current procedural terminology Professional Edition Current CPT Editorial Panel Mark S. Synovee, MD*, Chair JoEllyn C, Moore, MD, FACC, FHRS Christopher L. Jagmin, MD, FAAFP*, Vice Chair Douglas C. Morrow, OD Zach Hochstetles, MPP, MBA, CPC, Daniel J. Nagle, MD, FACS, FAAOS Linda M. Barney, MD, FACS Judith A. O'Connell, DO, MHA, FAAO ‘Aaron D. Bossler, MD, PhD Robert N, Piana, MD, FACC* Daniel E. Buffington, PharmD, MBA Daniel Picus, MD, FACR, RCC’ Samuel L. Church, MD Jordan G. Pritzker, MD, MBA, FACOGT Richard A. Frank, MD, PhD Lawrence M. Simon, MD, MBA, FACS Michael O. Idowu, MD, MPH Timothy L. Swan, MD, FACR, FSIR David M. Kanter, MD, MBA, CPC, FAAP Kevin E. Vorenkamp, MD, FASA Barbara S. Levy, MD, FACOG Gloria A. Wilder, MD, MPH Janet L. McCauley, MD, MHA, CPC, FACOG AMA\ "Member of the CPT Executive Commitee ‘Former CPT Editorial Pane! Member, who was active during 2023 content creationSymbols Revised cose New code Nero revised text Fetotace to CP Assistant, lineal Examples in Paoogy and CPT Changes Addon cade Exarptions to mater 51 Prodvet pending FDA apron ‘Qurot numeral sequence code Telemedicine Audroniy Duplicate PLA test Category PLA axanaroe Ofer Modifiers (See tonendix or definitions 22 eases Roce! Ses 22 Unusual Anesthesia 24 Unrelated easton nd Management Seve ty he Same Phys er Olid Hoa Care Prussia Dal aPoxoprte Pa 25 Sapicar Separately enable Evuaton and Marayene Sais by th Same Pysclan or Other Qhatfiogcalth Car Peessonlon ‘he Sone Oa ofthe Frc Oh Seen FotestonaCanpone Manda Sesies Preventive Services Aves by Soon Bist Pooaie Multiple Prcedies Reed Serves Diconned Proecee Supa! Care Oy Postoptate Marogement Oly Preoperative Management Oly Decne Sugary oad roca or Saice byte Same Phy rOter Oot Heat Cte Pessoa Ding tha Postpeate Prd Disint Procedural Seve Two Surgeons ProceduePrfamed on fans ess han ig Surgical Team Aepea Peete Seice Same Physician e Oar Acatd Heath Cre rofestnal Repeat Proce by Anata Pysion rhe uid Heath Co Pees! Unplanes Reto te Operating Procedure Room by he Sona Pysican Otel veath Cre Peso Felowing tal oceie fo aed Pocndre Dury te Postoave eri Unrelated Pricer ox Sen bythe Same Physician o ier dae Heath ar Froessenal Dg te Postopoatie Pod 0 Assistant Surion 1 Minimum Asta Surgeon {2 Asian Surgeon on quale ese surgeon ot % 9 eugagegzesene a 3 agage ‘vailabe) Reference (Outside Laboratery Repeat Cina Diagnostic Laboratory Test 82 _Aemative laboratory Platform Tetra 83 _Synetvonaus Telemedicine Sevice Rendered Via Telephone or (ther RealTime iterative Auso-OnyTlecommunicatons System 9% _Synctronas Telemedicine Senice Rendered via a Real Tine intractve Avia and Video Teleconmuneations System 9% Hobiitatve Services 97 Rehabilitative Sences 99° Muliple Meifies Category Il Modifiers. 1PFerfumance MaasureExusion Moifir due to Medical Reasons 2P _Porfumance Measure Exclusion Madi due to Patient Reasons BP Pertonoce Mesure Ecuson Moir deo Syston ‘W Performance measure reporting modiir-ation nt ‘formod, c3son net there specieg Anesthesia Physical Status Modifiers ‘Arora healthy pation ‘patient wath mld system disease ‘patient with saver systomic disease [A patint with sve systomic ease thats a constant teat oie ‘Amovioun paint who isnt expected to survive without the aeration ‘A declared brain dad patient whose organs ae being removed for dor purposes Modifiers Approved for Hospital Outpatient Use Level I (CPT) 25 Sancant. Separately dete Evaluation and Management Senice by tho Same Psa o Other Gusti Heath Care Professional