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Current Procedural Coding Expert CPT® codes with Medicare essentials for enhanced accuracy

Current Procedural

Coding Expert

PROFESSIONAL

CEP_CEP20_CVR.indd 1 11/20/18 12:42 PM

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© 2019 Optum360, LLC CPT © 2019 American Medical Association. All Rights Reserved. 1

Contents

ContentsIntroduction ................................................................................... i

Getting Started with Current Procedural Coding Expert Professional Edition ....................................................................... i

General Conventions ................................................................................ iResequencing of CPT Codes ................................................................... iCode Ranges for Medicare Billing ........................................................ iiIcons ............................................................................................................ iiAppendixes ............................................................................................... iv

Anatomical Illustrations ............................................................. viiBody Planes and Movements .............................................................. viiIntegumentary System ........................................................................ viii

Skin and Subcutaneous Tissue ................................................ viiiNail Anatomy ................................................................................ viiiAssessment of Burn Surface Area ............................................ viii

Musculoskeletal System ........................................................................ ixBones and Joints ........................................................................... ixMuscles ............................................................................................. xHead and Facial Bones ................................................................. xiNose .................................................................................................. xiShoulder (Anterior View) ............................................................. xiShoulder (Posterior View) ........................................................... xiShoulder Muscles .......................................................................... xiElbow (Anterior View) ................................................................. xiiElbow (Posterior View) ................................................................ xiiElbow Muscles .............................................................................. xiiElbow Joint .................................................................................... xiiLower Arm ..................................................................................... xiiHand ................................................................................................ xiiHip (Anterior View) ..................................................................... xiiiHip (Posterior View) .................................................................... xiiiKnee (Anterior View) .................................................................. xiiiKnee (Posterior View) ................................................................. xiiiKnee Joint (Anterior View) ........................................................ xiiiKnee Joint (Lateral View) ........................................................... xiiiLower Leg ...................................................................................... xivAnkle Ligament (Lateral View) ................................................. xivAnkle Ligament (Posterior View) ............................................. xivFoot Tendons ............................................................................... xivFoot Bones .................................................................................... xiv

Respiratory System ................................................................................ xvUpper Respiratory System ......................................................... xvNasal Turbinates ........................................................................... xvParanasal Sinuses ........................................................................ xviLower Respiratory System ........................................................ xviLung Segments ............................................................................ xviAlveoli ............................................................................................ xvi

Arterial System ..................................................................................... xviiInternal Carotid and Arteries and Branches ....................... xviiiExternal Carotid Arteries and Branches ...............................xviiiUpper Extremity Arteries ......................................................... xviiiLower Extremity Arteries ......................................................... xviii

Venous System ...................................................................................... xixHead and Neck Veins ................................................................... xxUpper Extremity Veins ................................................................ xxVenae Comitantes ........................................................................ xxVenous Blood Flow ...................................................................... xxAbdominal Veins .......................................................................... xx

Cardiovascular System ......................................................................... xxiCoronary Veins ............................................................................. xxiAnatomy of the Heart ................................................................ xxiHeart Cross Section ..................................................................... xxiHeart Valves .................................................................................. xxi

Heart Conduction System ........................................................ xxiiCoronary Arteries ....................................................................... xxii

Lymphatic System .............................................................................. xxiiiAxillary Lymph Nodes .............................................................. xxivLymphatic Capillaries ............................................................... xxivLymphatic System of Head and Neck .................................. xxivLymphatic Drainage ................................................................. xxivSpleen Internal Structures ....................................................... xxvSpleen External Structures ...................................................... xxv

Digestive System ................................................................................. xxviGallbladder ................................................................................. xxviStomach ...................................................................................... xxviMouth (Upper) .......................................................................... xxviiMouth (Lower) .......................................................................... xxviiPancreas ..................................................................................... xxviiLiver ............................................................................................. xxviiAnus ............................................................................................ xxvii

