Medicine section guidelines are as follows:

 

• The Medicine section (90281-99607) reports diagnostic and therapeutic services that are generally noninvasive (not entering a body cavity), and invasive (entering a body cavity) procedures in the section, such as cardiac catheterization.

 

• The section begins with Subsection Information and Guidelines applicable to all of the Medicine section codes, such as

• Add-on Codes,

• Separate Procedures,

• Unlisted Service/Procedure,

• Special Report, and

• Supplied Materials.

​

• The various subsections of Medicine contain many specific notes to be applied with a certain group of codes, so be certain to read all notes that pertain to the group of codes with which you are working

​

FORMAT

 

• Many specialized types of tests are located in the Medicine section (e.g., biofeedback, audiologic function tests, electrocardiograms). Codes in this section do not usually include the supplies used in the testing, therapy, or diagnostic treatments unless specifically stated in the code description or guidelines.

​

• You report supplies, including drugs, separately unless otherwise instructed in the code information.

​

• CPT code 99070 is the supplies and materials code used to identify the supplying of drugs, trays, supplies, or materials needed to provide the service or the specific HCPCS supply code, which is usually what the payer will require.

 

INTRODUCTION TO IMMUNIZATIONS

 

• There are two types of immunization—active and passive.

 

• Active immunization is the type given when it is anticipated that the person will be in contact with the disease.

• Active immunization agents can be toxoids or vaccines.

• Toxoids are bacteria that have been made nontoxic and when injected, produce an immune response that builds protection against a disease.

• Vaccines are viruses that are given in small doses and cause an immune response.

 

• Passive immunization does not cause an immune response; rather, the injected material contains a high

level of antibodies against a disease (e.g., rabies, hepatitis B, tetanus), called immune globulins.

The first three subsections in the Medicine section are:

1. Immune Globulins, Serum or Recombinant Products

2. Immunization Administration for Vaccines/Toxoids

3. Vaccines, Toxoids

​

INTRODUCTION TO IMMUNIZATIONS

 

1. Immune Globulins (90281 – 90399)

• The immune globulins are passive immunization agents obtained from pooled human plasma that is

immune to a particular disease.

• The codes in this subsection identify only the immune globulin product and must be reported with the appropriate administration code.

• Codes in the Immune Globulins subsection are categorized according to the:

• Type of immune globulin (rabies, hepatitis B, etc.)

• Method of injection (IM, IV, etc.)

• Type of dose (full dose, mini-dose, etc.)

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INTRODUCTION TO IMMUNIZATIONS

2. Immunization administration for Vaccines/toxoids (90460 – 90474)

• Immunization reporting requires two codes: one to report the administration and one to report the substance administered.

• A variety of administration methods are utilized to deliver the vaccine/toxoid: percutaneous, intradermal, subcutaneous, intramuscular, intranasal, or oral. The administration codes are divided based on the method

of administration and in some codes, the patient age, when administered with physician counseling.

• Report each dose administered—single or combination with the appropriate administration code.

• Codes 90460-90461 report immunization administration for patients through age 18 and for which

counseling has been provided to the patient’s family regarding the vaccine/toxoid. Report 90460 for each vaccine administered. For vaccines with multiple components (combined vaccines), report 90460 in conjunction with 90461 for each additional component in the vaccine.

• Codes 90471-90474 report immunizations at which the physician did NOT provide counseling for patients

of any age, including patients through age 18.

​

2. Immunization administration for Vaccines/toxoids (90460 – 90474) (Contd..) Example:

• You can report multiple administrations by reporting 90471 for the first administration and then reporting 90472 for each administration after the first

• If several vaccines were administered, report the service as

​

3. Vaccines, Toxoids (90476 – 90749)

​

• These codes report vaccine products for immunizations.

• The subsection contains many codes for a single disease (e.g., 90716 Varicella virus vaccine [VAR]) as well as codes for a combination of diseases (e.g., 90700 for diphtheria, tetanus, and acellular pertussis [DTaP]).

• In many of the code descriptions, specific ages or dosages are identified. Example

• Vaccines have adult, pediatric/adolescent, or dosage amounts listed on the label of the vial.

• You must carefully review the description of the vaccine product to determine which disease is specified in the code you are assigning.

• When one code is available to describe multiple products given, the combination code must be assigned. If each vaccine were to be listed separately when a combination vaccine was administered, it would be considered unbundling.

​

NOTE:

➢ When reporting an adult dose of a pneumococcal vaccine (90732) the pneumococcal administration

code is G0009 with a diagnosis code of Z23 (prophylactic vaccination, streptococcus pneumoniae).

If the payer accepts a HCPCS Level II administration code for a vaccine, the CPT administration code is not accepted. These exceptions will be briefed during work conditions.

➢ There are often multiple codes available for variations of the product. For example, there are eight codes with combinations of diphtheria. Read all descriptions carefully before assigning a code.

• There are codes with schedules for a vaccine, such as a three-dose or four-dose schedule.

• For example, 90633 is a two-dose hepatitis A vaccine that is intended to be administered on a two dose schedule. Each time the vaccine is administered, 90633 is reported along with the date of the injection. The term “schedule” refers to the number of doses provided and the timing of the administration.

The doses and timing must be exactly as specified in the code.

​

• The CPT Guidelines state that modifier -51 (multiple procedures) should not be reported for the vaccines/toxoids when performed with administration procedures. Most payers want you to report the administration codes multiple times or use the “times” symbol (×) to indicate the number of injections given.

• If a patient is given a vaccine in the course of an E/M service, the administration and Vaccines/Toxoids

 codes are assigned in addition to the E/M code.

 

NOTE:

If the only service is administration of vaccines and no other service was provided, do not report an E/M service.

​

PSYCHIATRY (90785 – 90899)

​

• The Psychiatry subsection (90785-90899) has a lengthy note under the heading detailing the use of psychiatric codes. If psychiatric treatments are rendered on the same day as E/M services, both the E/M service and the psychiatric treatment are reported with one code from the Psychiatry subsection.