onthe Sama Dayo the Pooadut er Other Serace Mulipie Outpatient Hospital f/M Encounters on be Same Date Preventve Serveas Bilateral Procedure Feduoed Services Staged or Rlatad Procedure or Sec by the Same Prion or hor (valfied Health Care Professional During the Postoperave Period Distinet Procedural Senive Discontinued Outpatient Procedure ror to Anesthesia Administration Discontinued Outptiant Pocedure After Anastasia Adminstration Repeat Procedure or Seice by Sane Pysican or Other Qualified Heath Cate Profesional Fepeat Procedure by Another Phystan or Other valid HealthCare Professional Unplanned Return to the Operating Procedure Roam by he Same Prien or Other Ouales Heath Care Professional Following ntl Procedure fora Rested Procedure During tho Pastopaatve Prod Unveate Procasue or Serie by the Same Physician or Other Qualified Health Cre Professional Dating the Postoperative Prod ‘Repeat Clncel Diagnostic Laboratory Test {evel II (HCPCS/National) EI Uy lt eyelid £2 Lowor et oy EB Upper ight, eyed EA Lowor ight eyelid FA Left hae, thumb FL Left hae, second digit F2 Left hand, third digit Lett and fourth gt Left hand fifth digit Fight hand thu Fight hand, second digit Fight hand, thir iit ight hand fourth digit Right and ith git Performance and payment of a sereening mammogram and diagnostic rmamogram onthe same gate, same day Diagnostic mararaggar convert am seeing nanrnogram on same day Left ircumfescoonary artery Left antrior descending coronary artery Left main crenary artery Left side used o identify procedures performed onthe ltt side of the body Ambulance service provided under arangement by a prover of services| ‘Aamulance service fished dct by a provider of sorices Right coronary artery Ramus intermedius coronary artery Aight side used to identity procotures performed onthe right side of the bey) Lei oot, great oe Left fot second digit Left foot third lt Left foot fourth digit Left foot fit digit Fight foot, great oe Fight foot, second digit Fight foot, hie digit Fight foot, fur digit Right foot. th digit wo axa eeess 2 Beg S652 guazanza daddddasag C C Cc Cc Cc e q Cc c Cc Cc ry a mf aA A Ae am OmUse these tabs to mark section openers and important pages in your CPT’ 2023 Professional Edition codebook for quick reference and review. QS 8 Cc 2 2. sh & B : 7 8 ° = 7 z m E| i gs = z2 a o a a ot 2 8 i a3 ORE 2 m 3 = BS = 2 i a 23 5 ) 2 x= SO g EF z# 2 5 2 a | a e 8 gs) s ¢& Zz o ) ° a = = 8 o|' 58 5 3 a 9° . 668 Copyright © 2022 American Medica Association,Customize your CPT° 2023 Professional codebook and make it work for you. These removable and reusable tabs can be used to flag the code sections and codes that you refer to regularly. Use the printed tabs to flag the section openers of each section. Use the red tabs to flag key pages in Evaluation and Management, Radiology, Category Il and Category Ill. Use the blue tabs to flag key pages in Anesthesia, Pathology and Laboratory, Appendixes, and Index. Use the green tabs to flag key pages in the Surgery and Medicine. Use the yellow tabs to flag codes that you commonly use in your practice, codes that you need to research further, or personal notes that you've written into your codebook.Place-of-Service Codes for Professional Claims Listed below are placeof service codes and descriptions. These codes should be esed on profesional cums o specify the en where service(s) were rendered, Check with individual pets (6g, Medicare, Medicaid, ther privat insurance for imburscmen polices tepurding these