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Sample
© 2016 Optum360, LLC CPT © 2016 American Medical Association. All Rights Reserved. i
Contents
ContentsIntroduction ................................................................................... i
Getting Started with Current Procedural Coding Expert ................... iGuidelines ................................................................................................... iResequencing of CPT Codes ................................................................... iCode Ranges for Medicare Billing ........................................................ iiIcons ............................................................................................................ iiAppendixes ................................................................................................ v
Anatomical Illustrations ............................................................. viiBody Planes and Movements .............................................................. viiIntegumentary System ........................................................................ viiiMusculoskeletal System ........................................................................ ixMusculoskeletal System ......................................................................... xMusculoskeletal System ........................................................................ xiMusculoskeletal System ....................................................................... xiiMusculoskeletal System ...................................................................... xiiiMusculoskeletal System ...................................................................... xivRespiratory System ................................................................................ xvArterial System ...................................................................................... xviArterial System ..................................................................................... xviiArterial System ....................................................................................xviiiVenous System ...................................................................................... xixVenous System ....................................................................................... xxLymphatic System ................................................................................ xxiLymphatic System ............................................................................... xxiiDigestive System ................................................................................. xxiiiDigestive System ................................................................................. xxivGenitourinary System ......................................................................... xxvGenitourinary System ........................................................................ xxviEndocrine System ..............................................................................xxviiEndocrine System .............................................................................xxviiiNervous System ................................................................................... xxixNervous System .................................................................................... xxxEye .......................................................................................................... xxxiEar and Lacrimal System .................................................................. xxxii
Index ...................................................................................Index–1
Tabular ........................................................................................... 1Anesthesia .................................................................................................. 1Integumentary.........................................................................................12Musculoskeletal System ........................................................................33Respiratory System ................................................................................96Cardiovascular System ....................................................................... 110Digestive System.................................................................................. 157Urinary System...................................................................................... 200Genital System...................................................................................... 215Endocrine System ................................................................................ 235Nervous System.................................................................................... 237Eye and Ocular Adnexa....................................................................... 263Radiology ............................................................................................... 279Pathology and Laboratory................................................................. 314Medicine................................................................................................. 384Evaluation & Management................................................................ 446Category II Codes ................................................................................. 471Category III Codes ................................................................................ 487