 

For example, if a patient is admitted to the hospital with a drug overdose secondary to depression, and the physician spends 60 minutes in crisis psychotherapy with the patient several hours after he was admitted

to the hospital, services are reported with 90839 (Other Psychotherapy) for the psychiatric treatment and medical evaluation/management on the same day.

 

• If the psychiatric treatment is provided on a different day than the E/M service, a code from the E/M section would be reported in addition to the psychiatry code. You will work closely with third party payers to determine any specific regional instructions for coding psychiatric services.

 

• Partial hospitalization refers to a hospital setting in which the patients are in the hospital during the

day and return to their homes in the evenings and on weekends.

• When a physician admits a patient to a partial hospital facility, the physician is responsible for preparing

all of the admission paperwork that is prepared for admission to an acute care hospital.

• E/M Initial Hospital Care and Subsequent Hospital Care codes (99221-99233) report inpatient stays.

• The psychiatric services the physician provides to the patient are listed separately unless the

E/M service and psychiatric service are provided on the same day.

These same-day services are reported with codes from the Psychiatry subsection.

 

• A psychiatrist is a physician who specializes in psychiatry, the practice of diagnosing and treating mental disorders. A psychologist is not a physician but is a qualified specialist in psychiatry.

 

• Time is the major billing factor in the Psychiatry subsection. Diagnostic and therapeutic time must be documented in the patient’s record to provide accurate billing.

​

• Codes 90791 and 90792, psychiatric diagnostic evaluation and comprehensive psychiatric service, are described as the elicitation (gathering) of a complete medical (including past, family, social) and psychiatric history, establishment of a tentative diagnosis, and an evaluation of the patient’s ability and willingness

to work to solve the mental problem.

​

• An E/M service may be substituted for the initial interview procedure, including consultation codes (99241-99245), provided the required elements of the E/M service are provided.

• Consultation services require, in addition to the history and examination, a written report of the consultation’s opinion or advice. Consultation does not include psychiatric treatment.

​

• Psychotherapy is the therapeutic treatment of a psychological disorder or behavior and is reported with codes 90832-90838. The codes are time-based (30, 45, or 60 minutes) and subdivided based on if the psychotherapy was provided in addition to another primary procedure.

• The medical record must identify the time spent providing the psychotherapy service.

• If the time spent providing the service is not recorded on the medical record, the physician should be queried.

• If no time can be identified, report the service with an E/M code, not a Psychotherapy code.

• The psychotherapy service is provided to the patient only.

 

• Crisis psychotherapy (90839, 90840) provides treatment to a patient experiencing a reaction to a more specific event or situation; for example, a drug overdose, attempted suicide, or an episode of severe depression.

• Crisis psychotherapy focuses on the immediate assessment and treatment of the patient in a crisis and is

not intended to treat chronic psychological conditions.

​

• The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive interactions, and interpretation of unconscious motivation, that were applied to produce the therapeutic change.

• The medical record should document the symptoms, the goals of therapy, and the methods of monitoring the outcome. It should also document why the chosen therapy is the appropriate treatment modality either instead of or in addition to another form of psychiatric treatment.

​

BIOFEEDBACK (90901 – 90913)

​

• Biofeedback is the process of giving a person self-information. The information can be used by patients to gain control over physiologic processes, such as blood pressure, heart rate, or pain.

• Patients are trained to use biofeedback by a professional and then continue the use of the therapy on their own.

• Biofeedback training is often incorporated in individual psychophysiologic therapy.

• When biofeedback is part of the individual psychophysiologic therapy, one code is reported for both the biofeedback training and the individual psychophysiologic therapy (90875-90876).

• Biofeedback codes (90901, 90911) are located in the CPT manual index under the main terms “Training”

and “Biofeedback.”

​

DIALYSIS (90935 – 90999)

• Dialysis is the cleansing of the blood of waste products when it is not possible for the body to perform the cleansing function adequately on its own.

• Dialysis may be temporary, as in the case of a patient who has acute renal failure from which he or she recovers, or permanent, as in the case of a patient with end-stage renal disease (ESRD) who will not recover without a kidney transplant.

• The Dialysis subsection of the Medicine section (90935-90999) is divided into types of dialysis

​

Hemodialysis

• Hemodialysis is the routing of blood and its waste products to the outside of the body where it is filtered.

• After the blood is cleansed, it is returned to the body. Hemodialysis codes (90935 and 90937) are reported for each day the service is provided.

• The codes in the hemodialysis category are based on the number of times the physician evaluates the patient during the procedure.

​

Peritoneal Dialysis

• Peritoneal dialysis (90945, 90947) involves using the peritoneal cavity as a filter.

• Dialysis fluid is introduced into the cavity and left there for several hours so cleansing can take place. The dialysis fluid is then drained from the peritoneal cavity.

• Peritoneal dialysis is reported on the basis of each day the service is provided. Some patients learn how to perform dialysis for themselves.

• Dialysis teaching codes are located under Other Dialysis Procedures.

 

End Stage Renal Disease

• The subheading (End Stage Renal Disease Services) deals with dialysis of an ongoing nature.

• The 90951-90966 codes reflect all services included in treating a patient with ESRD and are listed according to patient age (e.g., younger than 2 years of age, 2-11 years of age) and number of visits (1, 2-3, 4+)

per month.

• Dialysis services are reported as a monthly fee. For those cases in which a patient may be, for example, visiting the area and will not require a full month of dialysis, daily fees may be reported using codes 90967-90970 in the ESRD category.

• Few third-party payers allow E/M codes to be reported in addition to dialysis service codes. Most payers consider the dialysis codes to be bundled to include all the treatment necessary for a patient with renal disease, including the E/M services.

• To report a separate E/M service, the condition would have to be unrelated to the renal condition, and modifier -25 must be added to the E/M code.

• The diagnosis code reported would also indicate that the E/M service was unrelated to the ESRD service.

• Dialysis is usually performed in an outpatient setting at a hospital or other outpatient dialysis facility.

• The physician services are reported based on the type of dialysis the patient is receiving, the complexity of the service, and the number of visits the physician provides to the patient.

