORRECT CODING EDITS
CORRECT CODING EDITS
¥<36000
> ❆, ¥<36410
> ❍, ¥<77750
> ✓, ¥<77761
> ✓, ¥<77762
> ✓, ¥<77763
> ✓, ¥<77776
> ✓, ¥<77777
> ✓, ¥<77778
> ✓,
¥<36000
> ❆, ¥<36410
> ❍, ¥<76000
> ■, ¥<76003
> ■, ¥<76942
> ■, ¥<76986
> ■, ¥<77750
> ✓, ¥<77761
> ✓, ¥<77762
> ✓, ¥<77781
> ✓, ¥<77782
> ✓, ¥<77783
> ✓, ¥<77784
> ✓, ¥<77789
> ✓, ¥<77790
> ❆, ¥<79200
> ✓, ¥<90780
> ❆, 90784❆
¥<77763
> ✓, ¥<77776
> ✓, ¥<77777
> ✓, ¥<77778
> ✓, ¥<77781
> ✓, ¥<77782
> ✓, ¥<77783
> ✓, ¥<77784
> ✓, ¥<77789
> ✓, ¥<77790
> ❆,
¥<79400
> ✓, ¥<90780
> ❆, 90784❆
79200-26 Intracavitary radioactive colloid therapy 79400-TC Radiopharmaceutical therapy, nonthyroid, nonhematologic by inter-
venous injection
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
1.98 0.08 0.69 0.69 2.75 2.75 NA 0.00 0.14 2.60 2.60 2.74 2.74 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 A 2 NA NPD NPD DOC 09 A
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Radiology–179
CPT only ©2003 American Medical Association. All Rights Reserved.
Radiology
70010 Myelography, posterior fossa, radiological supervision and interpre- 70015-TC Cisternography, positive contrast, radiological supervision and inter-
tation pretation
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
1.18 0.29 4.70 4.70 6.17 6.17 NA 0.00 0.08 1.34 1.34 1.42 1.42 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 A 2 NA NPD NPD DOC 03 A
CORRECT CODING EDITS
¥<36000
> ❆, ¥<36406
> ❆, ¥<36410
> ❆, ¥<76000
> ❆, ¥<76001
> ❆, ¥<76003
> ❆, ¥<76005
> ❆, 90782❆, 90783❆, 90784❆
70030 Radiologic examination, eye, for detection of foreign body
RELATIVE VALUE UNITS
70010-26 Myelography, posterior fossa, radiological supervision and interpre-
Work MP PE–nf PE–f Total–nf Total–f Global P
tation
0.17 0.03 0.48 0.48 0.68 0.68 NA
RELATIVE VALUE UNITS
MODIFIERS INDICATORS
Work MP PE–nf PE–f Total–nf Total–f Global P
-50 -51 -62 -66 -80, -82 Suprv Status
1.18 0.07 0.40 0.40 1.65 1.65 NA
3 NA NPD NPD DOC 09 A
MODIFIERS INDICATORS
CORRECT CODING EDITS
-50 -51 -62 -66 -80, -82 Suprv Status
NA
2 NA NPD NPD DOC 09 A
70010-TC Myelography, posterior fossa, radiological supervision and interpre- 70030-26 Radiologic examination, eye, for detection of foreign body
tation RELATIVE VALUE UNITS
RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P 0.17 0.01 0.06 0.06 0.24 0.24 NA
0.00 0.22 4.30 4.30 4.52 4.52 NA MODIFIERS INDICATORS
MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status 3 NA NPD NPD DOC 09 A
2 NA NPD NPD DOC 03 A
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Radiology–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Pathology/Laboratory Services (CPT Codes 80000–89999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
result (e.g. 88104-88108, 88142-88143, 88150-88154, If the abnormal cells in two or more specimens are morphologically
88164-88167, etc.) is to be reported. If multiple services (i.e., sep- similar and testing on one specimen by one method (88342 or
arate specimens) are reported, the -59 modifier should be used to 88180) establishes the diagnosis, the other method should not be
indicate that different levels of service were provided for different reported on the same or similar specimen. Similar specimens would
specimens. This should be reflected in the cytopathologic reports. A include, but are not limited to:
cytopathology preparation from a fluid, washing, or brushing is to
be reported using one code from the range of CPT codes 88104- (1) blood and bone marrow;
88108. It is inappropriate to additionally use CPT codes 88160-
88162 because the smears are included in the codes referable to (2) bone marrow aspiration and bone marrow biopsy;
fluids (washings or brushings) and 88160-88162 references “any
(3) two separate lymph nodes; or
other source” which would exclude fluids, washings, or brushings.
(4) lymph node and other tissue with lymphoid infiltrate.
4. The CPT codes 80500 and 80502 are used to indicate that a
pathologist has reviewed and interpreted, with a subsequent writ- 8. Quantitative immunohistochemistry by digital cellular imaging
ten report, a clinical pathology test. These codes additionally are should not be reported as CPT code 88342 with CPT code 88358.
not to be used with any other pathology service that includes a phy- Prior to January 1, 2004, it should be reported as CPT code 88342.
sician interpretation (e.g. surgical pathology). If an evaluation and Beginning January 1, 2004, it should be reported as CPT code
management service (face-to-face contact with the patient) takes 88361. CPT code 88361 should not be used to report any service
place by the pathologist, then the appropriate E/M code is reported, other than quantitative immunocytochemistry by digital cellular
rather than the clinical pathology consultation codes, even if, as part imaging. Digital cellular imaging includes computer software anal-
of the evaluation and management service, review of the test result ysis of stained microscopic slides.