codes. I'you woul ike to comment ona codes) or description), plese send yout request o posinfogaems hs gov Place of Service Code(s) | Place of Service Name_| Place of Service Description 7 ‘Tacit o location where dugs and other medically related items and sewies ar sold, dispensed, a Pramecy ar otherwise provided rect to patients (ect 0/1/05) Telehealth Frovdeg Other) TW#l0cation where heath services ad health related services ae provided or received, trough o Fees Prove telecormmuricaton ecology Paint i ot ested in ther Rame when cing health sees heath tanin Patient's Home tolated services through teerommunication tecnolgy.(tertve 1/1/17) @ Schoo ‘A fcity whose primar purpose i edvetion ies 17/03) ‘A fxilty or location whose prmary purpose so provide teprary Hsing Homeless indus o Homeless Shelter (eg, emergoncy shel, inviual rf shetersh fective 1/0) mia feats ‘A fcity recto, owned and operated the indian Health Seni, which provides daghaste,Herpeie 05 Indian Heath Senica {surge and on sugeal, ond enabltation serves o American Incans ard Alaska Natves who do not fe Standing Facity Fequve hasptaleation (tect 1/1/03) ‘A foityo locaton, cum and operated bythe Indian Wealth Seve, whieh provides diagnostic, herapautic Indian Heath Senice } « Isurgel and non sical ang rehabilitation series rendered by, r vader te supervision, physio a Frovitr-osedFocity | mpea nda and Asta Nate amited 3s patents patients, Elect 1/103) “ibe a8 -Afelity or location owned and cperated bya federal recogtized Amaican indian or Alaska Native vibe o 0 ee J ogenization under a 638 agreement, which provides degnoste, therapeutic sugical and non-surgical toning Facility and rehabilitation services t trital members who do not require hospitalization. (EMfective 1/1/03), “ial oe ‘A faci or locaton cued an opera by a federally recognized American Indian Ales Natv he or 06, in tbl organization under a 638 areerent.whicn provides dagost therapeutic sugcal and nonsurgical, der Based Facity and ehabltaton seas total menbers adnited as inpatient xoutpavetsEectve 1/103) ‘A prison, eermatory, work fa detention centr, or any athe ini ality meirtied by ether Fr © Prisor/Carectional Failty | ‘Stte, orca autores for he purpose coninenent er retaitaten of acu orien crmnal oer (Giecive 71/06, The locain wero hoalth ances and heal elated series are pronded oeceed, vowh 10 Telehealth Provided in telecommunicatian tecnology, Patients located in ther home (whichis 2 location otter than 2 hospital or ther Patient's Home ‘acy where the patient ecaives care ina private residence) when reoeiving health sence or heath elated serves through telcommunicato technology (fective 1/1/22) Location, oer than a hospital skied using fciy [SFL military eat faci, community heath canter, " ice Stato iol publ heal cic, mtemedat et faci IF) where the heath fessional ote rds heath examinations, egress, nd teatmet of ines rinjury onan ambulatory basis 2 Home Location, ter then hasta her fait, wher the patent ees cre ina peat residence Cengragat sional acity with sel-comaneé ng units raving assessment ofeach resident sands 13 Assisted Living Facty andesite support 24 hours 2 ay 7 days. a week, with he copay ta deve or aang fo sence inuting Some health cre andotersevics.Efective 10/1/03) 7 cael ‘A esienc, with shard lng tes, where cents recive supeison ad ote sowoes sah as sl andor oup Home behavioral servees, usta Serve, and minal sevioes eg, medicaten adnstation)(eectwe 10/1/08). “A fcity/uit that moves trom olace-o-ace equipped to