Genitourinary System ...................................................................... xxviiiUrinary System ........................................................................ xxviiiNephron ...................................................................................... xxixMale Genitourinary ................................................................... xxixTestis and Associate Structures ............................................. xxixMale Genitourinary System .................................................... xxixFemale Genitourinary ............................................................... xxxFemale Reproductive System ................................................. xxxFemale Bladder ........................................................................... xxxFemale Breast ............................................................................. xxx

Endocrine System ............................................................................... xxxiStructure of an Ovary ............................................................... xxxiThyroid and Parathyroid Glands .......................................... xxxiiAdrenal Gland ........................................................................... xxxiiThyroid ........................................................................................ xxxiiThymus ....................................................................................... xxxii

Nervous System ................................................................................. xxxiiiBrain ........................................................................................... xxxivCranial Nerves .......................................................................... xxxivSpinal Cord and Spinal Nerves .............................................. xxxvNerve Cell .................................................................................. xxxvi

Eye ....................................................................................................... xxxviiEye Structure ...........................................................................xxxviiPosterior Pole of Globe/Flow of Aqueous Humor .......... xxxviiEye Musculature ..................................................................... xxxviiEyelid Structures ....................................................................xxxvii

Ear and Lacrimal System ............................................................... xxxviiiEar Anatomy ...........................................................................xxxviiiLacrimal System .................................................................... xxxviii

Index ................................................................................... Index–1

Tabular........................................................................................... 1Anesthesia .................................................................................................. 1Integumentary......................................................................................... 13Musculoskeletal System........................................................................37Respiratory System ..............................................................................107Cardiovascular, Hemic, and Lymphatic ..........................................125Digestive System...................................................................................181Urinary System ......................................................................................233Genital System.......................................................................................251Endocrine System .................................................................................275Nervous System.....................................................................................277Eye, Ocular Adnexa, and Ear...............................................................307Radiology ................................................................................................325

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Contents Current Procedural Coding Expert

2 CPT © 2019 American Medical Association. All Rights Reserved. © 2019 Optum360, LLC

Contents Pathology and Laboratory................................................................. 363

Medicine................................................................................................. 441Evaluation and Management Services Guidelines ...................... 519Evaluation and Management ........................................................... 524Category II Codes ................................................................................. 547Category III Codes ................................................................................ 563

Appendix A — Modifiers ........................................................... 581CPT Modifiers ....................................................................................... 581Modifiers Approved for Ambulatory Surgery Center (ASC)

Hospital Outpatient Use ........................................................ 583

Appendix B — New, Changed and Deleted Codes.................... 587New Codes............................................................................................. 587Changed Codes .................................................................................... 591Deleted Codes....................................................................................... 593No Longer Resequenced—Icon Removed .................................... 593Resequenced Icon Added .................................................................. 593Web Release New and Changed Codes.......................................... 593

Appendix C — Evaluation and Management Extended Guidelines ..................................................................................595

Appendix D — Crosswalk of Deleted Codes..............................611

Appendix E — Resequenced Codes........................................... 613

Appendix F — Add-on Codes, Modifier 51 Exempt, Optum Modifier 51 Exempt, Modifier 63 Exempt, and Modifier 95 Telemedicine Services ...............................................................617

Add-on Codes ........................................................................................617AMA Modifer 51 Exempt Codes ........................................................617Modifier 63 Exempt Codes .................................................................617Optum Modifier 51 Exempt Codes ...................................................617Telemedicine Services Codes.............................................................617

Appendix G — Medicare Internet-only Manuals (IOMs) .......... 619Medicare IOM references ..................................................................619

Appendix H — Quality Payment Program ................................ 739Changes Implemented for 2018 .......................................................739Proposed 2019 Changes .....................................................................740

Appendix I — Medically Unlikely Edits (MUEs)......................... 741Professional ............................................................................................741OPPS.........................................................................................................767

Appendix J — Inpatient-Only Procedures ................................ 793

Appendix K — Place of Service and Type of Service................. 805

Appendix L — Multianalyte Assays with Algorithmic Analyses..................................................................................... 809