Appendix A — Modifiers .......................................................... 499CPT Modifiers ........................................................................................499Modifiers Approved for Ambulatory Surgery Center
(ASC) Hospital Outpatient Use ..............................................501
Appendix B — New, Changed and Deleted Codes ................... 507New Codes .............................................................................................507Changed Codes ....................................................................................510Deleted Codes ......................................................................................513AMA Icon Changes ..............................................................................513
Appendix D — Crosswalk of Deleted Codes ............................ 515
Appendix E — Resequenced Codes ......................................... 517
Appendix F — Add-on Codes, Modifier 51 Exempt, Optum Modifier 51 Exempt, Modifier 63 Exempt, and Moderate Sedation Codes ................................................. 525
Add-on Codes .......................................................................................525AMA Modifer 51 Exempt Codes .......................................................525Modifier 63 Exempt Codes ................................................................525Moderate Sedation Codes .................................................................525Optum Modifier 51 Exempt Codes ..................................................526
Appendix G — Pub 100 References .......................................... 527Medicare IOM references ..................................................................527
Appendix H — Physician Quality Reporting System (PQRS) ........................................................................... 615
Appendix I — Medically Unlikely Edits (MUEs)
— Professional ........................631
Professional ...........................................................................................631OPPS ........................................................................................................653
Appendix J — Inpatient Only Procedures ................................ 675
Appendix K — Place of Service and Type of Service ................. 685
Appendix L — Multianalyte Assays with Algorithmic Analyses ................................................................................... 689
Appendix M — Glossary ............................................................ 691
Appendix N — Listing of Sensory, Motor, and Mixed Nerves . 703 Motor Nerves Assigned to Codes 95900 and 95907-95913 ......703 Sensory and Mixed Nerves Assigned to Codes 95907–95913...704
Appendix C — Evaluation and Management Extended Guidelines ................................................................................ 514
Sample
Current Procedural Coding Expert Anatomical Illustrations
© 2016 Optum360, LLC CPT © 2016 American Medical Association. All Rights Reserved. xv
Anatom
ical Illustrations
Respiratory System
Nasal bones
Septal
cartilage
Septal
cartilage
Lateral
nasal
cartilages
Greater
alar
cartilageLateral
crus
Medial
crus
Nose
Nasopharynxregion
Oropharynxregion
Hypopharynxregion
Vocal cord
Larynx
Epiglottis
Auditory tube
Trachea
Nasalcavity
Pharynx
Upper
lobe
Lower
lobe
Lower
lobe
Diaphragm
Middle
lobe
Upper lobe
Right lung
(three lobes)
Left lung
(two lobes)
Lungs
Ethmoid air
cells (sinus)
Maxillary
sinus
Eye
orbit
Inferior
turbinate
Middle
turbinate
Superior
turbinate
Mid frontal cutaway view
Nasal Turbinates
Sternum
Trachea
Aorta
T5
L1
Esophagus
Left main
bronchus
Abdominal
esophagus
Diaphragm
Pericardium
Respiratory
Trachea
Superior
lobe
bronchi
Middle
lobe
bronchi
Inferior
lobe
bronchi
Pulmonary
arterial
trunk
Bronchi
Paranasal Sinuses
Frontal
Ethmoid
Sphenoid
Maxillary
FrontalEthmoid
Sphenoid
Maxillary
Sample
Excision of skin and subcutaneous tissue for hidradenitis,inguinal; with simple or intermediate repair
11462
Tgec8FUD 0906 10.55 6.88
AMA: 2015,Jan,16; 2014,Jan,11; 2012,May,13; 2010,Apr,3-4
with complex repair11463Tgec8FUD 0906 14.05 9.35
AMA: 2015,Jan,16; 2014,Jan,11; 2012,May,13; 2010,Apr,3-4
Excision of skin and subcutaneous tissue for hidradenitis,perianal, perineal, or umbilical; with simple or intermediaterepair
11470
Tg8FUD 0906 11.65 8.02
AMA: 2015,Jan,16; 2014,Jan,11; 2012,May,13; 2010,Apr,3-4
with complex repair11471Tge8FUD 0906 14.35 9.89
AMA: 2015,Jan,16; 2014,Jan,11; 2012,May,13; 2010,Apr,3-4
11600-11646 Skin Lesion Removal: Malignant1 Biopsy on same lesion
Excision of additional margin at same operative sessionFull thickness removal including marginsLesion measurement before excision at largest diameter plus marginLocal anesthesiaSimple, nonlayered closure
2 Destruction (17260-17286)Excision of additional margin at subsequent operative session (11600-11646)
Code also complex closure (13100-13153)Code also each separate lesionCode also intermediate closure (12031-12057)Code also modifier 58 if re-excision is performed during postoperative periodCode also reconstruction (15002-15261, 15570-15770)Do not report with adjacent tissue transfer. Report only adjacent tissue transfer code.