​

NOTE:

​

If a patient is admitted to the hospital and requires management of his/her dialysis while in the hospital, the physician can report those services but then cannot report the monthly service for the time period the patient is in the hospital. The monthly service for services provided when the patient was not in the hospital is then reported with 90967-90970, which are per day codes.

 

• When a patient does not receive a full month of dialysis in the outpatient setting because of a kidney transplant, relocation, or death, report the number of days the patient had dialysis.

• For example, a 50- year-old patient receives peritoneal dialysis from March 1 through 10. On March 11, the patient receives a kidney transplant. The 10 days of service are reported with 90970 × 10.

• “Dialysis” is the main term to be referenced in the CPT manual index.

​

GASTROENTEROLOGY (91010 – 91299)

• The Gastroenterology subsection (91010-91299) contains many types of tests and treatments that are performed on the esophagus, stomach, and intestine.

• Several intubation codes are listed in the Gastroenterology subsection.

• You must carefully review the code descriptions to determine which services are bundled into the code.

​

OPHTHALMOLOGY (92002 – 92499)

• The notes located at the beginning of the Ophthalmology subsection (92002-92499) describe the services included in the various types of ophthalmologic services.

• Ophthalmology is a very specialized field and ophthalmologists treat patients for a variety of diseases and injuries.

• There are extensive subsection notes that are required reading before you code in the subsection.

• The notes explain the levels of service and present excellent examples to clarify the assignment of the

codes.

​

OPHTHALMOLOGY (92002 – 92499) 

​

• The general ophthalmologic services (e.g., routine yearly eye examinations) are located in the subheading General Ophthalmological Services.

• The codes in this subsection are based on whether the patient is a new or an established patient and on

the complexity of service provided.

• There are two levels of service (intermediate and comprehensive). Of special note are the definitions of

new and established patients.

• The subheading Special Ophthalmological Services contains bilateral codes.

• Each service in this subheading is performed on both eyes, and the codes do not require a modifier to indicate that two eyes were examined or tested.

• In fact, should you need to report only one eye from these codes, you add modifier -52 to indicate a

reduced service.

• Special Ophthalmological Service codes are those services that are not normally performed in a

general eye examination. Services in this group are performed for medically indicated reasons.

​

• For example, an ophthalmological examination under general anesthesia with manipulation of the globe

of the eye to determine the range of motion (92018).

​

• The decision to assign an ophthalmology code or an E/M code is determined by the service provided. The ophthalmology codes have specific notes prior to code 92002 that serve as a guideline for an intermediate

or comprehensive service. Documentation should include the chief complaint, history, and general medical examination.

 

Testing may include the following types of measures:

• External examination, ophthalmoscopy, and biomicroscopy

• Visual acuity (clarity of vision)

• Basic sensorimotor examination (tests sensory and motor coordination)

• Confrontation visual fields (peripheral vision)

• Tonometry (intraocular pressure)

• Evaluation of complete visual system

• May include mydriasis (excess dilation of pupil) for ophthalmoscopy

• Initiation of diagnosis and treatment programs

​

• An intermediate ophthalmological service (92002, 92012) describes an evaluation of a new or existing condition complicated with a new diagnosis or management problem not necessarily relating to the primary diagnosis.

• A comprehensive service (92004, 92014) describes a general evaluation of the complete visual system. The comprehensive services constitute a single service that may be performed at different sessions but is

reported only once.

• The initiation of a diagnostic and treatment program includes the prescription of medication and

arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory

procedures, and radiological services.

​

Special Otorhinolaryngologic services (92015 – 92287)

• The services in this subsection are special tests or studies of the ears, nose, and larynx.

• Audiology (hearing) testing is also located in the Special Otorhinolaryngologic Services subsection. An audiology test may be performed by a physician, or an audiologist trained in this area.

• Otorhinolaryngologic diagnostic and treatment services are usually reported using codes from the Surgery section.

• Special services are reported using the otorhinolaryngologic codes from the Medicine section.

​

For example, a nasopharyngoscopy with endoscopy provided during an office visit would be reported with 92511 (nasopharyngoscopy with endoscopy, the procedure) and a code from the E/M section for the office visit (with modifier -25)

 

CARDIOVASCULAR CODING IN THE MEDICINE SECTION

• Services in the Cardiovascular subsection of the Medicine section (92920-93799) can be either invasive/noninvasive or diagnostic/therapeutic.

• The invasive treatments are not a matter of cutting open the body so the surgeon can view it,

as was the case in the Cardiovascular subsection of the Surgery section but are invasive in that there is an incision into or a puncture of the skin.

• Review the subheadings in the Cardiovascular subsection in the Medicine section of the CPT manual.

 

Therapeutic services and Procedures

• It is within the Therapeutic Services and Procedures subheading (92920-92998) that you locate many commonly assigned cardiovascular codes, such as cardioversion, infusions, thrombolysis, placement of catheters and stents, atherectomy, and angioplasty.

• Many of these services used to be performed as open operative procedures, but with the advent of

modern techniques, many are now performed by means of percutaneous access.

• Division of the codes is based on method (balloon, blade), location (aorta or mitral valve), and number (single or multiple vessels).

​

• Thrombolysis, as described in 92975, is a percutaneous procedure in which the physician inserts a catheter into a coronary vessel and injects contrast material into the vessel to further enhance the visualization of a blood clot. The clot is then destroyed by a drug that the physician injects through the catheter.

The Medicine section code 92975 represents the total procedure when the thrombolysis is performed in a coronary vessel. If vessels other than the coronary vessels are treated, a code from the Surgery section, Cardiovascular subsection, would be assigned to report a transcatheter infusion for thrombolysis (see 37211-37214)

 

 Endoluminal imaging of the coronary vessels can be reported using the two codes 92978 and 92979, depending on the number of vessels being diagnosed.

• A needle is inserted percutaneously into the vessel and a guidewire introduced, followed by an ultrasound probe. The probe allows a two-dimensional image of the inside of the vessel to be viewed on the ultrasound monitor.

• The physician can assess the vessel before and after treatment. The physician may reposition the probe to assess additional vessels, and 92979 is reported to indicate this subsequent placement.