Appendix M — Glossary ............................................................ 815

Appendix N — Listing of Sensory, Motor, and Mixed Nerves ........................................................................................ 829

Motor Nerves Assigned to Codes 95900 and 95907-95913 .......829Sensory and Mixed Nerves Assigned to Codes 95907–95913...830

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Introduction Current Procedural Coding Expert

ii CPT © 2019 American Medical Association. All Rights Reserved. © 2019 Optum360, LLC

Intr

oduc

tion

This differs from the AMA CPT book, in which the coder is directed to a code range that contains the resequenced code and description, rather than to a specific location.

Resequenced codes will appear in brackets in the headers, section notes, and code ranges. For example:

27327-27329 [27337, 27339] Excision Soft Tissue Tumors Femur/Knee. Codes [27337, 27339] are included in section 27327-27329 in their resequenced positions.

Code also toxoid/vaccine (90476-90749 [90620, 90621, 90625, 90630, 90644, 90672, 90673, 90674, 90750, 90756])

This shows codes 90620, 90621, 90625, 90630, 90644, 90672, 90673, 90674, 90750, and 90756 are resequenced in this range of codes.

Code Ranges for Medicare BillingAppendix E identifies all resequenced CPT codes. Optum360 will display the resequenced coding as assigned by the AMA in its CPT products so that the user may understand the code description relationships.

Each particular group of CPT codes in Current Procedural Coding Expert is organized in a more intuitive fashion for Medicare billing, being grouped by the Medicare rules and regulations as found in the official CMS online manuals, that govern payment of these particular procedures and services, as in this example:

99221-99233 Inpatient Hospital Visits: Initial and SubsequentCMS: 100-4,11,40.1.3 Independent Attending Physician Services; 100-4,12,100.1.1 Teaching Physicians E/M Services; 100-4,12,30.6.10 Consultation Services; 100-4,12,30.6.15.1 Prolonged Services With Direct Face-to-Face Patient Contact; 100-4,12,30.6.4 Services Furnished Incident to Physician’s Service; 100-4,12,30.6.9 Hospital Visit and Critical Care on Same Day

Icons ● New Codes

Codes that have been added since the last edition of the AMACPT book was printed.

▲ Revised CodesCodes that have been revised since the last edition of the AMA CPT book was printed.

● New Web ReleaseCodes that are new for the current year but will not be in the AMA CPT book until 2019.

▲ Revised Web ReleaseCodes that have been revised for the current year, but will not be in the AMA CPT book until 2019.

# Resequenced CodesCodes that are out of numeric order but apply to the appropriate category.

★ Telemedicine ServicesCodes that may be reported for telemedicine services. Modifier95 must be appended to code.

❍ Reinstated CodeCodes that have been reinstated since the last edition of the book was printed.Pink Color Bar—Not Covered by MedicareServices and procedures identified by this color bar are never covered benefits under Medicare. Services and procedures that are not covered may be billed directly to the patient at the time of the service.Gray Color Bar—Unlisted ProcedureUnlisted CPT codes report procedures that have not been assigned a specific code number. An unlisted code delays payment due to the extra time necessary for review.

Green Color Bar—Resequenced CodesResequenced codes are codes that are out of numeric sequence—they are indicated with a green color bar. They are listed twice, in their resequenced position as well as in their original numeric position with a note that the code is out of numerical sequence and where the resequenced code and description can be found.

1 Includes notesIncludes notes identify procedures and services that would be bundled in the procedure code. These are derived from AMA, CMS, NCCI, and Optum360 coding guidelines. This is not meant to be an all-inclusive list.

2 Excludes notesExcludes notes may lead the user to other codes. They may identify services that are not bundled and may be separately reported, OR may lead the user to another more appropriate code. These are derived from AMA, CMS, NCCI, and Optum360 coding guidelines. This is not meant to be an all-inclusive list.

