Assignment - Practical Coding (CPT) "Medicine" Section
Please read the overview and instructions before attempting
this assignment. You may refer to Buck Step By Step Ch 26
"Medicine". Copy and Paste your completed assignment (only) on a
separate MS word document or compatible file, and submit
electronically via Moodle prior to due date.
OVERVIEW
Procedure coding is the transformation of written descriptions
of procedures and professional services into numeric designations
(code numbers). The physician rendering medical care either writes
or dictates this information into the patient’s health record.
Then, the insurance billing specialist reads through the pertinent
information and verifies this with the procedure codes.
The primary coding system used in physicians’ offices for
professional services and procedures is Current Procedural
Terminology (CPT), ∗ published and updated annually by the American
Medical Association (AMA).
CPT uses a basic five-digit system for coding services
rendered by physicians and two-digit add-on modifiers to indicate
circumstances in which a procedure as performed differs in some way
from that described in the code. Procedure code numbers represent
diagnostic and therapeutic services on medical billing statements
and insurance forms.
Example Current Procedural Terminology Procedure Code
Numbers
CPT Code Description of Services
99203 Office visit, new patient (E/M service)
73030 Radiologic examination, shoulder, two views (Diagnostic
service)
20610 Arthrocentesis inj.; major joint, shoulder (Therapeutic
service)
Main terms
The CPT index is organized according to main terms, which can
stand alone or be followed by modifying terms. Main terms can
represent:
Procedure or service (e.g., endoscopy, consultation)
Organ or anatomic site (e.g., colon, arm)
Condition (e.g., abscess, hernia)
Synonyms, eponyms, and abbreviations (e.g., Bricker Operation,
Fibrinase, EEG)
STEPS FOR CODING PROCEDURES:
Step 1 – Read through each statement.
Step 2 – Identify the main term for each statement (Remember,
codes can be searched by: condition, procedures, organ, anatomic,
synonyms, eponym, and or abbreviations.
Step 3 – Code only what is documented in each statement.
Step 4 – Assign the applicable code number(s) needed to
accurately classify the statement being coded.
EXAMPLES
Angiography, AV Shunt See Arteriovenous Shunt
In this example, the main term entry can be either angiography
or Arteriovenous Shunt CPT code 75791
Closed treatment of wrist dislocation, 1 bone with
manipulation
In this example, the main term entry would be dislocation CPT
code 25660
Dilation and curettage of cervical stump
In this example, the main term entry can be either dilation
and curettage or cervix. CPT code 57558
Medicine
Medicine I covers injections, psychiatry, dialysis services,
diagnostic medical services for gastroenterology, and nonsurgical
procedures on the eye and ear.
Medicine II has cardiovascular and pulmonary diagnostic and
therapeutic services, procedures for allergy, and neurology.
Medicine III includes genetics, chemotherapy and physical
medicine. The special services of osteopaths and chiropractors,
additional anesthesia codes, and other special procedures and
services are the final subsections of CPT. The Category II and III
codes may not be accepted by all insurance plans. Some of the
special services, procedures, and reports also may be excluded from
payment. Many CPTs ago, office visits were part of the Medicine
section. Then they became evaluation and management services and
are now listed separately. The invasive procedures in this section
are diagnostic and are usually considered non-surgical. This may
seem strange since coronary angioplasty, the procedure some people
have instead of open-heart surgery, is in this section.
Many doctors use services from this section, such as
injections, electrocardiograms (ECGs), and pulmonary function
testing. Generally, as you can see from the subsection listing,
these services belong to a medical specialty. Study these services
carefully. The guidelines for this section should be familiar. Now
we apply them to medical services rather than surgery.
Caution: Watch for multiple codes, modifiers, and quantity
reporting. One item requires a code from the E/M section.
Medicine – (90281-92700)
1. Three injections of allergen with the provision of the
extract and professional service.
CPT Code: ___________________
2. Two photo patch tests.
CPT Code: ___________________ × _______
3. Replacement of contact lenses.
CPT Code: ___________________
4. Patient is fitted for bifocal spectacles.
CPT Code: ___________________
5. Electro-oculography with interpretation and report.
CPT Code: ___________________
6. Optokinetic nystagmus test.
CPT Code: ___________________
7. Positional nystagmus test, with recording, five
positions.
CPT Code: ___________________
8. An esophagus acid reflux test with nasal catheter electrode
placement for detection of gastroesophageal reflux.
CPT Code: ___________________
9. Peritoneal dialysis with two (repeated) physician
evaluations.
CPT Code: ___________________
10. Hypnotherapy.
CPT Code: ___________________
11. Bernstein test for esophagitis.
CPT Code: ___________________
12. Evaluation of auditory rehabilitation status, 1
hour.
CPT Code: ___________________
13. A total of 50 minutes spent on family psychotherapy
without the patient present.
CPT Code: ___________________
14. Hemodialysis access flow study to determine blood flow in
grafts.
CPT Code: ___________________
15. Puretone audiometry; air and bone.
CPT Code: _______________