prendeprvetve, Srening, diognostc, 7 Mabie Unit and/or teatment services. eMective 1/1/03) "A shart tem acconodation sch as ote carp ground, Fest cruise ship ot eso where the patent « Temporary Leng feces tare and which sot detid by any oer POS coe. ecve 4/0) ‘A wallcn eath ln, othe than an ofc, urgent care feciiy, phamocy, oF independent cline, and not ” Walkin etal Health lnc) exebed by any ater Place of Sorc cde, tha located vnhin a etal operation and prods, onan ambulatory bas, pavontwe and primary care serves. ectve 5/1/10) ‘A location, ot described by any oer FOS code, owned ox opertedb 9 public or pvate entity where the 8 Pace ofEmployent/ patient is ployed, and here a heal professional pads on-going ot esd ceupatonal mada, Worse therapeutic or ehabitative services to the india. (This cage acalable for use effective Jonuary 1, 2013 butin later than May 1, 2013) Dione! * partion of n of eamqu hospital powder based department whieh powdes agnosie hrapeute bom 13 OF Cas suigeal and norsugial and rehabitation serves to Sicko nued persons who donarequte hsptalation patent Hospital ar ntutonalzaton (fective January 1, 2016) "| a acne cation, distinct rom a hospital emergency room, an ffs, or acl whose paose isto diagnose and vest, gent Gare Facity ies or nj er nschedued,araulatry patios soaking media medica attention (Eetve 1/103) ’ city, other tan psychi, which primarily provides clagneste.theapedti bot surgical and 2 Inpatient Hosp nonsurgical and rehabilitation servos by. or under, the supesin of physicians To patints admitted for 2 vatty of medical enitns one ‘portion of aspias main campus which provides dagnoste therapeutic bth surgical and 2 On Camps al ror-sugicall andrea sere To Sex or mura persons who donot require hesplation patent Ho Or nstittealzaton (Dasrtion change fete Januaty 1, 2018) B ErergeneyRoom—Hosptal_| A porn of hespital where emergency diagnosis ad treatment ess ori is provided 7 ‘Ambulatory Sua ’teestanding fly ater han a physicians ofc, whee sugtal and agnote ss re provided oo Centr an abulatery bas ‘A feclity, ther than a hospital’ matey fie ora pice’ offie which provides sting for labo. %s Birthing Center Galery, and immediate pstpartum creas wel as immesiate care of nwbom nants. ‘A medical faiity opetad by oe or more th Unarmed Sees. Miltary Teatment acy [MF abo B Miltary Treatment Fecity | refers to certain farmer US. Public Health Senice (USPHS) faites now designated as Uniformed Service | Treatment actives (STE. 7-0 Unassigned [wa“Rfaciiy which primarily provides inpatient sled rursing cae an related sevice To patents Who requre a Stites wusigFactiy | medal nursing or eho seuss bt does rol prod tele car teaent tle inahoxpil 7a hich pinay pds owes led nrg oe and aad sen rb ehsbavan 2 Ning Fy ied Gale oS pone oa el tsi, betel cae saves above the lvl of etl {ire oer ton ils th tle Seabhoes = Alay at vids oom ad ar tar personal aianc evs, ec oa longo ak, ad 8 Custodial Care Facility which dogs not include a medical component. 