(14000-14302)
Excision, malignant lesion including margins, trunk, arms, orlegs; excised diameter 0.5 cm or less
11600
Ts8tFUD 0106 5.435 3.42
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2012,Jan,15-42; 2011,Jan,11;2010,Apr,3-4; 2010,Jan,3-5
excised diameter 0.6 to 1.0 cm11601Ts8tFUD 0106 6.455 4.26
AMA: 2015,Jan,16; 2014,Mar,12; 2014,Mar,4; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2012,Mar,4-7; 2010,Apr,3-4;2010,Jan,3-5
excised diameter 1.1 to 2.0 cm11602Ts8tFUD 0106 6.985 4.67
AMA: 2015,Jan,16; 2014,Mar,12; 2014,Mar,4; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 2.1 to 3.0 cm11603Ts8tFUD 0106 7.995 5.60
AMA: 2015,Jan,16; 2014,Mar,12; 2014,Mar,4; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 3.1 to 4.0 cm11604Tg8tFUD 0106 8.895 6.17
AMA: 2015,Jan,16; 2014,Mar,12; 2014,Mar,4; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter over 4.0 cm11606Tg8tFUD 0106 12.75 9.16
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
Excision, malignant lesion including margins, scalp, neck,hands, feet, genitalia; excised diameter 0.5 cm or less
11620
Ts8tFUD 0106 5.495 3.46
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,Jul,12-14; 2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 0.6 to 1.0 cm11621Ts8tFUD 0106 6.495 4.30
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 1.1 to 2.0 cm11622Ts8tFUD 0106 7.235 4.91
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 2.1 to 3.0 cm11623Ts8tFUD 0106 8.495 6.08
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 3.1 to 4.0 cm11624Tg8tFUD 0106 9.575 6.88
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter over 4.0 cm11626Tg8tFUD 0106 11.55 8.47
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
Excision, malignant lesion including margins, face, ears,eyelids, nose, lips; excised diameter 0.5 cm or less
11640
2 Eyelid excision involving more than skin (67800-67808,67840-67850, 67961-67966)
Ts8tFUD 0106 5.655 3.58
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 0.6 to 1.0 cm116412 Eyelid excision involving more than skin (67800-67808,
67840-67850, 67961-67966)Ts8tFUD 0106 6.715 4.47
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 1.1 to 2.0 cm116422 Eyelid excision involving more than skin (67800-67808,
67840-67850, 67961-67966)Ts8tFUD 0106 7.655 5.27
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 2.1 to 3.0 cm116432 Eyelid excision involving more than skin (67800-67808,
67840-67850, 67961-67966)Ts8tFUD 0106 9.045 6.61
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter 3.1 to 4.0 cm116442 Eyelid excision involving more than skin (67800-67808,
67840-67850, 67961-67966)Tg8tFUD 0106 11.15 8.17
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2010,Apr,3-4; 2010,Jan,3-5
excised diameter over 4.0 cm116462 Eyelid excision involving more than skin (67800-67808,
67840-67850, 67961-67966)Tg8tFUD 0106 14.65 11.3
AMA: 2015,Jan,16; 2014,Mar,4; 2014,Mar,12; 2014,Jan,11;2012,May,13; 2012,Jan,15-42; 2011,Jan,11; 2010,Apr,3-4;2010,Jan,3-5
11719-11765 Nails and Supporting StructuresCMS: 100-02,15,290 Foot Care2 Drainage of paronychia or onychia (10060-10061)
Trimming of nondystrophic nails, any number11719Zq8tFUD 0006 0.395 0.22
AMA: 2015,Jan,16; 2014,Jan,11
Debridement of nail(s) by any method(s); 1 to 511720Zq8tFUD 0006 0.915 0.42
AMA: 2015,Jan,16; 2014,Jan,11
6 or more11721Zq8tFUD 0006 1.265 0.70
AMA: 2015,Jan,16; 2014,Jan,11
; Female Only: Male Onlyc Bilateralg-w ASC Pmtb/f PC/TC Comp Onlyd/e Surg Assist Allowed / w/DocA-Y OPPSICMS: Pub 100AMA: CPT Asst
5 Facility RVU 6 Non-Facility RVU 4 Lab Crosswalk 3 Radiology Crosswalk
© 2016 Optum360, LLC (Blue Text)CPT © 2016 American Medical Association. All Rights Reserved. (Black Text)Medicare (Red Text)16
Integumentary System11462In
tegu
men
tary
Sys
tem
1146
2—
117
21
Sample
© 2016 Optum360, LLC © 2016 American Medical Association. All Rights Reserved. 631
Appendix I —
Medically U
nlikely Edits (MU
Es) — Professional
Appendix I — Medically Unlikely Edits (MUEs) — Professional
The Centers for Medicare & Medicaid Services (CMS) began to publish many of the edits used in the medically unlikely edits (MUE) program for the first time effective October 2008. What follows below is a list of the published CPT codes that have MUEs assigned to them and the number of units allowed with each code. CMS publishes the updates on a quarterly basis. Not all MUEs will be published, however. MUEs intended to detect and discourage any questionable payments will not be published as the agency feels the efficacy of these edits would be compromised. CMS added another component to the MUEs—the MUE Adjudication Indicator (MAI). The appropriate MAI can be found in parentheses following the MUE in this table and specify the maximum units of service (UOS) for a CPT/HCPCS code for the service. The MAI designates whether the UOS edit is applied to the line or claim.