• Note that both 92978 and 92979 are add-on codes intended to be reported only in conjunction with the primary procedure. For example, endoluminal imaging with coronary stent placement would be reported as 92928 (placement of stent) and 92978 (endoluminal imaging).

​

• Intracoronary stent placement (92928, 92929) is performed using a catheter to reinforce a coronary vessel that has collapsed or is blocked. The placement of the stent is usually accomplished with radiographic guidance which is included. The codes are divided on the basis of whether more than one coronary vessel

was cleared of obstruction and had a stent placed within it.

• Percutaneous transluminal coronary angioplasty (PTCA) is described in codes 92920 and 92921. The codes are divided on the basis of whether a single vessel or additional vessels are treated during the procedure. Add-on code 92921 (PTCA for each additional vessel) is of interest because it can be assigned not only with 92920, but also with other codes in the category.

 

Valvuloplasty can also be performed by inserting a catheter percutaneously.

• The procedure opens a blocked valve by using a balloon, which is inflated to clear the blockage.

• Codes 92986-92990 are divided based on the valve being repaired.

• The balloon technique is also used to treat congenital heart defects such as vessels that are too narrow. A blade can also be deployed inside the coronary vessels.

• A special catheter that has a retractable blade is guided into the vessel and the surgeon manipulates the blade to enlarge the area, using ultrasound or fluoroscopic guidance.

 

Cardiography and Cardiovascular Monitoring Services

​

• This category (93000-93278) of the Cardiovascular System subsection contains frequently assigned codes, such as those for electrocardiograms and heart monitoring, which are certain to be used in most office practices, even if the practice does not include a cardiologist.

 

• The Cardiography subheading codes report electrocardiographic procedures such as stress tests.

Stress tests are performed to assess the adequacy of the amount of oxygen getting to the heart muscle

(at rest and during exercise) and thus indicate the presence or absence of heart disease.

 

• The top number on a blood pressure reading is systole (heart muscle is contracting); the bottom number is diastole (heart muscle is relaxing). The heart muscle is fed by three coronary arteries and their branches. If these arteries are clear, the amount of blood going to the muscle is adequate during rest and exercise. The heart muscle is fed only during diastole. Normal blood pressure is about 120/80 mm Hg, and the normal

heart rate is about 60-100 beats per minute. During low blood pressure, little blood and oxygen get to the heart.

​

 

CARDIOVASCULAR CODING IN THE MEDICINE SECTION

Cardiography and Cardiovascular Monitoring Services

​

• As the heart beats faster, such as during exercise, the heart rate increases and diastolic pressure time decreases, meaning that there is less time to supply blood to the heart muscle.

As the heart beats faster, more oxygen is required. With narrowing of coronary arteries and branches,

too little blood may circulate to the heart muscle, supplying even less oxygen than during rest.

Chest pain may result as an indication that heart muscle tissue is dying.

Indications of heart disease during a stress test are chest pain and a depressed or elevated ST

wave segment on the ECG.

​

• A cardiovascular stress test is used to evaluate and diagnose chest pain, to screen for heart disease, to evaluate irregular heart rhythms, and to investigate many other cardiovascular abnormalities.

• The patient is placed on a treadmill, or a stationary bicycle and ECG leads are attached. The patient then exercises until he or she reaches maximal (220 minus age) or submaximal (85% of maximal) heart rate.

During certain intervals, recordings are taken by means of ECG, heart rate, and blood pressure of the

patient.

 

• The codes for stress tests (93015-93018) are divided on the basis of the components provided.

• Code 93015 reports the global outpatient service, and 93016-93018 reports components (parts) of the service.

• The ECG is bundled into the stress test, so do not unbundle and report an ECG or any reading separately. Medication can be administered to mimic the stressing of the heart and is used when factors are

present that limit a patient’s ability to exercise, such as arthritis, morbid obesity, or stroke.

• Stress test codes are used for both stress-induced (exercise) and pharmacologically induced (drug) studies. Medications and radiology services may be reported separately.

​

Implantable and Wearable cardiac device evaluations

​

• Cardiovascular monitoring is a diagnostic service that may be performed in person or using technology to access cardiovascular data, and these services are reported with codes in the 93279-93299 range. Codes 93279-93285 are reported per procedure, such as a single, dual, or multiple lead pacemaker or implantable defibrillator programming device evaluation. There are extensive notes before the subheading that are must reading before you begin to assign these codes.

• Codes 93286 and 93287 report periprocedural (shortly before or shortly after) evaluation of a device based on if the device is a pacemaker or an implantable defibrillator. The codes may be reported once before and once after surgery because they are the testing of the device to ensure it functions correctly.

• Codes in the 93288-93292 range are reported per procedure and are in-person evaluations of a pacemaker or an implantable defibrillator system based on the type of device and the type of analysis performed.

• Evaluation of a pacemaker by means of a telephone is reported once in a 90-day period with 93293. The service includes the written report of the data analysis. Face-to-face evaluations of the device are referred

to as interrogation device evaluations and are reported with 93294- 93299. These codes are divided based on the type of device (pacemaker or implantable defibrillator) and the time period.

 

For example, 93297 reports remote interrogation evaluation(s) up to 30 days and 93294 reports remote interrogation evaluation(s) up to 90 days.

​

Echocardiography

​

• Echocardiography (93303-93355) is a noninvasive diagnostic method that uses ultrasonographic images to detect the presence of heart disease or valvular disease. A sliced image is used to detail the various walls of the heart. A transducer is placed on the outside of the chest wall, and it sends sound waves through the chest .

• As the sound reflects from each organ wall, dots are recorded, indicating the point of reflection.

• When the heart is in systole, it is contracting, and the dots on the recording appear farther apart.

When the heart is in diastole, it is relaxing, and the dots on the recording appear closer together.

 

• Bundled into the complete echocardiography procedures (93303- 93355) are the obtaining of the

signal from the heart and great arteries by means of two-dimensional imaging and/or Doppler ultrasound,

the interpretation, and the report. Modifiers -26, professional service only, and -TC, technical component,

may be applied to these codes if only one component is provided.