7 a ‘gly ob: oy asthe a wha ac pe ow TEA weal__| Wrassned NA a Anus land Alan ei apa aig pad ad sad Tes nd waaporing i ko re 2 Ante Arnis | BQBi Noe DIC Gre Staaten avanti este aia | Brassed Wh losin, ot pat oa oslo eBay any ar Pav of Sars sle at gated and 6 dependence coer to pode preventive guste herpaie, wshiate,o paltveseves io aupstens en tbcctne ta) 7 7 Fedral Ouafed ‘A fait ested nae undead are a roves Meare baeGares woveive pay feat Center medal ae unr he etl econ os py, ' Tac Faahay | A city at roves inpatient pyc: snes rh agnosis and weatnen a nna ess ona 2 = Jnationt Psychiatric Facity | hr basis, by or under the supeiston ofa physician oye Fecly ATI rte Gagrosis ard vest fn lei at ods a pane arpeae pom 2 Peyeniatic Foci Patients wh donot equrefl ime hsptlzation, But who need broader proarams thr ae posse fom tal Hosp ‘outpatient visits to a hospital-based or hospital-affiliated facility: ‘A facility that provides the following services: outpatient services, including specialized outpatient services for Clan eye ae sc nd reser ne Gs meant artes te 7 Comunity Mens ‘hohe been Gerhage tm roa! vate at meni heath aly 2 ado emergence Hel Cner ‘Serica vstnent lr paral horpliton sree a paste eabltaton sever seenng fr patents beng coma ssn fo Slate menalneai eles o dele Be apropatness | dnt, ad conto sn edo serves Temata Cre fact which inary pods hel ted cave and snes above laf toda creo se Faciynwuae wih | indvdsls th feta Gals br bes not pode te eel caro eatmet slate asp melita! Deaiies | or SNE : Abas | Aaliyah proves vata rasan oan abi eens who do ot nite a ae ist, cg and sips, pylori, en oom an bad _ 7 Pej Rogdenia | Actor dsc pt of fact for scat cr which pow a al Dhar Braap Fea Comer and polessonaly Sted gaup ln er erng ero T Nonsesitentl Substance Alocation which provides nestrent fo substance aloha nd va abuse onan ambulatory basis, Services 9 Nancie Substance eo asia ny aan one, aml easing bry 3s, Oa a sips and | “ ‘psychological testing. (Effective 10/1/03) 7 Tesreiial Op? Ancation tat prods extent or pid se Gast oan ant ba, Sees nce nahadoe | Treatment Facity ‘and ther forms of Medication sisted Treatment (MAT Eective January 1, 2020) 8 Unassigned NA ‘ain aes Bald sine nel pana nd Whoa vu acs a it lsslnmicaton contr | as see as leone aa dane, ppt lan, rng te string method. Th goer aes 0 Mass snail pléca in a mass immunization setting, such as, @ public health center, pharmacy, oF mall but may include @ Brice fis sting 7 7 lacy prods corer enabiatn sonics une We spain oo pono aon A Congres mgaient | eh pyacalSsoblies Sarr nce gyal thea, conpatnal heey. pach alg, slab ty psychological services, and orthotics and prosthetis savices. Aa tat pode conoretense reilatian cvs ude upton oa py options Somphensve owpatont | abies Sees nude hyseal hap. ccapavoal ep. on spe @ meget tet | we ea Sine Svc wenn ap eet Rea, oo pepo Be | Uhasined NA : : _| 7 End-Stage foal Dasase | Atal ane han spa, which proves das wearer maitenane ado anno pate Treamat Fatty carats onan ably ame ee has, E70 | asia Wi 7 a oon ii ‘ay aid rea Sats lath departs at ovis nly pinay medal are eth Cine nde tegen ection a psa | area ‘Acetic whichis eatin a wal nadia andosered aa al provides abla anay n Aol Heath Clinic ‘medical tare under the general direction ofa physician, Teat__| Wrasse rm 7 spre ran, | acta to Japon rcs wldonen wasn ays a8 [assed rm # (ie Pace of Saco | Ot pe of sno nt did abvcurrent procedural terminology Professional Edition Current CPT Editorial Panel Mark S. Synovee, MD*, Chair JoEllyn C. Moore, MD, FACC, FHRS Christopher L. Jagmin, MD, FAAFP*, Vice Chair Douglas C. Morrow, OD Zach Hiochstedex, MPP, MBA, CPC, Secretary Daniel J. Nagle, MD, FACS, FAAOS Linda M. Barney, MD, FACS Judith A. O'Connell, DO, MHA, FAAO Aaron D. Bossler, MD, PhD Robert N. Piana, MD, FACC* Daniel E. Buffington, PharmD, MBA Daniel Picus, MD, FACR, RCC* Samuel L. Church, MD Jordan G. Priteker, MD, MBA, FACOG? Richard A. Frank, MD, PhD Lawrence M. Simon, MD, MBA, FACS Michael 0. Idowu, MD, MPH ‘Timothy L. Swan, MD, FACR, FSIR David M. Kanter, MD, MBA, CPC, FAAP Kevin E. Vorenkamp, MD, FASA Barbara S. Levy, MD, BACOG Gloria A. Wilder, MD, MPH Janet L. McCauley, MD, MHA, CPC, FACOG AMA’ “Member of the CPT Executive Commirree Former CPT Editorial Panel Member, who was active during 2023 content creationSenior Vice President, Health Solutions: Lori Prescesater Vice President, Coding and Reimbursement Policy and Strategy: Jay Ablmsst Director, CPT Coding and Regulatory Services: Zach Horhseeer Director, CPT Contene Management and Development: Leslie W. Prellwite ‘Manager, CPT Editorial Panel Processes: Desiree Rove Manager, CPT Content Management and Development: Karen E, O'Hara Vice President, Operations Health Solutions: Denise C. Foy Senior Manager, Publishing and Fulfilment: Elizabeth Goodman Dake Manager, Developmental Editing? Lisa Chin-Johnson Production Specialist: Mary Ann Albancse Vice President, Sales and Marketing: Sue Wilson Director, Print, Digital and Guides: Exin Kalitowski Director, CPT Operations and Infrastructure: Barbara Benstead Director, Product Management, CPT Infrastructure: Julio Redhiguee Marketing Manager II: Vanessa Prieco Printed in che United States of America. 2223 24/ BD-RD/98 7654321 Profesional ISBN: 978-1-64016-213-6 ISSN: 0276-8283 Garros Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2022 by the American Medical Assocation. All ight eserved Ise Edition printed 1966 2nd Editon printed 1970 3rd Ediion princed 1973, 4h Edition princed 1977 Revised: 1978, 1979, 1980, 1981, 1982, 1984, 1985, 1986, 1987, 1988, 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2019, 2020, 2021, 2022 iced, in any form [No patt of his publication may be reproduced, stored in a cetrieval system, or tansn cor by any means electronic, mechanical, photocopying, recording, or otherwise, widhout the prior written permission of the publisher To purchase additional CPT products, contact (800) 621-8535 or vist the AMA Store at amastore. com. Refer to product number EPOS4123. 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We appreciate your efforts and cooperation in reducing content piracy and Smproving copyright protections.About CPT Gurnent Procedural Terminology (CPT®), Fourth Edition, isa liscing of desciprive tems and identifVing codes for reporting ‘medical services and procedures performed by physicians and other qualified health cate professionals. The purpose of the terminology is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services, and will thereby provide an effective means for reliable nationwide communication among physicians and other qualified health care professionals, patients, and third parties CPT 2023 is the most recent revision of a work that fist appeared in 1966, CPT descriptive terms and identifying codes currently serve a wide variety ofimporseae functions inthe field of medical nomenclature. The CPT code set is useful for administrative ‘management purposes such as claims processing and forthe development of guidelines for medical care review. The uniform language is also applicable ro medical education and outcomes, haalth services, and quality research by providing 2 useful bass for local, regional, and nacional utilization comparisons. The CET code sets the mose widely accepted nomenclature forthe reporting of physician and other qualifed health care professional procedures and services under government and private health insurance programs. In 2000, the CPT code sec was designated by the