Code Also This note identifies an additional code that should be reported with the service and may relate to another CPT code or an appropriate HCPCS code(s) that should be reported along with the CPT code when appropriate.

Code First Found under add-on codes, this note identifies codes for primary procedures that should be reported first, with the add-on code reported as a secondary code.

4 Laboratory/Pathology CrosswalkThis icon denotes CPT codes in the laboratory and pathology section of CPT that may be reported separately with the primary CPT code.

3 Radiology CrosswalkThis icon denotes codes in the radiology section that may be used with the primary CPT code being reported.

f Technical Component OnlyCodes with this icon represent only the technical component (staff and equipment costs) of a procedure or service. Do not use either modifier 26 (physician component) or TC (technical component) with these codes.

b Professional ComponentOnly codes with this icon represent the physician’s work or professional component of a procedure or service. Do not use either modifier 26 (physician component) or TC (technical component) with these codes.

c Bilateral ProcedureThis icon identifies codes that can be reported bilaterally when the same surgeon provides the service for the same patient on the same date. Medicare allows payment for both procedures at 150 percent of the usual amount for one procedure. The modifier does not apply to bilateral procedures inclusive to one code.

d Assist-at-Surgery AllowedServices noted by this icon are allowed an assistant at surgery with a Medicare payment equal to 16 percent of the allowed amount for the global surgery for that procedure. No documentation is required.

e Assist-at-Surgery Allowed with DocumentationServices noted by this icon are allowed an assistant at surgery with a Medicare payment equal to 16 percent of the allowed amount for the global surgery for that procedure. Documentation is required.

+ Add-on CodesThis icon identifies procedures reported in addition to the primary procedure. The icon “+” denotes add-on codes. Anadd-on code is neither a stand-alone code nor subject to multiple procedure rules since it describes work in addition tothe primary procedure.

According to Medicare guidelines, add-on codes may be identified in the following ways:

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10021-10022 Fine Needle Aspiration2 Percutaneous localizationclipplacementduringbreastbiopsy (19081-19086)

Percutaneous needle biopsy of:Abdominal or retroperitoneal mass (49180)Bone (20220, 20225)Bonemarrow (38220-38221)Epididymis (54800)Kidney (50200)Liver (47000)Lung or mediastinum (32405)Lymph node (38505)Muscle (20206)Nucleus pulposus, paravertebral tissue, intervertebral disc (62267)Pancreas (48102)Pleura (32400)Prostate (55700, 55706)Salivary gland (42400)Spinal cord (62269)Testis (54500)Thyroid (60100)

Soft tissue percutaneous fluid drainage by catheter using image guidance(10030)

Thyroid cyst (60300)

Fine needle aspiration; without imaging guidance100214 (88172-88173)

Tse8FUD XXX6 3.475 2.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11;2012,Jan,15-42

with imaging guidance100223 (76942, 77002, 77012, 77021)4 (88172-88173)

Tse8FUD XXX6 4.005 1.88


10030-10180TreatmentofLesions:SkinandSubcutaneousTissues2 Excision benign lesion (11400-11471)

Image-guided fluid collection drainage by catheter (eg,abscess, hematoma, seroma, lymphocele, cyst), soft tissue(eg, extremity, abdominal wall, neck), percutaneous

10030

1 Radiologic guidance (75989, 76942, 77002-77003,77012, 77021)

2 Percutaneous drainage with imaging guidance of:Peritoneal or retroperitoneal collections (49406)Visceral collections (49405)

Transvaginal or transrectal drainage with imagingguidance of:

Peritoneal or retroperitoneal collections (49407)Code also every instance of fluid collection drained using a

separate catheter (10030)Tre8FUD 0006 19.85 4.47

AMA: 2017,Aug,9; 2017,Jan,8; 2016,Jan,13; 2015,Jan,16;2014,May,9; 2014,May,3; 2013,Nov,9

Placement of soft tissue localization device(s) (eg, clip,metallicpellet,wire/needle, radioactiveseeds),percutaneous,including imaging guidance; first lesion