is performed. Reporting of these services (CPT codes 80500 and
80502) requires the written order for consultation by a treating 9. DNA ploidy and S-phase analysis of tumor by digital cellular imag-
physician. ing technique should not be reported as CPT code 88313 with CPT
code 88358. Prior to January 1, 2004, it should be reported as
5. The CPT codes 88321-88325 are to be used to review slides, tis- CPT code 88313. Beginning January 1, 2004, it should be
sues, or other material obtained and prepared at a different location reported as CPT code 88358. Prior to January 1, 2004, CPT code
and referred to a pathologist for a second opinion. (These codes 88358 should be utilized to report DNA ploidy and
should not be reported by pathologists reporting a second opinion
on slides, tissue, or material also examined and reported by S-phase analysis of tumor by non-digital cellular imaging tech-
another pathologist in the same provider group.) Medicare gener- niques. CPT code 88358 should not be used to report any service
ally does not pay twice for an interpretation of a given technical ser- other than DNA ploidy and S-phase analysis. One unit of service
vice (e.g., EKGs, radiographs, etc.). When reporting CPT codes for CPT code 88358 includes both DNA ploidy and S-phase analy-
88321-88325, providers should not report other pathology CPT sis.
codes such as 88312, 88313, 88342, 88180, etc., for interpreta-
tion of stains, slides or material previously interpreted by another 10. CPT code 83721 (lipoprotein, direct measurement; direct measure-
pathologist. CPT codes 88312, 88313 and 88342 may be ment, LDL cholesterol) is used to report direct measurement of the
reported with CPT code 88323 if provider performs and interprets LDL cholesterol. It should not be used to report a calculated LDL
these stains de novo. These codes are not to be used for a face-to- cholesterol. Direct measurement of LDL cholesterol in addition to
face evaluation of a patient. In the event that a physician provides total cholesterol (CPT code 82465) or lipid panel (CPT code 80061)
an evaluation and management service to a patient and, in the may be reasonable and necessary if the triglyceride level is too high
course of this service, specimens obtained elsewhere are reviewed to permit calculation of the LDL cholesterol. In such situations, CPT
as well, this is part of the evaluation and management service and code 83721 should be reported with modifier -59.
is not to be reported separately. Only the evaluation and manage-
ment service would be reported.
7. Medicare does not pay for duplicate testing. CPT codes 88342
(immunocytochemistry, each antibody) and 88180 (flow cytometry)
should not in general be reported for the same or similar speci-
mens. The diagnosis should be established using one of these
methods. The provider may report both CPT codes if both methods
are required because the initial method is nondiagnostic or does not
explain all the light microscopic findings. The provider can report
both methods utilizing modifier -59 and document the need for
both methods in the medical record.
80061 Lipid panel This panel must include the following: Cholesterol,
serum, total (82465) Lipoprotein, direct measurement, high density 80100 Drug screen, qualitative; multiple drug classes chromatographic
cholesterol (HDL cholesterol) (83718) Triglycerides (84478) method, each procedure
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
NA NA NA NA NA 09 NON NA NA NA NA NA 09 NON
CORRECT CODING EDITS CORRECT CODING EDITS
¥<80500
> ❆, ¥<80502
> ❆, ¥<82465
> ▲, ¥<83718
> ▲, ¥<83721
> ■, ¥<84478
> ▲ ¥<80101
> ◆, ¥<80500
> ❆, ¥<80502
> ❆, ¥<82486
> ◆, ¥<82487
> ◆, ¥<82488
> ◆, ¥<82489
> ◆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Pathology–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI Version 10.0)
89100 Duodenal intubation and aspiration; single specimen (eg, simple 89135 Gastric intubation, aspiration, and fractional collections (eg, gastric
bile study or afferent loop culture) plus appropriate test procedure secretory study); one hour
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
0.60 0.02 1.62 0.22 2.24 0.84 NA 0.79 0.04 1.61 0.25 2.44 1.08 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 A 2 NA NPD NPD DOC 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<43752
> ■, ¥<G0272
> ■ ¥<43752
> ■, ¥<G0272
> ■
89105 Duodenal intubation and aspiration; collection of multiple fractional 89136 Gastric intubation, aspiration, and fractional collections (eg, gastric
specimens with pancreatic or gallbladder stimulation, single or dou- secretory study); two hours
ble lumen tube RELATIVE VALUE UNITS
RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P 0.21 0.01 1.66 0.09 1.88 0.31 NA
0.50 0.02 2.26 0.17 2.78 0.69 NA MODIFIERS INDICATORS
MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status 2 NA NPD NPD DOC 09 A
2 NA NPD NPD DOC 09 A CORRECT CODING EDITS
CORRECT CODING EDITS ¥<43752
> ■, ¥<89135
> ◆, ¥<G0272
> ■
¥<43752
> ■, ¥<89100
> ▼, ¥<G0272
> ■
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
F. Ophthalmology tified in the CPT Manual for a given procedure, these can be sepa-
General ophthalmological services (e.g. CPT codes 92002-92014) describe rately reported.
components of the ophthalmologic examination. When evaluation and
management codes are reported, these general ophthalmological service 3. Cardiac output measurement (e.g. CPT codes 93561-93562) is rou-
codes (e.g. CPT codes 92002-92014) are not to be reported; the same ser- tinely performed during cardiac catheterization procedures per CPT
vices would be represented by both series of codes. definition and, therefore, CPT codes 93561-93562 are not to be
reported with cardiac catheterization codes.
Special ophthalmologic services represent specific services not described as
part of a general or routine ophthalmological examination. Special ophthal- 4. CPT codes 93797 and 93798 describe comprehensive services pro-
mological services are recognized as significant, separately identifiable ser- vided by a physician for cardiac rehabilitation. As this includes all
vices. services referable to cardiac rehabilitation, it would be inappropriate
to bill a separate evaluation and management service code unless
For procedures requiring intravenous injection of dye or other diagnostic an unrelated, separately identifiable, service is performed and docu-
agent, insertion of an intravenous catheter and dye injection are necessary mented in the medical record.
to accomplish the procedure and are included in the procedure. Accordingly,
HCPCS/CPT codes 36000 (introduction of a needle or catheter),36410 5. When a physician who is in attendance for a cardiac stress test
(venipuncture),90780 (IV infusion),and 90784 (IV injection)as well as selec- obtains a history, and performs a limited examination referable spe-
tive vascular catheterization codes are not to be separately reported with cifically to the cardiac stress test, a separate evaluation and manage-
services requiring intravenous injection (e.g. CPT codes 92230, 92235, ment service is not reported unless a significant, separately
92240, 92287, for angioscopy and angiography). identifiable service is performed unrelated to the performance of the
cardiac stress test and in accordance with the evaluation and man-
G. Otorhinolaryngologic Services agement guidelines. The evaluation and management service
CPT coding for otorhinolaryngologic services involves a number of tests that would be reported with the -25 modifier in this instance.