The three MAIs are defined as follows:
MAI 1 (Line Edit) This MAI will continue to be adjudicated as the line edit on the claim and is auto-adjudicated by the contractor.
MAI 2 (Date of Service Edit, Policy) This MAI is considered to be the “absolute date of service edit” and is based on policy. The total unit of services (UOS) for that CPT code and that date of service (DOS) are combined for this edit. Medicare contractors are required to review all claims for the same patient, same date of service, and same provider.
MAI 3 (Date of Service Edit: Clinical) This MAI is also a date-of-service edit but is based upon clinical standards. The review takes current and previously submitted claims for the same patient, same date of service, and same provider into account. When medical necessity is clearly documented, the edit may be bypassed or the claim resubmitted.
The quarterly updates are published on the CMS website at http://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp.
Professional
CPT MUE01996 1(2)0019T 1(1)0042T 1(1)0051T 1(2)0052T 1(2)0053T 1(2)0054T 2(1)0055T 2(1)0058T 1(1)0071T 1(2)0072T 1(2)0075T 1(2)0076T 2(1)0095T 1(1)0098T 1(1)0099T 2(2)0100T 2(2)0101T 1(1)0102T 2(2)0103T 1(1)0106T 4(2)0107T 4(2)0108T 4(2)0109T 4(2)0110T 4(2)0111T 1(1)0123T 2(2)0126T 1(1)0159T 2(2)0163T 2(1)0164T 4(2)0165T 4(2)0169T 1(1)0171T 1(2)0172T 3(1)0174T 1(1)0175T 1(1)0178T 1(1)0179T 1(1)0180T 1(1)
0182T 3(1)0184T 1(1)0190T 2(2)0191T 2(2)0195T 1(2)0196T 1(2)0198T 2(2)0200T 1(2)0201T 1(2)0202T 1(3)0206T 1(1)0207T 2(2)0208T 1(1)0209T 1(1)0210T 1(1)0211T 1(1)0212T 1(1)0213T 1(2)0214T 1(2)0215T 1(2)0216T 1(2)0217T 1(2)0218T 1(2)0219T 1(2)0220T 1(2)0221T 1(2)0222T 1(1)0223T 1(1)0224T 1(1)0225T 1(1)0228T 1(2)0230T 1(2)0232T 1(1)0233T 1(1)0234T 2(2)0235T 2(1)0236T 1(2)0237T 2(1)0240T 1(1)0241T 1(1)0243T 1(2)
CPT MUE0244T 1(2)0249T 1(2)0253T 1(1)0254T 2(2)0255T 2(2)0262T 1(1)0263T 1(1)0264T 1(1)0265T 1(1)0266T 1(1)0267T 1(1)0268T 1(1)0269T 1(1)0270T 1(1)0271T 1(1)0272T 1(1)0273T 1(1)0274T 1(2)0275T 1(2)0278T 1(1)0281T 1(2)0282T 1(3)0283T 1(3)0284T 1(1)0285T 1(1)0286T 1(2)0287T 2(1)0288T 1(2)0289T 2(2)0290T 1(1)0291T 1(2)0292T 1(1)0293T 1(2)0294T 1(1)0295T 1(2)0296T 1(2)0297T 1(2)0298T 1(2)0299T 1(2)0300T 1(1)0301T 1(1)