Department of Health and Human Services a the national coding standard for physician and other health care professional services and procedures under the Health Insurance Portability and Accountability Act (HIPAA). This means that for all nancial and administrative health care transactions sent clectronically, the CPT code set will eed to be used. “The changes that appear inthis revision have been prepared by the CPT Ealtrial Panel withthe assistance of physicians and representatives of ocher health care profesions representing all specialties of medicine, and with important contributions fiom many thied-party payers and govereatental agencies. ‘The American Medical Association trusts that this revision will continue the usefulness of its predecessors in identifying, describing, and coding medical, surgical, and diagnostic services, Maintenance and Authorship of the CPT Code Set ‘The CPT Edivorial Panel (Panel) is tasked with ensuring chat CPT codes remain up to date and reflect the latest medical care provided to patienes. in order todo this, che Panel maintains an ‘pen process and convenes meetings ata minimum three cimes per year ‘The Panel wishes to sincerely thank the many national medical specialty societies, health insurance organizations and agencies, and individual physicians and other health professionals who hhave made contriburioas. In particular, the Panel acknowledges the efforts of the following Panel Organizational and Coding Liaison Participants: Sue Bowman, RHIA, American Health Information Management Association Raemarie Jimenes, CPC, American Academy of Profsonal Codes Nelly Leon-Chisen, RHIA, American Hospital sociation ‘Tammy R. Love, RHIA, CC Auciation 1B, CMA, Amarin Hospital Mary E. Little, RN, CPC, Blue Cros and Blue Shield Ascciation Edith Hambrick, MD, JD, MPH, Centers for Medteare Medicaid Services Karen Nakano, MD, MS, Coser for Medicare & Medicaid Service ‘Also key to authorship of the code set and resulting CPT Professional Edition codebook is AMA CPT staff. This experienced team prepares agenda materials for each panel meeting, facilitates the application process, compiles and reviews advisor commenus, econciles differences in opinions, and vleimrately compiles all resulting informacion into a codebook filled with informative guidelines, practical tips, and procedural illustrations. AMA CPT Staff Shawn Agyeman Jay T. Ahiman Samantha L. Ashley, MS Thilani Atale, MS Jennifer Bell, BS, RHIT, CPC, CPM, CPC-1, CEMC, CPEDC Barbara Benstead Ande Besleaga, BS, RHIT Kemi Borokini, RHIA, CCS Kyle Dahl Martha Espronceda Desiree D. Evans, BS Kerri Fei, MSN, RN DeHandro Hayden, BS Zach Hochsteder, MPR, MBA, CPC Mark Levine CChamiece J. Martin, MBA, RHIA, CCS, Caidlin Mora Sara E Nakira, BS Karen E. O'Hara, BS, Leslie W. Prellwite, MBA, CCS, CCS-P Desiree Rozell, MPA Naney Spector, BSN, MSC Lianne Seancik, BA, RHIT Keisha A. Sutton-Asaya, MHA, CPC Donna Tyler, BS, CPC, COBGC Olewara Uzoh ‘Ada Walker, CA Atletrice Watkins, MHA, RHIA Rejine L. YoungAMA CPT Advisory Committee American Academy of Child & Adolescent Pychiatry Benjamin N. Shain, MD, PRD Jason V. Chang, MD American Academy of Dermatology ‘Alexander Milles, MD ‘Ann F. Haas, MD American Academy of Family Physicians Bradley P. Fox, MD, FAAFP. Mary Krebs, MD American Academy of Neurology Bruce H. Cohen, MD, FAAN Neil A. Busis, MD American Academy of Ophthalmology Michael X. Repka, MD, MBA. John M. Haley, MD American Academy of Orthopaedic Surgeons Frank R. Voss, MD Julie ¥. Bishop, MD