can be performed qualitatively by confrontation during physical examina-
tion or quantitatively with electrical recording equipment. CPT definition 6. Routine monitoring of EKG rhythm and review of daily hemody-
specifies which is the case for each code. CPT codes 92552-92557, and namics, including cardiac outputs, is a part of critical care evaluation
92561-92589 can be performed qualitatively or quantitatively but accord- and management. Separate billing for review of EKG rhythm strips
ing to CPT definition these can be reported only if calibrated electronic and cardiac output measurements (e.g. CPT codes 93040-93042,
equipment is used. Confrontational estimation of these tests by the physi- 93561, 93562) and critical care services is inappropriate. An
cian is part of the evaluation and management service. exception to this may include a sudden change in patient status
associated with a change in cardiac rhythm requiring a return to the
H. Cardiovascular Services
ICU or telephonic transmission to review a rhythm strip. If reported
Cardiovascular medicine services include non-invasive and invasive diag-
separately, time included for this service is not included in the criti-
nostic testing (including intracardiac testing) as well as therapeutic services
cal care time calculated for the critical care service.
(e.g. electrophysiological procedures). Several unique issues arise due to
the spectrum of cardiovascular codes included in this section. I. Pulmonary Services
1. When cardiopulmonary resuscitation is performed without other CPT coding for pulmonary function tests includes both comprehensive and
evaluation and management services (e.g. a physician responds to component codes to accommodate variation among pulmonary function lab-
a “code blue” and directs cardiopulmonary resuscitation with the oratories. As a result of these code combinations, several issues are
patient's attending physician then resuming the care of the patient addressed in this policy section.
after the patient has been revived), only the CPT code 92950 for 1. Alternate methods of reporting data obtained during a spirometry
CPR should be reported. Levels of critical care services and pro- or other pulmonary function session cannot be separately reported.
longed management services are determined by time; when CPT Specifically, the flow volume loop is an alternative method of calcu-
code 92950 is reported, the time required to perform CPR is not lating a standard spirometric parameter. The CPT code 94375 is
included in critical care or other timed evaluation and management included in standard spirometry (rest and exercise) studies.
services.
2. When a physician who is in attendance for a pulmonary function
2. In keeping with the policies outlined previously, procedures rou- study, obtains a limited history, and performs a limited examination
tinely performed as part of a comprehensive service are included in referable specifically to the pulmonary function testing, separately
the comprehensive service and not separately reported. A number coding for an evaluation and management service is not appropri-
of therapeutic and diagnostic cardiovascular procedures (e.g. CPT ate. If a significant, separately identifiable service is performed
codes 92950-92998, 93501-93545, 93600-93624, 93640- unrelated to the technical performance of the pulmonary function
93652) routinely utilize intravenous or intra-arterial vascular test, an evaluation and management service may be reported.
access, routinely require electrocardiographic monitoring, and fre-
quently require agents administered by injection or infusion tech- 3. When multiple spirometric determinations are necessary (e.g. CPT
niques; accordingly, separate codes for routine access, monitoring, code 94070) to complete the service described in the CPT code,
injection or infusion services are not to be reported. Fluoroscopic only one unit of service is reported.
guidance procedures are integral to invasive intravascular proce-
dures and are included in those services. In unique circumstances, 4. Pulmonary stress testing (e.g. CPT code 94620) is a comprehensive
where these services are performed, not as an integral part of the stress test with a number of component tests separately defined in
procedure, the appropriate code can be separately reported with the the CPT Manual. It is inappropriate to separately code venous
-59 modifier. When supervision and interpretation codes are iden- access, EKG monitoring, spirometric parameters performed before,
99202 Office or other outpatient visit for the evaluation and management of 99205 Office or other outpatient visit for the evaluation and management of
a new patient, which requires these three key components: an a new patient, which requires these three key components: a com-
expanded problem focused history; an expanded problem focused prehensive history; a comprehensive examination; and medical deci-
examination; and straightforward medical decision making. Coun- sion making of high complexity. Counseling and/or coordination of
seling and/or coordination of care with other providers or agencies care with other providers or agencies are provided consistent with
are provided consistent with the nature of the problem(s) and the the nature of the problem(s) and the patient's and/or family's needs.
patient's and/or family's needs. Usually, the presenting problem(s) Usually, the presenting problem(s) are of moderate to high severity.
are of low to moderate severity. Physicians typically spend 20 min- Physicians typically spend 60 minutes face-to-face with the patient
utes face-to-face with the patient and/or family. and/or family.
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
0.87 0.06 0.79 0.32 1.72 1.25 NA 2.65 0.14 1.82 0.93 4.61 3.72 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 A 2 NA NPD NPD DOC 09 A
CORRECT CODING EDITS CORRECT CODING EDITS
¥<43752
> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼, ¥ <4
> 3752■,80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼,
94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆, 94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆,
95852❆, ¥<96115
> ✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■, 95852❆, ¥<9> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■,
97804■, 99239✓, 99435✓, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥<G0248
> ■, 97804■, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥<G > 0248■, ¥<G
> 0250■, G0270■,
¥<G0250
> ■, G0270■, G0271■, ¥<G0272
> ■, M0064◆ G0271■, ¥<G
> 0272■, M0064◆
99203 Office or other outpatient visit for the evaluation and management of 99211 Office or other outpatient visit for the evaluation and management of
a new patient, which requires these three key components: a an established patient, that may not require the presence of a physi-
detailed history; a detailed examination; and medical decision mak- cian. Usually, the presenting problem(s) are minimal. Typically, 5
ing of low complexity. Counseling and/or coordination of care with minutes are spent performing or supervising these services.
