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What are CPT® Codes

Current procedural terminology (CPT®) is a five-digit numeric coding system used to record services provided by or performed under the direct supervision of a physician or non-physician providers. CPT Codes are actually part of the HCPCS Coding System, discussed later in this chapter.

Within CPT® there are essentially two types of codes: one type for evaluation and management (E&M) services and one type for procedures and other services. In addition to these codes, Medicare and some private health plans recognize extensions or "modifiers," which are appended to the code to provide further details.

E&M Codes
E&M codes are represented by CPT® code numbers 99201 through 99499. E&M codes are used to describe patient visits and are divided into broad categories such as office visits, hospital visits and consultations. These categories are then divided even further.

For instance, office visits are categorized as either new or established patients, and hospital visits are categorized as either initial or subsequent. And finally, within each subcategory there are different levels. These levels indicate the varying degrees of effort, time, responsibility and medical knowledge expended during the visit.

The E&M codes have their own set of modifiers should there be a special circumstance surrounding the visit. You must use one of these modifiers to describe the circumstance and indicate to your carrier that your billing is, therefore, modified.

E&M Modifiers

-24 Unrelated E&M Service by the Same Physician During a Postoperative Period
-25 Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service
-57 Decision for Surgery

Procedure Codes
The second type of code, the procedure code, represents diagnostic and treatment services. For most urological procedures, the appropriate codes can be found in the urinary and male genital sections under CPT® codes 50010 through 55899. However, some procedures commonly billed by urologists are in other sections. (For example, ultrasound services are listed in the CPT® code 76xxx series.) Any code, which describes the service rendered, may be billed. (The only exception to this may be "bundling" edits captured in the signed contractual agreement with an insurance carrier or if a Medicare National Correct Coding Initiative (CCI) edit applies.)

Procedural Modifiers
To describe any special surgical circumstance to the payer, you must use the procedural modifiers.

-22 Increased Procedural Service
-23 Unusual Anesthesia
-26 Professional Component
-32 Mandated Service
-47 Anesthesia by Surgeon
-50 Bilateral Procedure
-51 Multiple Procedures
-52 Reduced Services
-53 Discontinued Procedure
-54 Surgical Care Only
-55 Postoperative Management Only
-56 Preoperative Management Only
-58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
-59 Distinct Procedural Service
-62 Two Surgeons
-63 Procedure Performed on Infants (less than 4 kgs)
-66 Surgical Team
-76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
-77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional
-78 Unplanned Return to the Operating/Procedure Room by Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
-79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
-80 Assistant Surgeon
-81 Minimum Assistant Surgeon
-82 Assistant Surgeon (when qualified resident surgeon not available)
-90 Reference (Outside) Laboratory
-91 Repeat Clinical Diagnostic Laboratory Test
-92 Alternative Laboratory Platform Testing
-99 Multiple Modifiers

Global Periods
For each CPT® code, there is a corresponding global period. These global periods indicate the number of postoperative days of care that are included in the payment for a procedure or surgery. Under Medicare there are several global periods.

Global Periods

000 Postoperative care is not included in the payment, but any related evaluation and management work is included if done on the same day
010 10 days of postoperative care are included in the payment
090 90 days of postoperative care are included in the payment
XXX Global concept does not apply and any evaluation and management and other services performed may be reported separately on the same day
YYY Global period is to be set by the carrier (e.g., unlisted surgery codes)
ZZZ The code is part of another service and falls within the global period for the other service

A service paid on a global basis includes:

Add-on Codes
Some CPT® procedures are usually done in addition to another (primary) procedure. These codes are termed "add-on codes." Add-on codes describe additional intra-service work associated with the primary procedure and are always performed with the primary procedure; they are never reported as a stand-alone code. Do not use modifier -51, Multiple Procedure, on an add-on code.


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