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.
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
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
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
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.