other providers or agencies are provided consistent with the nature RELATIVE VALUE UNITS
of the problem(s) and the patient's and/or family's needs. Usually,
Work MP PE–nf PE–f Total–nf Total–f Global P
the presenting problem(s) are of moderate severity. Physicians typi-
cally spend 30 minutes face-to-face with the patient and/or family. 0.17 0.01 0.41 0.06 0.59 0.24 NA
RELATIVE VALUE UNITS MODIFIERS INDICATORS
Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status
1.33 0.10 1.15 0.49 2.58 1.92 NA 2 NA NPD NPD DOC 09 A
MODIFIERS INDICATORS CORRECT CODING EDITS
-50 -51 -62 -66 -80, -82 Suprv Status ¥ <4
> 3752■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼,
94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆,
2 NA NPD NPD DOC 09 A 95852❆, ¥<9> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■,
CORRECT CODING EDITS 97804■, 99239✓, 99435✓, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥ <G
> 0248■,
¥ <G
> 0250■, G0270■, G0271■, ¥<G
> 0272■, M0064◆, Q0083■, Q0084■, Q0085■
¥<43752
> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼,
94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆,
95852❆, ¥<96115
> ✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■,
97804■, 99239✓, 99435✓, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥<G0248
> ■,
¥<G0250
> ■, G0270■, G0271■, ¥<G0272
> ■, M0064◆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Medicine–122
CPT only ©2003 American Medical Association. All Rights Reserved.
Medicine Services
90375 Rabies immune globulin (RIg), human, for intramuscular and/or sub- 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for per-
cutaneous use cutaneous use
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
NA NA NA NA NA 09 EXC NA NA NA NA NA 09 EXC
CORRECT CODING EDITS CORRECT CODING EDITS
90376✓ 90586✓, 90782✚
90378 Respiratory syncytial virus immune globulin (RSV-IgIM), for intra- 90632 Hepatitis A vaccine, adult dosage, for intramuscular use
muscular use, 50 mg, each
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA
0.00 0.00 0.00 0.00 0.00 0.00 NA
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
NA NA NA NA NA 09 EXC
NA NA NA NA NA 09 NON
CORRECT CODING EDITS
CORRECT CODING EDITS
90633✓, 90634✓, 90636✓, 90782✓
¥<36000
> ❆, ¥<36410
> ❆, ¥<90780
> ■, 90783■, 90784■, 90788■
90471 Immunization administration (includes percutaneous, intradermal, 90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule,
for intramuscular use
subcutaneous, intramuscular and jet injections); one vaccine (single
or combination vaccine/toxoid) RELATIVE VALUE UNITS
RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA
0.00 0.01 0.20 0.20 0.21 0.21 NA MODIFIERS INDICATORS
MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 EXC
2 NA NPD NPD DOC 09 A CORRECT CODING EDITS
CORRECT CODING EDITS 90634✓, 90636✓, 90782✓
90782✓, 90784✓
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Medicine–7
CPT only ©2003 American Medical Association. All Rights Reserved.
Category III Codes CPT Codes (0001T – 0099T)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Category III–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Category III Codes
0032T Speculoscopy; with directed sampling 0037T Open subclavian to carotid artery transposition performed in conjunction
with endovascular thoracic aneurysm repair, by neck incision, unilateral
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA
0.00 0.00 0.00 0.00 0.00 0.00 NA
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 C
2 NA NPD NPD DOC 09 C
CORRECT CODING EDITS
CORRECT CODING EDITS
¥<0031T
> ◆
¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ❆, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64417
> ■, ¥<64450
> ■, ¥<64470
> ■,
¥<64475
> ■, 69990■, ¥<90780
> ❆
0035T Placement of proximal or distal extension prosthesis for endovascular 0040T Placement of proximal or distal extension prosthesis for endovascular
repair of descending thoracic aortic aneurysm, pseudoaneurysm or dis- repair of descending thoracic aortic aneurysm, pseudoaneurysm or dis-
section; initial extension section, each extension, radiological supervision and interpretation
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
2 NA NPD NPD DOC 09 C 2 NA NPD NPD DOC 09 C
01926●, ¥<36000
> ❆, ¥<36410
> ❆, ¥<37202
> ❆, ¥<62318
> ■, ¥<62319
> ■, ¥<64415
> ■, ¥<64417
> ■, ¥<64450
> ■, 01916●
¥<64470
> ■, ¥<64475
> ■,
69990■, ¥<90780
> ❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 Category III–5
CPT only ©2003 American Medical Association. All Rights Reserved.