10035

1 Radiologic guidance (76942, 77002-77003, 77012,77021)

2 Sites with amore specific code descriptor, such as thebreast

Use of codemore than one time per site, regardless ofthe number of markers used

Code also each additional target on the same or opposite side(10036)

Tqec8FUD 0006 15.25 2.57

AMA: 2017,Jan,8; 2016,Jun,3

each additional lesion (List separately in addition to codefor primary procedure)

10036+

1 Radiologic guidance (76942, 77002, 77012, 77021)

2 Sites with amore specific code descriptor, such as thebreast

Use of codemore than one time per site, regardless ofthe number of markers used

Code first (10035)Nqe8FUD ZZZ6 13.15 1.28

AMA: 2017,Jan,8; 2016,Jun,3

Acne surgery (eg, marsupialization, opening or removal ofmultiple milia, comedones, cysts, pustules)

10040

Zq8FUD 0106 2.895 2.53


Incision and drainage of abscess (eg, carbuncle, suppurativehidradenitis, cutaneous or subcutaneous abscess, cyst,furuncle, or paronychia); simple or single

10060

Ts8FUD 0106 3.335 2.78

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11;2012,Oct,12; 2012,Sep,10; 2012,Jan,15-42

complicated or multiple10061Ts8FUD 0106 5.865 5.13

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11;2012,Oct,12; 2012,Sep,10

Incision and drainage of pilonidal cyst; simple10080Ts8FUD 0106 5.085 2.94

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11

complicated100812 Excision of pilonidal cyst (11770-11772)

Ts8FUD 0106 7.635 4.85

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11

Incision and removal of foreign body, subcutaneous tissues;simple

10120

Ts8FUD 0106 4.325 2.95

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11;2013,Dec,16; 2013,Apr,10-11; 2012,Oct,12; 2012,Sep,10

complicated101212 Debridement associated with a fracture or dislocation

(11010-11012)Exploration penetrating wound (20100-20103)

Jg8FUD 0106 7.775 5.31

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Jan,11;2013,Dec,16; 2012,Oct,12; 2012,Sep,10

Incision and drainage of hematoma, seroma or fluidcollection

10140

3 (76942, 77002, 77012, 77021)

Js8FUD 0106 4.635 3.38

AMA: 2017,Jan,8; 2016,Jan,13; 2015,Jan,16; 2014,Nov,5;2014,Jan,11; 2012,Jan,15-42

# ResequencedNot CoveredUnlisteds Revised Web Releasel New Web Releasem Reinstateds Revised Codel New Code, AMA Mod 51 Exempt B Optum Mod 51 Exempt L Mod 63 Exempt f Non-FDA Drug H Telemedicine x Maternity y Age Edit + Add-on AMA: CPT Asst © 2019 Optum360, LLC CPT © 2019 American Medical Association. All Rights Reserved. 13

10140Integumentary System10021

—10140

Integumentary

System

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Measles, mumps and rubella virus vaccine (MMR), live, forsubcutaneous use

90707

1 M-M-R IIBN8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,May,6; 2015,Jan,16;2014,Jan,11; 2013,Aug,10; 2012,Jul,7; 2012,Jan,15-42

Measles,mumps, rubella, andvaricella vaccine (MMRV), live,for subcutaneous use

90710

1 ProQuadBN8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,May,6; 2015,Jan,16;2014,Jan,11; 2013,Aug,10; 2012,Jan,15-42

Poliovirus vaccine, inactivated (IPV), for subcutaneous orintramuscular use

90713

1 IPOLBN8FUD XXX6 0.005 0.00


Tetanus and diphtheria toxoids adsorbed (Td), preservativefree, when administered to individuals 7 years or older, forintramuscular use y

90714

1 TenivacTetanus-diphtheria toxoids absorbed

BN8FUD XXX6 0.005 0.00


Tetanus, diphtheria toxoids and acellular pertussis vaccine(Tdap), when administered to individuals 7 years or older,for intramuscular use y