• The codes are divided based on whether it was a complete echocardiogram, or a follow-up/limited study, the type of echocardiogram, and the approach used.

​

Cardiac Catheterization

​

• Catheterization (93451-93598) is an invasive diagnostic medical procedure in which the physician percutaneously inserts a catheter and manipulates the catheter into coronary vessels and/or the heart.

• A percutaneous method of catheterization called the Seldinger technique, after the inventor of the

method.

• This catheterization is at the right subclavian artery.

• Following insertion of the fine-gauge needle, a guidewire and then a catheter are inserted. The cardiac catheter measures pressure, oxygen, and blood gases, takes blood samples, and measures the output of the heart.

​

• A cardiac catheterization is a study of both the circulation and the movement of the blood of the heart; the physician may inject a dye into the vessel or heart and observe the movement of the dye by means of angiography. When injection of contrast material is used to improve visualization, the injection is bundled

into the Cardiac Catheterization code.

• Component coding requires you to examine services that were provided to the patient, identify each component, or part, of that service, identify who performed each component, and code each service provided. The three cardiac catheterization components of catheter placement, injection, and imaging are reported in one combination code.

​

For example, 93456 includes catheterization, injection, and imaging. However, some cardiac catheterization codes require multiple codes.

 

For example, 93531 reports catheterization for congenital cardiac anomalies, but the injection/imaging code (93563/93564) must be added to completely describe the service provided. Only careful reading of the code descriptions in the cardiac catheterization codes will result in correct coding.

​

• If the private physician (such as the clinic physician) performs the catheterization procedure in the catheterization laboratory at the hospital, you would add modifier -26 to the cardiac catheterization code.

The hospital would submit charges for the technical component of the procedure.

• Access for cardiac catheterization can be made in several locations, depending on the patient’s condition and the physician’s preference— for example, the right femoral artery (access site).

• Cardiac catheterization can indicate valve disorders, abnormal flow of blood, and a variety of cardiac

output abnormalities. Often, a cardiac catheterization leads to a more definite treatment, such as a valvuloplasty, stent placement, angioplasty, or bypass.

• Bundled into the cardiac catheterization codes are the introduction, positioning, and repositioning of the catheter(s); the recording of pressures inside the heart or vessels; the taking of blood samples; rest/exercise studies; final evaluation; and final report.

​

• Injection codes 93563 and 93564 are only reported with cardiac catheterization codes 93530-93533,

which are codes for cardiac catheterization for congenital abnormalities. These two injection codes are

divided based on if the procedure was for “coronary angiography” (93563) or “aortocoronary venous or arterial bypass graft(s)” (93564). Both codes also include the imaging service. The codes are listed in

addition to the primary cardiac catheter procedure.

 

• There are also other injection codes (93565-93568) and these codes also include the imaging service.

These injection codes are assigned with cardiac catheterization codes when additional injections are performed. For example, 93456 reports right heart catheterization with injections/imaging/angiography.

If the physician also performed an aortography, the code reported for this additional service would be 93567.

 

• There are several codes (93561-93572) in the category. These codes are for the indicator dilution studies, which are already bundled into the cardiac catheterization codes and are to be reported only when the complete cardiac catheterization procedure was not performed. For example, if only the dye or thermal dilution study was performed, without a cardiac catheterization, an indicator dilution study code would be assigned to report the service.

​

Intracoronary Brachytherapy

​

• Intracoronary brachytherapy is the use of radioactive substances as a therapy for in-stent restenosis of a coronary vessel.

 

• For example, a patient has a coronary artery stent placed to open a vessel that is blocked with plaque (stenosis). The stent reopens the vessel so blood can once again flow without obstruction. However, the stent can also become occluded with plaque and when this happens, the physician may use intracoronary brachytherapy in which a radioactive strip of material is inserted by means of a catheter into the area of blockage, where it is left for up to 45 minutes and then removed.

 

• The procedure would usually be performed by an interventional cardiologist and a radiation oncologist.

The interventional cardiologist would place the radioactive-element guidewire and report that service with 92974 (add-on code), which is the catheter placement code. The radiation oncologist would then place the radioactive elements and report the services with codes 77770-77772.

​

Intracardiac Electrophysiologic procedures/studies

 

• Surgical electrophysiologic procedures (33250-33261) are those that repair the electrical system of the heart using invasive surgical procedures. In the Medicine section, the Intracardiac Electrophysiological Procedures/Studies category (93600-93662) contains codes that describe services that diagnose and treat the electrical system of the heart using less invasive procedures. Although the Medicine section procedures are invasive, they are percutaneous procedures, not open procedures.

 

• The electrical conduction system of the heart, which begins with the sinoatrial node (SA), known as the heart’s pacemaker.

• The sinoatrial node sends impulses to the atrioventricular (AV) node, which in turn passes the impulses to

the bundle of His, and finally on to the Purkinje fibers to stimulate the muscle tissues of the ventricles of the heart to contract. Lesions or diseases involving these structures along the electrical conduction pathway underlie many of the disturbances of cardiac rhythm.

 

• To diagnose the origin of an electrophysiologic abnormality, the physician takes recordings at various sites along the pathway. The physician may also stimulate the heart to induce arrhythmia by means of a catheter attached to a pacing device that sends electrical impulses to various sites within the heart.

​

 

• Pacing is the regulation of the heart rate. A cardiac pacemaker is a permanent pacer; but the pacing

referred to in the EP codes is a temporary pacing done in an attempt to stabilize the beating of the heart.

 

• Recording is a record of the electrical activity of the heart taken by means of an ECG. • Recording services are reported with codes in the range of 93600-93603, and pacing services are reported with codes 93610 and 93612.

• Combination codes that indicate both recording and pacing begin with 93619. These codes are not used as much as they used to be when EP was a new technique and readings were commonly taken at just one site.

• Today, more complex EP studies are usually done, including multiple pacing and recordings in

combinations based on established protocols using three or more catheters.

• These complex services are reported with codes in the 93619-93622 range. Carefully read the notes in parentheses following several of the combination codes, as the notes indicate when the use of the combination code is appropriate and even indicate the codes that are bundled into the one combination code.