HCPCS Level II [Supplemental Services] (Codes A0000–V9999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct
Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate
payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
G0239 Therapeutic procedures to improve respiratory function or increase G0245 Initial physician evaluation and management of a diabetic patient
strength or endurance of respiratory muscles, two or more individu- with diabetic sensory neuropathy resulting in a loss of protective
als (includes monitoring) sensation (lops) which must include: (1) the diagnosis of lops, (2) a
RELATIVE VALUE UNITS patient history, (3) a physical examination that con
Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS
0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P
MODIFIERS INDICATORS 0.87 0.06 0.79 0.32 1.72 1.25 NA
-50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS
2 NA NPD NPD DOC 09 C -50 -51 -62 -66 -80, -82 Suprv Status
CORRECT CODING EDITS 2 NA NPD NPD DOC 09 C
¥<G0237
> ◆, ¥<G0238
> ▼ CORRECT CODING EDITS
11040✚, 11041✚, 11042✚, 11043✚, 11044✚, 11055✚, 11056✚, 11057✚, 11305■,
11306■, 11307■, 11308■, ¥<1> 1420■, ¥<1> 1421■, ¥<1> 1422■, ¥<1> 1423■, ¥<1> 1424■, ¥<1> 1426■,
G0242 Multi-source photon stereotactic radiosurgery (cobalt 60 multi- 11719✚, 11720✚, 11721✚, 11755❍, 11765❆, 97601❆, G0127✚, G0246▼
source converging beams) plan, including dose volume histograms
for target and critical structure tolerances, plan optimization per-
formed for highly conformal distributions, plan positional accuracy G0246 Follow-up physician evaluation and management of a diabetic
and dose verification, all lesions treated, per course of treatment patient with diabetic sensory neuropathy resulting in a loss of pro-
tective sensation (lops) to include at least the following: (1) a patient
RELATIVE VALUE UNITS
history, (2) a physical examination that includes: (a)
Work MP PE–nf PE–f Total–nf Total–f Global P
RELATIVE VALUE UNITS
0.00 0.00 0.00 0.00 0.00 0.00 NA
Work MP PE–nf PE–f Total–nf Total–f Global P
MODIFIERS INDICATORS
0.45 0.02 0.56 0.16 1.03 0.63 NA
-50 -51 -62 -66 -80, -82 Suprv Status
MODIFIERS INDICATORS
NA NA NA NA NA 09 NON
-50 -51 -62 -66 -80, -82 Suprv Status
CORRECT CODING EDITS
2 NA NPD NPD DOC 09 C
20660❍, ¥<20661 > ✓, ¥<20693 > ✓, ¥<20694 > ✓, ¥<61304 > ✓, ¥<61305 > ✓, ¥<61312 > ✓, ¥<61313 > ✓, ¥<61314 > ✓,
¥<61315
> ✓, ¥<61320
> ✓, ¥<61321
> ✓, ¥<61330
> ✓, ¥<61332
> ✓, ¥<61333
> ✓, ¥<61440
> ✓, ¥<61450
> ✓, ¥<61458
> ✓, CORRECT CODING EDITS
¥<61460
> ✓, ¥<61470 > ✓, ¥<61480
> ✓, ¥<61490 > ✓, ¥<61500 > ✓, ¥<61510 > ✓, ¥<61512 > ✓, ¥<61514
> ✓, ¥<61516
> ✓, 11040✚, 11041✚, 11042✚, 11043✚, 11044✚, 11055✚, 11056✚, 11057✚, 11305■,
¥<61518> ✓, ¥<61519
> ✓, ¥<61520 > ✓, ¥<61521
> ✓, ¥<61522
> ✓, ¥<61524
> ✓, ¥<61526
> ✓, ¥<61530
> ✓, ¥<61563
> ✓, 11306■, 11307■, 11308■, ¥<1> 1420■, ¥<1> 1421■, ¥<1> 1422■, ¥<1> 1423■, ¥<1> 1424■, ¥<1> 1426■,
¥<61564 > ✓, ¥<61735 > ✓, 61795❆, 61862✓, 69990■, ¥<77280 > ❆, ¥<77285 > ❆, ¥<77290 > ❆, ¥<77295 > ❆, 11719✚, 11720✚, 11721✚, 11755❍, 11765❆, 97601❆, G0127✚
¥<77300 > ❆, ¥<77305
> ❆, ¥<77310
> ❆, ¥<77315
> ❆, ¥<77321
> ❆, ¥<77326
> ❆, ¥<77327
> ❆, ¥<77328 > ❆, ¥<77336 > ❆, ¥<77370 > ❆,
77401❆, 77402❆, 77403❆, 77404❆, 77406❆, 77407❆, 77408❆, 77409❆, 77411❆, 77412❆,
77413❆, 77414❆, 77416❆, ¥<77432 > ▼, ¥<99201
> ❆, ¥<99202
> ❆, ¥<99203
> ❆, ¥<99204 > ❆, ¥<99205 > ❆, ¥<99211 > ❆,
¥<99212 > ❆, ¥<99213 > ❆, ¥<99214 > ❆, ¥<99215 > ❆, ¥<99217 > ❆, ¥<99218 > ❆, ¥<99219 > ❆, ¥<99220 > ❆, ¥<99221 > ❆,
G0247 Routine foot care by a physician of a diabetic patient with diabetic
sensory neuropathy resulting in a loss of protective sensation (lops)
¥<99222 > ❆, ¥<99223 > ❆, ¥<99231 > ❆, ¥<99232
> ❆, ¥<99233
> ❆, ¥<99238❆,
> ¥ <9 > 9239❆, ¥<9 > 9271❆, ¥<9 > 9272❆,
to include, the local care of superficial wounds (i.e. superficial to
¥ <9 > 9273❆, ¥<9 > 9274❆, ¥<9 > 9275❆, ¥<9 > 9281❆, ¥<9 > 9282❆, ¥<9 > 9283❆, ¥<9 > 9284❆, ¥<9 > 9285❆, ¥<9 > 9291❆,
¥ <9 > 9292❆, ¥<9 > 9301❆, ¥<9 > 9302❆, ¥<9 > 9303❆, ¥<9 > 9311❆, ¥<9 > 9312❆, ¥<9 > 9313❆, ¥<9 > 9315❆, ¥<9 > 9316❆,
muscle and fascia) and at least the following if present: (1) local care
¥ <9 > 9321❆, ¥<9 > 9322❆, ¥<9 > 9323❆, ¥<9 > 9331❆, ¥<9 > 9332❆, ¥<9 > 9333❆, ¥<9 > 9341❆, ¥<9 > 9342❆, ¥<9 > 9343❆, of superficial wounds, (2) debridement of corns and calluses, and (3)
99347❆, 99348❆, 99349❆, ¥<9> 9354❆, ¥<9> 9355❆, ¥<9> 9356❆, ¥<9> 9357❆, ¥<9> 9360❆ trimming and debridement of nails
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
G0243 Multi-source photon stereotactic radiosurgery, delivery including col-
0.50 0.06 0.52 0.21 1.08 0.77 INC
