ICD, CPT Codes & Modifiers

ICD, CPT Codes & Modifiers
ICD Codes
ICD stands for International Classifications of Diseases and it is a medical classification of diseases,
disorders, injuries and other related health conditions attributed to human beings with digital codes
which are international standard for reporting.
World Health Organization (WHO) is the governing and authorizing body for medical classification.
ICD 10:
ICD-10 is the 10th revision of ICD coding and it contains alphanumeric codes for diseases, signs and
symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or
diseases.
It was adopted and implemented in USA on October 1, 2015 replacing ICD-9.
ICD 10-CM (Clinical Modification):

Used by healthcare providers and for diagnostic coding to report diagnoses in all clinical settings for
part B.
ICD Codes
 ICD-10 codes consist of 3 to 7 alphanumeric characters

 Codes longer than 3 characters always have decimal point after first 3 characters
 1st character: Alpha
 2nd through 7th characters: Alpha or Numeric
 7th character used in certain chapters (obstetrics, musculoskeletal, injuries, and external causes of
injury)
CPT Codes
Current Procedural Terminology (CPT) is a set of codes maintained by the American Medical
Association and describe medical, surgical, and diagnostic services
Code set is designed to communicate uniform information about medical services and procedures
among physicians, coders, patients, clearing houses and payers for administrative, financial, and
analytical purposes.
CPT codes are reported in conjunction with ICD-10 codes to health insurance companies for
reimbursement of services rendered by a healthcare provider.
Format:
 Five digit alpha numeric codes i.e. 99215, 3008F
 CPT codes are also called procedure codes
 Procedure codes should correlate with diagnoses code(s).
CPT Codes
Categories/Types of CPT code
Category I
 Codes for evaluation and management: 99201–99499
 Codes for anesthesia: 00100–01999; 99100–99150
 Codes for surgery: 10000–69990
 Codes for Radiology: 70000-79999
 Codes for pathology and laboratory: 80000–89398
 Codes for medicine: 90281–99099; 99151–99199; 99500–99607
CPT Codes
Categories/Types of CPT code
Category II
 (0001F-0015F) Composite measures
 (0500F-0575F) Patient management
 (1000F-1220F) Patient history
 (2000F-2050F) Physical examination
 (3006F-3573F) Diagnostic/screening processes or results
 (4000F-4306F) Therapeutic, preventive or other interventions
 (5005F-5100F) Follow-up or other outcomes
 (6005F-6045F) Patient safety
 (7010F-7025F) Structural Measures
Category III
 Emerging technology (0016T-0207T)
CPT Codes - Evaluation & Management
Evaluation & management codes are commonly known as E&M Codes.

It is the process by which physician-patient encounters are translated into five digit CPT codes to
facilitate billing.
E&M codes specifically begin with 99 and fall in category I.
Basic Components:
History
Physical Examination
Medical decision making
Time - Key or controlling factor when visit consists predominantly of counseling and coordination of
care.
CPT Codes - Evaluation & Management
New Patient:
A new patient is one who has not received any professional services from health care professional of
the exact same specialty, who belongs to the same group practice, within the past three years.
Established Patient:
An established patient is one who has received professional services from any health care
professional of the exact same specialty who belongs to the same group practice, within the past
three years.
Outpatient New
Codes 99201 99202 99203 99204 99205
Time (Min) 10” 20” 30” 45” 60”
Outpatient Established
Codes 99211 99212 99213 99214 99215
Time (Min) 5” 10” 15” 25” 40”
CPT Codes – Preventive Care
What is preventive health care or visit?
Preventive care includes immunizations, regular checkups, lab tests, screening, physical exams,
prescriptions, diagnostic services that help doctors to understand symptoms or to diagnose patient’s
illness.
 These checkups are important to prevent inherited diseases because doctor do checkups
according to patient’s health record, age and family history and these visits help one to identify the
disease at earlier stage.
 Preventive care relates to full body checkup to manage insignificant problems, while office visit is
focused on a particular decease.
 Exact content and extent of the exam is based on the patient’s age, gender and identified risk
factors; a comprehensive history and physical face-to-face visit.
 The ordering of appropriate immunizations or laboratory/diagnostic procedures.
 These are covered annually.
CPT Codes – Preventive Care
Annual Wellness (Preventive Visit Codes) Other than Medicare

Age (Years) Less than 1 1-4 5-11 12-17 18-39 40-64 65 or above
New 99381 99382 99383 99384 99385 99386 99387
Established 99391 99392 99393 99394 99395 99396 99397
Annual Wellness (Preventive Visit Codes) Medicare

Code G0402 G0438 G0439
Description Welcome to Medicare Initial Annual Wellness Subsequent Wellness
Duration First year of enrollment Enrollment more than a year One year after the initial visit
Modifiers
Modifier is two digit indicator that describes how a standard CPT has been modified in some way.
Modifier indicates additional information on a service performed.
Categories:
The following categories serve as a reference point when ranking modifiers.
A) Pricing or payment modifiers are used to determine the reasonable charge or fee for a service.
These modifiers impact on the payment of CPT Codes. For Example: TC & 26.
B) Statistical Modifiers provide additional information but don’t directly affect the payment. These are
used for documentation purposes and can affect the processing. For Example: 24, 25, 59, 76, 79
http://www.sccma-mcms.org/portals/19/assets/docs/modifier-reference-guide.pdf
Modifiers
Modifier TC – Technical Component

Certain procedures are a combination of professional and technical components. When only the
technical component is reported, the service is identified by adding modifier TC to the procedure
code.
Modifier 26 – Professional Component

Definition: Certain procedures are a combination of a physician component. When the physician
component is reported separately, the service may be identified by adding the modifier 26 to the
usual procedure.
Modifiers
Example of Modifier TC & 26:
If the x-ray were taken elsewhere, such as in a hospital, the hospital would bill the code 73600-TC,
indicating that the hospital is billing only for the technical component.
The radiologist at the hospital who read the x-ray would also bill the code 73600-26, indicating that he
or she read and interpreted the x-ray and wrote a report concerning his or her findings.
If the provider performed both the technical component and reading/interpretation of the x-rays no
modifier will be appended.

ICD, CPT Codes & Modifiers

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ICD, CPT Codes & Modifiers

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ICD, CPT Codes & Modifiers

ICD 10-CM (Clinical Modification):

 ICD-10 codes consist of 3 to 7 alphanumeric characters

Evaluation & management codes are commonly known as E&M Codes.

Annual Wellness (Preventive Visit Codes) Other than Medicare

Annual Wellness (Preventive Visit Codes) Medicare

Modifier TC – Technical Component

Modifier 26 – Professional Component

Example of Modifier TC & 26:

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