CPT MUE0302T 1(1)0303T 1(1)0304T 1(1)0305T 1(1)0306T 1(1)0307T 1(1)0308T 1(1)0309T 1(1)0310T 1(1)0311T 1(1)0312T 1(1)0313T 1(1)0314T 1(1)0315T 1(1)0316T 1(1)0317T 1(1)0329T 1(2)0330T 1(2)0331T 1(3)0332T 1(3)0333T 1(2)0335T 2(2)0336T 1(3)0337T 1(3)0338T 1(2)0339T 1(2)0347T 1(3)0348T 1(3)0349T 1(3)0350T 1(3)0351T 5(3)0352T 5(3)0353T 2(3)0354T 2(3)0355T 1(2)0356T 4(2)0357T 1(2)0358T 1(2)0359T 1(2)0360T 1(2)0361T 3(3)
CPT MUE0362T 1(2)0363T 3(3)0364T 1(2)0366T 1(2)0368T 1(2)0370T 1(3)0371T 1(3)0372T 1(3)0373T 1(2)0375T 1(2)0376T 2(3)0377T 1(2)0378T 1(2)0379T 1(2)0380T 1(2)0381T 1(2)0382T 1(2)0383T 1(2)0384T 1(2)0385T 1(2)0386T 1(2)0387T 1(3)0388T 1(3)0389T 1(3)0390T 1(3)0391T 1(3)0001M 1(1)0002M 1(1)0003M 1(1)0006M 1(2)0007M 1(2)0008M 1(3)10021 4(3)10022 4(3)10030 2(3)10040 1(2)10060 1(2)10061 1(2)10080 1(3)10081 1(3)10120 3(3)
CPT MUE10121 2(3)10140 2(3)10160 3(3)10180 2(3)11000 1(2)11001 1(3)11004 1(2)11005 1(2)11006 1(2)11008 1(2)11010 2(3)11011 2(3)11012 2(3)11042 1(2)11043 1(2)11044 1(2)11055 1(2)11056 1(2)11057 1(2)11100 1(2)11101 6(3)11200 1(2)11201 0(3)11300 5(3)11301 6(3)11302 4(3)11303 3(3)11305 4(3)11306 4(3)11307 3(3)11308 4(3)11310 4(3)11311 4(3)11312 3(3)11313 3(3)11400 3(3)11401 3(3)11402 3(3)11403 2(3)11404 2(3)11406 2(3)
CPT MUE11420 3(3)11421 3(3)11422 3(3)11423 2(3)11424 2(3)11426 2(3)11440 4(3)11441 3(3)11442 3(3)11443 2(3)11444 2(3)11446 2(3)11450 1(2)11451 1(2)11462 1(2)11463 1(2)11470 3(2)11471 2(3)11600 2(3)11601 2(3)11602 3(3)11603 2(3)11604 2(3)11606 2(3)11620 2(3)11621 2(3)11622 2(3)11623 2(3)11624 2(3)11626 2(3)11640 2(3)11641 2(3)11642 3(3)11643 2(3)11644 2(3)11646 2(3)11719 1(2)11720 1(2)11721 1(2)11730 1(2)11732 9(3)
CPT MUE11740 3(3)11750 6(3)11752 3(3)11755 4(3)11760 4(3)11762 2(3)11765 4(3)11770 1(3)11771 1(3)11772 1(3)11900 1(2)11901 1(2)11920 1(2)11921 1(2)11922 1(3)11950 1(2)11951 1(2)11952 1(2)11954 1(3)11960 2(3)11970 2(3)11971 2(3)11976 1(2)11980 1(2)11981 1(3)11982 1(3)11983 1(3)12001 1(2)12002 1(2)12004 1(2)12005 1(2)12006 1(2)12007 1(2)12011 1(2)12013 1(2)12014 1(2)12015 1(2)12016 1(2)12017 1(2)12018 1(2)12020 2(3)
CPT MUE
Sample