limator changes and custom plugging, complete course of treatment,
all lesions MODIFIERS INDICATORS
RELATIVE VALUE UNITS -50 -51 -62 -66 -80, -82 Suprv Status
Work MP PE–nf PE–f Total–nf Total–f Global P 2 NA NPD NPD DOC 09 C
0.00 0.00 0.00 0.00 0.00 0.00 NA CORRECT CODING EDITS
MODIFIERS INDICATORS 11040✚, 11041✚, 11042✚, ¥<1> 1043✚, ¥<1> 1044✚, 11055✚, 11056✚, 11057✚, 11305■,
11306■, 11307■, 11308■, ¥<1> 1420■, ¥<1> 1421■, ¥<1> 1422■, ¥<1> 1423■, ¥<1> 1424■, ¥<1> 1426■,
-50 -51 -62 -66 -80, -82 Suprv Status
11719✚, 11720✚, 11721✚, ¥<1> 1755❍, ¥<1> 1765❆, 97601❆, G0127✚
NA NA NA NA NA 09 NON
CORRECT CODING EDITS
20660❍, ¥<2> 0661✓, ¥<2> 0693✓, ¥<2> 0694✓, ¥<6> 1304✓, ¥<6> 1305✓, ¥<6> 1312✓, ¥<6> 1313✓, ¥<6> 1314✓, G0248 Demonstration, at initial use, of home inr monitoring for patient with
¥ <6
> 1315✓, ¥<6
> 1320✓, ¥<6
> 1321✓, ¥<6
> 1330✓, ¥<6
> 1332✓, ¥<6
> 1333✓, ¥<6
> 1440✓, ¥<6
> 1450✓, ¥<6
> 1458✓, mechanical heart valve(s) who meets medicare coverage criteria,
¥ <6
> 1460✓, ¥<6
> 1470✓, ¥<6
> 1480✓, ¥<6
> 1490✓, ¥<6
> 1500✓, ¥<6
> 1510✓, ¥<6
> 1512✓, ¥<6
> 1514✓, ¥<6
> 1516✓, under the direction of a physician; includes: demonstrating use and
¥ <6
> 1518✓, ¥<6
> 1519✓, ¥<6
> 1520✓, ¥<6
> 1521✓, ¥<6
> 1522✓, ¥<6
> 1524✓, ¥<6
> 1526✓, ¥<6
> 1530✓, ¥<6
> 1563✓, care of the inr monitor, obtaining at least one bloo
¥ <6
> 1564✓, ¥<6
> 1735✓, 61795❆, 61862✓, 69990■, ¥<7> 7280❆, ¥<7> 7285❆, ¥<7> 7290❆, ¥<7> 7295❆, RELATIVE VALUE UNITS
¥ <7
> 7300❆, ¥<7
> 7305❆, ¥<7
> 7310❆, ¥<7
> 7315❆, ¥<7
> 7321❆, ¥<7
> 7326❆, ¥<7
> 7327❆, ¥<7
> 7328❆, ¥<7
> 7332❆, ¥<7
> 7333❆,
¥ <7
> 7334❆, ¥<7
> 7336❆, ¥<7
> 7370❆, 77401❆, 77402❆, 77403❆, 77404❆, 77406❆, 77407❆, 77408❆, Work MP PE–nf PE–f Total–nf Total–f Global P
77409❆, 77411❆, 77412❆, 77413❆, 77414❆, 77416❆, ¥<7> 7432▼, ¥<9> 9201❆, ¥<9> 9202❆, ¥<9> 9203❆, 0.00 0.01 6.84 6.84 6.85 6.85 NA
¥ <9
> 9204❆, ¥<9 > 9205❆, ¥<9 > 9211❆, ¥<9 > 9212❆, ¥<9 > 9213❆, ¥<9 > 9214❆, ¥<9 > 9215❆, ¥<9 > 9217❆, ¥<9 > 9218❆,
MODIFIERS INDICATORS
¥ <9> 9219❆, ¥<9 > 9220❆, ¥<9 > 9221❆, ¥<9 > 9222❆, ¥<9 > 9223❆, ¥<9 > 9231❆, ¥<9 > 9232❆, ¥<9 > 9233❆, ¥<9 > 9238❆,
¥ <9 > 9239❆, ¥<9 > 9271❆, ¥<9 > 9272❆, ¥<9 > 9273❆, ¥<9 > 9274❆, ¥<9
> 9275❆, ¥<9 > 9281❆, ¥<9 > 9282❆, ¥<9 > 9283❆, -50 -51 -62 -66 -80, -82 Suprv Status
¥ <9 > 9284❆, ¥<9 > 9285❆, ¥<9 > 9291❆, ¥<9> 9292❆, ¥<9> 9301❆, ¥<9 > 9302❆, ¥<9 > 9303❆, ¥<9 > 9311❆, ¥<9 > 9312❆, 2 NA NPD NPD DOC 01 C
¥ <9 > 9313❆, ¥<9 > 9315❆, ¥<9 > 9316❆, ¥<9 > 9321❆, ¥<9 > 9322❆, ¥<9 > 9323❆, ¥<9 > 9331❆, ¥<9 > 9332❆, ¥<9 > 9333❆,
¥ <9 > 9341❆, ¥<9 > 9342❆, ¥<9 > 9343❆, 99347❆, 99348❆, 99349❆, ¥<9 > 9354❆, ¥<9 > 9355❆, ¥<9 > 9356❆,
CORRECT CODING EDITS
¥ <9 > 9357❆, ¥<9
> 9360❆ NA
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 HCPCS–19
CPT only ©2003 American Medical Association. All Rights Reserved.
HCPCS Level II Supplemental Services
A4644 Supply of low osmolar contrast material (200-299 mgs of iodine) G0001 Routine venipuncture for collection of specimen(s)
RELATIVE VALUE UNITS RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA
MODIFIERS INDICATORS MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status
NA NA NPD NPD NPD 09 NA NA NA NA NA NA 09 NON
CORRECT CODING EDITS CORRECT CODING EDITS
¥<A4645
> ✓, ¥<A4646
> ✓ ¥<36410
> ✓, ¥<82962
> ▼
A4645 Supply of radiopharmaceurical diagnostic imaging agent, I-131 tosi- G0008 Administration of influenza virus vaccine
tumomab, per dose
RELATIVE VALUE UNITS
RELATIVE VALUE UNITS
Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P
0.00 0.00 0.00 0.00 0.00 0.00 NA
0.00 0.00 0.00 0.00 0.00 0.00 NA
MODIFIERS INDICATORS
MODIFIERS INDICATORS
-50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status
NA NA NA NA NA 09 NON
NA NA NPD NPD NPD 09 NA
CORRECT CODING EDITS
CORRECT CODING EDITS
¥<90471
> ✓
¥<A4646
> ✓
C1080 Supply of radiopharmaceutical therapeutic imaging agent, I-131 G0009 Administration of pneumococcal vaccine
tositumomab, per dose RELATIVE VALUE UNITS
RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P
Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA
NA NA NA NA NA NA NA MODIFIERS INDICATORS
MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status
-50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 NON
NA NA NA NA NA NA NA NA CORRECT CODING EDITS
CORRECT CODING EDITS ¥<90471
> ✓
¥<78999
> ■, ¥<79900
> ◆, A4641◆, A9699◆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures
❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure
◆ CPT/HCPCS Procedure Code Definition
©2004 Ingenix, Inc. Jan. 04 HCPCS–3
CPT only ©2003 American Medical Association. All Rights Reserved.