90715

1 AdacelBoostrix

BN8FUD XXX6 0.005 0.00


Varicella virus vaccine (VAR), live, for subcutaneous use907161 Varivax

BM8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,May,6; 2015,Mar,3;2015,Jan,16; 2014,Jan,11; 2013,Aug,10; 2012,Jan,15-42

Yellow fever vaccine, live, for subcutaneous use907171 YF-VAX

BNq8FUD XXX6 0.005 0.00


Diphtheria, tetanus toxoids, acellular pertussis vaccine,hepatitis B, and inactivated poliovirus vaccine(DTaP-HepB-IPV), for intramuscular use

90723

1 PEDIARIXBM8FUD XXX6 0.005 0.00


Cholera vaccine, live, adult dosage, 1 dose schedule, for oraluse y

90625#

BE8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Oct,6; 2016,Jan,13

Pneumococcal polysaccharide vaccine, 23-valent (PPSV23),adult or immunosuppressed patient dosage, whenadministeredto individuals2yearsorolder, for subcutaneousor intramuscular use y

90732

1 Pneumovax 23BL?8FUD XXX6 0.005 0.00


Meningococcal conjugate vaccine, serogroups C & Y andHaemophilus influenzae type b vaccine (Hib-MenCY), 4 doseschedule,whenadministered tochildren6weeks-18monthsof age, for intramuscular use y

90644#

1 MenHibrixBM8FUD XXX6 0.005 0.00


Meningococcal polysaccharide vaccine, serogroups A, C, Y,W-135, quadrivalent (MPSV4), for subcutaneous use

90733

1 Menomune-A/C/Y/W-135BM8FUD XXX6 0.005 0.00


Meningococcal conjugate vaccine, serogroups A, C, Y andW-135, quadrivalent (MCV4orMenACWY), for intramuscularuse

90734

1 MenactraMenveo

BM8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Oct,6; 2016,Jan,13; 2015,May,6;2015,Jan,16; 2014,Jan,11; 2013,Aug,10; 2012,Jan,15-42

Meningococcal recombinant protein and outer membranevesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, forintramuscular use

90620s #

1 BexseroBM8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,May,6; 2015,Jan,16

Meningococcal recombinant lipoprotein vaccine, serogroupB (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use

90621s #

1 TrumenbaBM8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,May,6; 2015,Jan,16

Zoster (shingles) vaccine (HZV), live, for subcutaneousinjection

90736

1 ZostavaxBM8FUD XXX6 0.005 0.00


Zoster (shingles) vaccine (HZV), recombinant, sub-unit,adjuvanted, for intramuscular injection

90750l #

fBE8FUD XXX6 0.005 0.00

Japanese encephalitis virus vaccine, inactivated, forintramuscular use

90738

1 IxiaroBM8FUD XXX6 0.005 0.00


Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule,for intramuscular use

90739

fBE8FUD XXX6 0.005 0.00

AMA: 2017,Jan,8; 2016,Jan,13; 2015,May,6; 2015,Jan,16;2014,Jan,11; 2013,Aug,10

Hepatitis B vaccine (HepB), dialysis or immunosuppressedpatient dosage, 3 dose schedule, for intramuscular use

90740

1 Recombivax HBBFh8FUD XXX6 0.005 0.00


Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, forintramuscular use y

90743

1 Energix-BRecombivax HB

BFh8FUD XXX6 0.005 0.00


90707—

90743Medicine

l New Code s Revised Code m Reinstated l New Web Release s Revised Web Release Unlisted Not Covered # Resequenced

, AMA Mod 51 Exempt B Optum Mod 51 Exempt L Mod 63 Exempt f Non-FDA Drug H Telemedicine x Maternity y Age Edit + Add-on AMA: CPT Asst © 2019 Optum360, LLC CPT © 2019 American Medical Association. All Rights Reserved. 429

90743Medicine

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