Most of the EP codes have many items bundled into them, so read the description of each code

completely so as to avoid unbundling the services

​

• Bundle of His recording is a reading taken inside the heart (intracardiac) at the tip of the bundle of His.

• The bundle of His is also known as the atrioventricular bundle or AV bundle and is the bundle of cardiac muscle fibers that conducts electrical impulses that regulate heartbeats.

• The physician percutaneously inserts into a vessel a special catheter that can sense electrical impulses. The catheter is advanced to the right heart.

• The femoral vein is the usual site of entry, and fluoroscopic guidance is usually used for placement of the catheter into the heart.

 

• Codes 93602 and 93603 describe a single recording based on the location—intra-arterial or right ventricle. Codes 93610 and 93612 describe single intra-arterial or intraventricular pacing in an atrial or a ventricular location.

 

• Code 93631 reports pacing and mapping done during an open surgical procedure in which the surgeon opens the chest and exposes the heart. The EP physician performs the mapping (locating the origin of the arrhythmia and defining the pathway), and the surgeon then destroys the source of the arrhythmia. When reporting the services of both physicians for this procedure, use 93631 to report the mapping service and a surgery code from the range 33250-33261 to report the arrhythmia ablation. Make a notation next to the mapping code 93631 to report any surgical ablation (33250-33261) to remind yourself to code both

procedures if required. If the mapping is not done intraoperatively (during surgery), report the service with 93609 or 93613

​

​

• Ablation can also be performed by using a catheter with a tip that emits electric current. When the tip is placed on tissue and activated, the tissue is destroyed. Sometimes physicians destroy certain sites along the conduction pathway as a treatment for slow (bradycardia) or fast (tachycardia) heart rhythms.

• Ablation procedures are reported according to whether they were at the AV node (93650), a

separate (93655) or an additional treatment (93657).

• There are two ways ablation can be performed. The first way does not require open heart surgery.

An area of the patient’s upper thigh is numbed, but the patient is awake. Then the physician inserts a thin

tube through a blood vessel (usually the femoral vein) and all the way up to the heart.

At the tip of the tube is a small wire that can deliver radiofrequency energy to burn away the abnormal

areas of the heart. Then the heart can beat normally again.

• The second way ablation can be performed is by means of open-heart surgery. In the Maze procedure, the surgeon makes small cuts in the heart to direct healthy electrical rhythms. In cryoablation, a very cold substance is used to freeze the cells that are creating problems. In endocardial resection, the surgeon

removes a section of the thin layer of the heart where the abnormal rhythms originate.

 

Peripheral Arterial Disease Rehabilitation

 

• Peripheral arterial disease (PAD) rehabilitation sessions (93668) last 45 to 60 minutes; these are rehabilitative physical exercises done either on a motorized treadmill or on a track to build the patient’s cardiovascular endurance.

• An exercise physiologist or nurse supervises the sessions. If a session produces symptoms of angina or

other negative symptoms, the physician reviews the information and may determine to re-evaluate the

patient. The physician services are not included in the PAD codes, rather the physician services are reported with an additional Evaluation and Management (E/M) code.

 

Noninvasive Physiologic Studies and Procedures

 

• If a patient has a pacemaker or defibrillator in place, periodic monitoring must occur to ensure that the device is functioning properly. Codes from the Noninvasive Physiologic Studies and Procedures

(93701-93790) category and the Implantable and Wearable Cardiac Device Evaluations (93279-93299)

category reflect these services.

• Codes are assigned according to the type of pacemaker (single- or dual-chamber) or implantable defibrillator and whether reprogramming of an existing pacemaker or defibrillator was done

​

• Ambulatory blood pressure monitoring (93784-93790) is an outpatient procedure that is conducted over a 24-hour period by means of a portable device worn by the patient. There is a code for the total procedure— including recording, analysis, and interpretation/report—and there are codes for each of the individual components—recording only, analysis only, and interpretation/report only.

 

Other Procedures

• The Other Procedures codes (93797-93799) report physician services that are provided for cardiac rehabilitation of outpatients, either with or without electrocardiographic monitoring

​

PULMONARY (94002 – 94799)

• Codes in the Pulmonary subsection (94002-94799) report therapies, such as nebulizer treatments, incentive spirometry, and diagnostic tests, such as pulmonary function tests.

• A nebulizer is a device that produces a spray, which is inhaled.

• Pulmonary function tests monitor the function of the pulmonary system and examine the lung capacity of patients with, for example, emphysema.

• In most cases, several pulmonary function tests are performed together. The data are then compiled, and a diagnosis is made.

• Several indicators must be present from a variety of tests, and those tests must be performed many times and produce the same result each time for the results to be considered conclusive. In most cases, each type of test is reported separately, unless it is specifically stated otherwise in the code description.

 

NOTE:

Add -26 to the code when reporting only the physician interpretation of the test if the physician does not own the testing equipment.

 

ALLERGY AND CLINICAL IMMUNOLOGY (95004 – 95199)

 

• Read the notes that appear at the beginning of the Allergy and Clinical Immunology subsection (95004- 95199). The subsection is divided into three parts.

​

• The first is Allergy Testing, which describes allergy testing by various methods (percutaneous,

intracutaneous, inhalation) and the type of tests (allergenic extracts, venoms, biologicals, food).

• The number of tests must always be specified for reporting purposes because for most of these codes, payment is made per test.

• Allergy testing consists of the performance, evaluation, and interpretation of allergens.

• The testing should be based on a complete history and physical examination of the patient and correlated with signs and symptoms related to the presence of possible allergy diagnoses during allergy testing (95004-95071).

​

• The second subheading is Ingestion Challenge Testing (95076, 95079). Code 95076 reports the initial 120 minutes of testing time and 95079 reports each additional 60 minutes.

• The third subheading is Allergen Immunotherapy and the codes specify three types of services: Injection only, prescription and injection, provision of antigen only.

• All the codes in Allergen Immunotherapy have specific notes that you must read to know whether the code is for injection, prescription and injection, or antigen only

• Allergen Immunotherapy is the repeated administration of allergens to patients for the purpose of providing protection against the allergic symptoms and reactions associated with exposure to these allergens.