Appendix A: Geographic Practice Cost Indices by Medicare Locality
Note: At the time of printing there was legislation pending that may affect the GPCIs for 2004. If changes are made to the GPCI, you will be notified via
e-mail of the changes and given instructions as to where to locate the revised information on the Ingenix Web site.
Carrier No. Locality No. Locality Name Work Practice expense Malpractice
00510 00 Alabama 0.978 0.870 0.779
00831 01 Alaska 1.064 1.172 1.126
00832 00 Arizona 0.994 0.978 1.090
00520 13 Arkansas 0.953 0.847 0.389
31146 26 Anaheim/Santa Ana, CA 1.037 1.184 0.955
31146 18 Los Angeles, CA 1.056 1.139 0.955
31140 03 Marin/Napa/Solano, CA 1.015 1.248 0.669
31140 07 Oakland/Berkeley, CA 1.041 1.235 0.669
31140 05 San Francisco, CA 1.068 1.458 0.669
31140 06 San Mateo, CA 1.048 1.432 0.663
31140 09 Santa Clara, CA 1.063 1.380 0.622
31146 17 Ventura, CA 1.028 1.125 0.763
31146 99 Rest of California* 1.007 1.034 0.740
31140 99 Rest of California* 1.007 1.034 0.740
00824 01 Colorado 0.985 0.992 0.821
00591 00 Connecticut 1.050 1.156 0.933
00902 01 Delaware 1.019 1.035 0.802
00903 01 DC + MD/VA Suburbs 1.050 1.166 0.917
00590 03 Fort Lauderdale, FL 0.996 1.018 1.790
00590 04 Miami, FL 1.015 1.052 2.399
00590 99 Rest of Florida 0.975 0.946 1.268
00511 01 Atlanta, GA 1.006 1.059 0.951
00511 99 Rest of Georgia 0.970 0.892 0.951
00833 01 Hawaii/Guam 0.997 1.124 0.817
05130 00 Idaho 0.960 0.881 0.478
00952 16 Chicago, IL 1.028 1.092 1.832
00952 12 East St. Louis, IL 0.988 0.924 1.720
00952 15 Suburban Chicago, IL 1.006 1.071 1.648
00952 99 Rest of Illinois 0.964 0.889 1.175
00630 00 Indiana 0.981 0.922 0.459
00826 00 Iowa 0.959 0.876 0.593
00650 00 Kansas* 0.963 0.895 0.738
00740 04 Kansas* 0.963 0.895 0.738
00660 00 Kentucky 0.970 0.866 0.875
00528 01 New Orleans, LA 0.998 0.945 1.240
00528 99 Rest of Louisiana 0.968 0.870 1.066
31142 03 Southern Maine 0.979 0.999 0.652
31142 99 Rest of Maine 0.961 0.910 0.652
00901 01 Baltimore/Surr. Cntys, MD 1.021 1.038 0.931
Carrier No. Locality No. Locality Name Work Practice expense Malpractice
00901 99 Rest of Maryland 0.984 0.972 0.767
31143 01 Metropolitan Boston 1.041 1.239 0.803
31143 99 Rest of Massachusetts 1.010 1.129 0.803
00953 01 Detroit, MI 1.043 1.038 2.741
00953 99 Rest of Michigan 0.997 0.938 1.545
00954 00 Minnesota 0.990 0.974 0.431
00512 00 Mississippi 0.957 0.837 0.750
00740 02 Metropolitan Kansas City, MO 0.988 0.967 0.896
00523 01 Metropolitan St. Louis, MO 0.994 0.938 0.893
00740 99 Rest of Missouri* 0.946 0.825 0.842
00523 99 Rest of Missouri* 0.946 0.825 0.842
00751 01 Montana 0.950 0.876 0.815
00655 00 Nebraska 0.948 0.877 0.442
00834 00 Nevada 1.005 1.039 1.138
31144 40 New Hampshire 0.986 1.030 0.883
00805 01 Northern NJ 1.058 1.193 0.916
00805 99 Rest of New Jersey 1.029 1.110 0.916
00521 05 New Mexico 0.973 0.900 0.898
00803 01 Manhattan, NY 1.094 1.351 1.586
00803 02 Nyc Suburbs/Long I., NY 1.068 1.251 1.869
00803 03 Poughkpsie/N Nyc Suburbs, NY 1.011 1.075 1.221
14330 04 Queens, NY 1.058 1.228 1.791
00801 99 Rest of New York 0.998 0.944 0.720
05535 00 North Carolina 0.970 0.931 0.618
00820 01 North Dakota 0.950 0.880 0.630
00883 00 Ohio 0.988 0.944 0.967
00522 00 Oklahoma 0.968 0.876 0.413
00835 01 Portland, OR 0.996 1.049 0.438
00835 99 Rest of Oregon 0.961 0.933 0.438
00865 01 Metropolitan Philadelphia, PA 1.023 1.092 1.400
00865 99 Rest of Pennsylvania 0.989 0.929 0.790
00973 20 Puerto Rico 0.881 0.712 0.268
00870 01 Rhode Island 1.017 1.065 0.896
00880 01 South Carolina 0.974 0.904 0.336
00820 02 South Dakota 0.935 0.878 0.385
05440 35 Tennessee 0.975 0.900 0.612
00900 31 Austin, TX 0.986 0.996 0.922
00900 20 Beaumont, TX 0.992 0.890 1.318
00900 09 Brazoria, TX 0.992 0.978 1.318
00900 11 Dallas, TX 1.010 1.065 0.996
00900 28 Fort Worth, TX 0.987 0.981 0.996
00900 15 Galveston, TX 0.988 0.969 1.318
00900 18 Houston, TX 1.020 1.007 1.316
00900 99 Rest of Texas 0.966 0.880 1.047
Payment for this service will be made in addition to the global surgery -50 Bilateral Procedure
payment. Add to the second unilateral surgical procedure code when a bilateral
surgical procedure is performed and there is no code for the bilateral
-25 Significant, Separately Identifiable Evaluation and Manage- procedure. Some carriers prefer the addition of the -50 modifier to the
ment Service by the Same Physician on the Same Day of a first CPT code instead of reporting the code twice. Both procedures
Procedure or Other Service must be performed during the same session, and each procedure must
Indicates that a physician performed a separately identifiable evalua- have required a separate incision.
