components for each system

The elements for each system are listed here. 

Constitutional (all)

 • Three vital signs

 • Appearance

Head and face (all) 

• Head and face

• Palpation or percussion of face

Eyes (one)

 • Inspection of conjunctivae and lids

 Ears, nose, mouth and throat (all) 

 • Otoscopic exam of auditory canals and tympanic membranes 

 • Inspection of nasal mucosa, septum and turbinates 

 • Inspection of teeth and gums

 • Examination of oropharynx

Neck (one) 

• Neck 

 Thyroid Respiratory (all)

 • Auscultation of lungs

 • Assessment of respiratory effort 

Cardiovascular (all) 

• Auscultation of heart 

• Observation and palpation of peripheral vascular system 

Gastrointestinal (all)

 • Examination of abdomen

 • Examination of liver and spleen 

Lymphatic (one)

 • Palpation of lymph nodes in neck, axillae, groin or other location 

Extremities (one) 

• Inspection and palpation of digits and nail

Neurologic/psychiatric (one) 

• Time, place, person orientation 

• Mood and affect Other

• Additional exam components determined by the physician that are appropriate for patient’s presenting complaint

CPT index

The CPT index gives a listing of all the codes. The different methods you may use to find a code in the index are:

1. Name of the procedure 

2. Anatomic site or organ 

3. Condition 

4. Eponym – the name of the person who developed the procedure or service or who it is named for 
5. Symptom

6. Common abbreviation

Category I codes are used for reimbursement of physician services and procedures. However, use of a CPT Category I code does not guarantee payment. Each carrier may have specific reimbursement guidelines that will indicate that a Category I code is not payable. For example, CMS (Medicare) will not pay for a spirometry (94010) and a flow-volume curve (94375) when they are performed on the same day.

Category II codes provide information on performance measures and data collection. There is no monetary value for these codes. Category II codes are not required for submission of claims for reimbursement at this time. PQRS (Physician Quality Reporting System) is currently optional but it is proposed to be a required component of coding in the future by Centers of Medicare and Medicaid Services. For 2015, CMS has proposed taking a small percentage of deductions from their allowed amount of payment on claims if the PQRS information is not provided by the providers. For other payers, however, it may or may not be necessary to include these codes on a claim when submitting for reimbursement.

Category III codes are used to track new procedures and technology. These codes are not recognized by payers as payable codes. These codes need to be used in addition to an unlisted procedure code to indicate to the payer/carrier the type of service being provided. The payer/carrier then may make a determination as to whether it chooses to reimburse for the new procedure and/or technology. Two category codes that may be used in the allergy practice are the following:

• 0243T – Intermittent measurement of wheeze rate for bronchodilator or bronchial-challenge diagnostic evaluations(s), with interpretation and report 

• 0244T – Continuous measurement of wheeze rate during treatment assessment or during sleep for documentation of nocturnal wheeze and cough for diagnostic evaluation for three to 24 hours, with interpretation and report

The codes above have a sunset of January 2016. If there is not sufficient acceptance and use as a standard of care by January 2016, these codes will be deleted.

PROCEDURE CODING

Healthcare Common Procedure Coding System

CPT-4 is a component of the HCPCS (Health Care Procedural Coding System). HCPCS codes were created by the AMA, and are maintained and renewed on a yearly basis by the AMA with the guidance of an editorial panel and advisory committee. The CPT (Current Procedural Terminology) Book is a standardized code set used to describe the medical, surgical and diagnostic services and procedures provided by physicians and other healthcare providers.

CPT codes are divided into three categories. Category I codes describe procedures which are accepted as standards of care codes and are also the primary codes used for reimbursement for physician and non-physician provider services from thirdparty payers and patients. Category II codes are used for performance measures and data collection. Category III codes are temporary codesfor emerging technologies, services and procedures.

According to the general instructions for use of the CPT book, any procedures or services in any section of the book may be used to designate the services rendered by any qualified physician or healthcare professional. CPT does not determine the reimbursement for services. This amount is determined by contracts between the healthcare providers and the insurance carriers that cover the provider’s patient population. The CPT guidelines also indicate that any service or procedure performed should be documented in the patient’s medical record to support the code(s) chosen. If a service or procedure provided by the physician or other healthcare provider is not described in the CPT book, the unlisted procedure code for the appropriate section should be chosen.

TheCategory ICPTcodes are divided into six sections. Each section is further divided into subsections. Each section and subsection has instructions on the appropriate use of the codes. The codes in Category I are listed in numeric order with the exception of the evaluation and management codes (99201-99499), which are listed in the beginning of the book, because most physicians will use these codes in their practices.

The six sections of the CPT Category I codes are: 

• Evaluation and Management (E/M) 99201-99499 

• Anesthesiology 00100-01999 

• Surgery 10021-69999 

• Radiology 70000-79999 

• Pathology and Laboratory 80000-89356

• Medicine 90000-99602

In addition to the Category I codes, the CPT book includes Category II codes, Category III codes and several appendices. Appendix A provides a list of all modifiers and descriptions of the modifiers.