• Immunotherapy (hyposensitization) may extend over a period of months, usually on an increasing dosage scale. This is followed by a build-up of tolerance to the antigen (as evidenced by the higher doses that can be administered) and a decline in the symptoms and medication requirements.

• Indications for allergen immunotherapy are determined by diagnostic testing appropriate to the individual needs of each patient and his/her clinical history of allergic diseases.

 

ENDOCRINOLOGY (95249 – 95251)

 

• This subsection contains only codes used to report glucose monitoring (95250, 95251). • Continuous glucose monitoring is a procedure in which a probe is inserted subcutaneously and attached to a monitor that is worn by the patient.

• The monitor records the glucose level for a 72-hour period at which time the probe is removed and the data are downloaded from the monitor.

• The patient records his or her insulin administration, meals, exercise, and any hypoglycemic events during the monitoring period, in addition to performing the usual finger stick glucose four times a day during the 3-day period.

• The service includes the initial hookup, calibration of the monitor, patient training, removal of sensor, printout of recording, and interpretation and report (95251)

 

NEUROLOGY AND NEUROMUSCULAR PROCEDURES (95700 – 96020)

 

• There are codes in the Neurology and Neuromuscular Procedures (95782-96020) subsection for sleep testing, muscle testing (electromyography), range of motion measurements , cerebral seizure monitoring, and a variety of neurologic function tests.

• The codes in this subsection are usually reported by physicians who specialize in neurology (neurologists). Sleep studies in newborns are performed by pediatric pulmonologists.

• A neurologist usually is a consultant to a physician who is seeking the advice and input of another physician concerning a patient with suspected neurologic problems.

• One of the specialized tests conducted in the neurology specialty area is sleep studies (95800-95811).

• Sleep studies are the monitoring of a patient’s sleep for 6 or more hours. The studies include the tracing (technical component) and the physician’s review, interpretation, and report (professional component). If a physician performs only the professional component, modifier -26 is reported.

• Sleep studies diagnose various sleep disorders and measure a patient’s response to therapy.

​

• An electroencephalogram (EEG) is a procedure that records changes in brain waves. Polysomnography is the measurement of the brain waves during sleep but with the added feature of recording the various stages of sleep (i.e., excited, relaxed, drowsy, asleep, or deep sleep). During each of these stages, the rate and amplitude (height) of the brain waves are measured and compared with normal ranges.

 

• Nerve conduction tests (95905-95913) are usually performed in conjunction with conventional motor nerve conduction studies of the same nerve and may include F-wave studies.

• F-wave studies assess motor nerve function along the entire extent of that nerve. An impulse generated at the stimulating electrode travels up the motor nerves to the motor neuron cell bodies in the spinal cord.

• The impulse then travels down the same motor nerves to the neuromuscular junction, and then to the muscle.

• Codes 95907-95913 are to be reported for each nerve tested, regardless of the number of stimulation sites along the sensory or motor nerve being tested.

​

• For a given patient, multiple motor or sensory nerve conduction codes may be assigned if multiple motor or sensory nerves are tested. Appendix J of the CPT manual lists the specific nerves tested for codes 95905-95913.

• Codes 95905-95913 report both sensory and motor nerve conduction studies with or without F-wave study and includes the interpretation and report.

• Code 95905 reports motor and/or sensory nerve conduction using preconfigured electrodes that have been customized to specific anatomic sites

• Parameters are what are being measured during a sleep test. For example, parameters include the measurement of snoring or blood pressure.

• The number of parameters measured is listed in the code description.

• The patient’s medical record will contain the parameters, or measurements, recorded during the test.

• To report sleep tests accurately, you must know the parameters and stages of testing. Additionally, many codes include a time component; so, it is important to have the duration of the test stated in the medical record.

• Electromyographic (EMG) studies use needles and electric current to stimulate nerves and record the results. Assessments of dysphasia, developmental testing, neurobehavior status, and neuropsychological test codes are also located in this subsection

 

CENTRAL NERVOUS SYSTEM ASSESSMENTS/TESTS (96105 – 96146)

 

• The Central Nervous System Assessments/Tests codes (96105 -96127) identify psychological testing, speech/language (aphasia) assessment, developmental progress assessments, and thinking/reasoning status examination (neurobehavioral).

• Except for the basic developmental testing, the codes are defined on a per-hour basis. The results of all the tests are to be developed into a report that is included in the patient record.

​

HEALTH AND BEHAVIOR ASSESSMENT AND INTERVENTION (96156 – 96161, 96164 – 96171)

 

• The codes in this subsection (96150-96155) do not report preventive medicine services, nor do they report psychiatric treatments. Instead, these codes report assessment and/or intervention for behavioral, emotional, social, psychological, or knowledge factors that are affecting the patient’s health.

• Examples of assessments are clinical interview, behavior observation, and questionnaires. Examples of interventions are individual, group, or family sessions.

• All services are based on 15-minute increments. These services are not performed by a physician.

• If these services are performed by a physician, they are reported with E/M codes.

​

HYDRATION (96360 – 96361)

 

• Codes 96360 and 96361 report hydration services.

• Bundled into the hydration services are local anesthesia, placing the intravenous line, accessing an indwelling access line/catheter/port, flushing at the end of the infusion, and all standard supplies.

• Codes 96360 and 96361 report intravenous hydration infusions that include the prepackaged fluid and electrolytes. If other than a prepackaged substance is used, that substance would be reported separately.

• Saline is not reported separately unless given alone for hydration. If the drugs are mixed into the saline, then only the drug is reported, and the saline is bundled into the cost of the drug and not reported separately.

• Included in these hydration codes are the physician supervision and oversight of the staff providing the service.

• Code 96360 reports 31 minutes to 1 hour of intravenous infusion hydration service and 96361, the add-on code, reports each additional hour. You can only report 96361 if the service is at least 31 minutes over the 1 hour that was reported with 96360. Time under 31 minutes is not reported.