tion and management service beyond the usual preoperative and post-
operative care associated with the procedure performed. The This modifier should not be used with add-on codes, those designated
evaluation and management service may be prompted by the symptom with the “+” symbol in the CPT manual and usually contain the phrase
or condition for which the service and/or procedure was provided. "each additional" in the code narrative.
This modifier should not be used to report an evaluation and manage- Medicare will allow 150 percent of the approved amount for bilateral
ment service that resulted in a decision to perform surgery. procedures.
Separate entries with associated RVUs for codes that may be reported This modifier should not be used with add-on codes, those designated
with a -26 modifier are included in this manual. with the “+” symbol in the CPT manual and usually contain the phrase
“each additional” in the code narrative. In addition the –51 modifier
may not be used with procedures that are usually performed in con-
junction with a primary procedure, but are not designated as add-on
codes. The CPT manual uses the “ “ symbol to identify these codes.
–73 Discontinued Out-Patient Hospital/Ambulatory Surgery Cen- Payment is made based on the billed amount or 16 percent of the glo-
ter (ASC) Procedure Prior to Administration of Anesthesia bal surgical fee, whichever is lower, for procedures approved for assis-
This modifier is used in an outpatient hospital or ambulatory surgery tant surgery.
center setting to indicate that a procedure was terminated prior to the
administration of anesthesia. A physician may elect to discontinue or Medicare will deny payment for assistant at surgery for surgical proce-
terminate a procedure due to extenuating circumstances. The addition dures in which a physician is used as an assistant in less than 5 per-
of the –73 modifier to the intended procedure code indicates that the cent of the cases nationally.
preparations for the procedure were made but discontinued prior to the
administration of anesthesia. -81 Minimum Assistant Surgeon
Use to indicate minimum surgical assistant services.
–74 Discontinued Out-Patient Hospital/Ambulatory Surgery Cen-
ter (ASC) Procedure After Administration of Anesthesia Medicare will deny payment for assistant at surgery for surgical proce-
This modifier is used in an outpatient hospital or ambulatory surgery dures in which a physician is used as an assistant in less than 5 per-
center setting to indicate that a procedure was terminated after the cent of the cases nationally.
administration of anesthesia. A physician may elect to discontinue or
-82 Assistant Surgeon (when qualified resident surgeon not
terminate a procedure due to extenuating circumstances. The addition
available)
of the –73 modifier to the intended procedure code indicates that the
Used most frequently in teaching hospitals where students and interns
preparations for the procedure were made but discontinued after the
are on staff.
administration of anesthesia.
Used for an assistant surgeon when a qualified resident is not avail-
-76 Repeat Procedure by Same Physician
able.
Use when the same physician who performed the original procedure
needs to repeat it. Medicare allows 16 percent of the approved amount for surgical
assists unless the procedure is listed as one which restricts and pre-
The repeat procedure should not be planned.
vents payment for surgical assistants.
Documentation may be required by the carrier.
Medicare will deny payment for assistant at surgery for surgical proce-
-77 Repeat Procedure by Another Physician dures in which a physician is used as an assistant in less than 5 per-
Use when a physician, other than the one who originally performed the cent of the cases nationally.
procedure, repeats it.
-90 Reference (Outside) Laboratory
The repeat procedure should not be planned. Identify laboratory procedures done by a party other than the treating
or reporting physician by using this modifier.
Documentation may be required by the carrier.
-91 Repeat Clinical Diagnostic Laboratory Test
-78 Return to the Operating Room for a Related Procedure in Use to report a repeat lab test on the same day to obtain subsequent
the Postoperative Period results.
Use when an additional, related procedure requires a return to the
operating room during the postoperative period. If a CPT code exists -99 Multiple Modifiers
for the procedure, Medicare will pay the full value of the intraoperative When more than one modifier is needed to identify the services or pro-
portion of a given procedure. cedures provided, add modifier -99 to the procedure code first, fol-
lowed by the other modifiers.
If no CPT code exists, assign the correct unlisted procedure code; and
Medicare will pay 50 percent of the value of the intraoperative service Medicare will recognize up to two additional modifiers assigned to a
originally performed. procedure.
Documentation should be submitted with the claim to describe the clin- -TC Technical Component
ical circumstances. Certain procedures are a combination of a technical and a physician or
professional component. When the technical component is to be
-79 Unrelated Procedure or Service by the Same Physician Dur- reported separately, the service is identified by modifier -TC.
ing the Postoperative Period
Use when an unrelated procedure is performed during the postopera- Separate entries with associated RVUs for codes that may be reported
tive period. with a -TC modifier are included in this manual.
Specific ICD-9-CM codes will substantiate the medical necessity of the CMS now requires CPT and HCPCS Level II modifiers in reporting outpatient
unrelated procedure. services. These modifiers must be reported using the two-digit format.
The following modifiers are approved for hospital outpatient services pro-
Documentation will be required to describe the clinical circumstances.
vided in Ambulatory Surgery Centers (ASC).
A new global period begins for any procedure modified by -79. -25 Significant, Separately Identifiable Evaluation and Management
Service by the Same Physician on the Same Day of a Procedure or
-80 Assistant Surgeon
Other Service
Use to indicate surgical assistant services.