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THERAUPEUTIC, PROPHYLACTIC, AND DIAGNOSTIC INJECTIONS AND INFUSIONS (96365 – 96379)

 

• Codes 96365-96379 report the administration of therapeutic, prophylactic, or diagnostic intravenous infusion or injection.

• Intravenous infusions are reported with 96365-96368 and are divided based on the time and type of infusion.

• The initial infusion is reported with 96365 (up to 1 hour), and each additional hour (over 30 minutes) is reported with 96366.

• Sometimes one infusion is provided followed by another infusion with a different medication (sequential infusions), in which case the initial infusion is listed first and the sequential infusion (add-on code 96367) is listed second.

• There are times when more than one infusion is provided at the same time, which is a concurrent infusion.

 

• A concurrent infusion is when there is one site and two lines infusing at the same time. Report the initial infusion first and then the concurrent infusion (96368).

• Subcutaneous infusions are reported with codes 96369-96371. Initial set up and first hour are reported with 96369. Each additional hour is reported with 96370. Additional set up for a new infusion site is reported with 96371.

​

THERAUPEUTIC, PROPHYLACTIC, AND DIAGNOSTIC INJECTIONS AND INFUSIONS (96365 – 96379) (Contd..)

 

• To report therapeutic, prophylactic, and diagnostic injections (96372-96376), the physician must be present. Note that add-on code 96376 can only be reported when the service is provided in a facility.

• Therapeutic, prophylactic, and diagnostic injections are divided based on the method used for the administration

• Subcutaneous and intramuscular injections are reported with 96372 in addition to a code to report the substance injected. For example, if the injection was a subcutaneous human rabies immune globulin, report 90375 for the substance and 96372 for the administration.

• The administration codes for vaccines/toxoids are reported with 90460/90461 or 90471-90474. Code 96372 is not used to report chemotherapy administration (see 96401-96549).

• Injections for allergen immunotherapy are reported with 95115/95117, not with therapeutic, prophylactic, or diagnostic injection codes.

• Intra-arterial (96373) and intravenous push (96374/96375/96376) are reported with therapeutic, prophylactic, and diagnostic injection codes.

​

CHEMOTHRAPHY ADMINISTRATION (96401 – 96549)

 

• Chemotherapy codes 96401-96549 report a variety of chemotherapy services.

• The Injection and Intravenous Infusion Chemotherapy codes (96401-96417) report subcutaneous/intramuscular, intralesional, and intravenous chemotherapy.

• Intra-Arterial Chemotherapy codes (96420-96425) report various forms of chemotherapy administered via the arteries.

• Other Injection and Infusion Services codes (96440-96549) report other types of chemotherapy, such as pleural (96440), peritoneal via an indwelling port (96446), and central nervous system (96450), in addition to refilling/maintenance of portable or implantable pumps or reservoirs (96521, 96522).

• In addition to these CPT codes, Level II HCPCS “J” codes report the substances injected or infused.

• Included (not reported separately) with chemotherapy infusion or injection codes 96401-96549 are the following:

• Use of local anesthesia

• IV start

• Access to indwelling intravenous, subcutaneous catheter, or port

• Flush at the conclusion of infusion

• Standard tubing, syringes, and supplies

• Preparation of the chemotherapy agent(s)

​

CHEMOTHRAPHY ADMINISTRATION (96401 – 96549)

​

• If other services are provided, they may be reported separately.

• The initial intravenous infusion (the treatment) is reported with 96365 and each additional hour of infusion, up to 8 hours, is reported with 96366.

• If a sequential (one after another) intravenous therapy is provided, the service is reported with 96367. When a concurrent (at the same time as another) intravenous therapy is provided the service is reported with 96368.

• A concurrent infusion is one in which multiple infusions are provided through the same intravenous line.

• A concurrent infusion can be billed only once per patient encounter.

• If more than one substance is placed in the one bag, it is considered one infusate and one infusion. You would report one administration code and a Level II HCPCS J code for each substance or drug.

• Any administration that is 15 minutes or less is considered a push, not an infusion. The administration of an initial or single intravenous push is reported with 96374 and each additional push is reported with 96375. Report only one push per drug.

 

• For example, if a patient is given a push of morphine 2 mg at the beginning of a service and morphine 2 mg later in the service, bill one administration code for the two IV pushes of morphine. The appropriate units of the J code (J2270 —morphine up to 10 mg × 1) would also be billed for the total dose.

​

• If two drugs are mixed in the same bag and administered for 15 minutes or less, the service is reported with the appropriate push CPT code (initial or subsequent) × 1 unit. The drug(s) or substance would be separately reported with the appropriate J code based on the amount and type.

​

• A patient will often receive hydration and ancillary medications before or after chemotherapy. Only one initial administration code can be reported for each encounter; other services are reported with secondary or subsequent codes.

​

• Modifier -59 should be reported to indicate that hydration was provided prior to or following chemotherapy. Hydration provided at the same time as chemotherapy to facilitate drug delivery is not reported separately. All infusions must have a documented start and stop time.

​

• The patient may also receive medications before and/or after chemotherapy, such as anti-nausea medications. These medications are reported in addition to the chemotherapy because chemotherapy is always the primary service. When the patient receives multiple intravenous infusions of medications and these medications are administered individually, each is reported separately; but if the medications are mixed together and given in one infusion, they are reported as one infusion.

​

• Code 96375 is an add-on code and is only reported with another code, such as 96413, Chemotherapy administration.

• If a significant identifiable office visit service was provided in addition to the chemotherapy administration, report that service with an E/M code, adding -25 to indicate the service was separate and significant.

​

PHOTODYNAMIC THERAPY (96567 – 96574)

 

• The photodynamic therapy services (96567, 96571) are add-on codes reported in conjunction with the bronchoscopy or endoscopy services.

• An agent is injected into the patient that remains in cancerous cells longer than in the normal cells.

• After the agent has dissipated from the normal cells, the patient is exposed to laser light.

• The agent absorbs the light and the light produces oxygen, destroying the cancerous cells.

• Codes for endoscopic application are divided on the basis of time— the first 30 minutes and each additional 15 minutes.

• External application of light (96567) is based on each exposure session.