American Academy of Otolaryngic Allergy Paul T. Fass, MD, FACS American Academy of Otolaryngology Head and Neck Surgery James Lin, MD, FACS Jay Shah, MD American Academy of Pain Medicine Eduardo M. Fraifeld,MD Gregory R. Polston, MD American Academy of Pediaeris qToel F. Bradley Js, MD, FAAP Renee F Slade, MD, FAAP American Academy of Physical Medicine and Rehabilitation Annie D. Purcell, DO Scott I. Horn, DO American Academy of Sleep Medicine Lawrence J. Epstein, MD# Vikas Jain, MD, FAASM* American Association for Thoracic Surgery Scott C. Silvestry, MD Charles C. Canver, MD* American Association of Clinical Endocrinologiss William C., Biggs, MD, FACE, ECNU Pavan Chava, DO, FAC! American Association of Clinical Urologists Jeffery Glaser, MD, FACS American Asociation of Newrlagical Surgeons Joseph S. Cheng, MD, MS, FACS, FANS Joshua M, Rosenow, MD, FAANS, FACS* American Association of Neuromuscular and Electrodiagnostie Medicine John C. Kincaid, MD Earl J. Craig, MD American Clinical Neurophysiology Society Mare R, Nuwer, MD, PhD, FAAN, FACP "New Advisors American College of Alergy, Asthma and Immuno James L. Sublet, MD Gary N. Gross, MD American College of Cardiology Randall C. Thompson, MD Barbara Pisani, DO, FAHA, FACC? American College of Chest Physicians Steve G. Peters, MD. Michael E. Nelson, MD, FCCP American College of Emergency Pbysicians J. Mark Meredith, II, MD, MMM, FACEP Michael J. Lemanski, MD, FACEP, FAAFP American College of Gastroenterology Christopher ¥. Kim, MD, MBA, FACG, FASGE, AGAB, FACP American College of Medical Geneves and Genomics David B. Flannery, MD American Collegeof Mohs Surgery David B. Pharis, MD, PC Kishwer S. Nehal, MD American College of Nuclear Medicine Gary L. Dillehay, MD, FACNP, FACR Alan K. Kliczke, MD, FACNM American College of Obstetricians and Gynecologits Judith Volkar, MD, MBA Jordan G. Prisker, MD, MBA, FACOG* American College of Occupational and Environmental Medicine Jill A. Rosenthal, MD, FACOEM* American College of Physicians Jeannine Z. Engel, MD, FACP American College of Preventive Medicine ‘Andrew Karasick, MD. American College of Radiation Oncology Sheila Rege, MD, FACRO Andy W. Su, MD American College of Radiology Mark D. Alson, MD, FACR, RCC Timothy A. Crummy, MD, RCC American College of Rheumatology Joseph E. Hufiseutter, MD American College of Surgeons Samuel D. Smith, MD Megan E. MeNally, MD, FACS American Dental Association Joshua E. Everts, DDS, MD ‘Adam S. Pies, DDS, MD American Gastroenterological Asociation Braden Kuo, MD Joseph Losusdo, MD American Geriatrts Society Robere A. Zorowite, MD, MBA, FACP, AGS, CMD American Insticuee of Ulrasound in Medicine James M, Shwaydes, MD, JD American Orthopaedic Association Blair C. Filler, MD 1M, Bradford Henley, MD. American Medical Association vikAmerican Orthopaedic Foot and Ankle Society John A. DiPreca, MD. Scott B. Shawen, MD, FAOA American Osteopathic Awociation ‘ames M. Bailey, DO, PhD Boyd Buser, DO, FACOFP American Prychiatric Asociation Jeremy S. Musher, MD, DEAPA Sarah E. Parsons, MD American Rhinologie Society Bradford Woodworth, MD Stacey Gray, MD American Roentgen Ray Society Eric M. Rubin, MD Dana H. Smetherman, MD, MPH, FACR American Society for Aeshetic Plastic Surgery Ine Paul R. Weiss, MD American Society for Clinical Pathology Lee H. Hilborne, MD, MPH, FASCP American Society for Dermatologic Surgery ‘Murad Alam, MD, MBA American Society for Gastroincstinal Endescapy Glenn D. Liaenberg, MD, MACP Daniel C, DeMarco, MD, FACP American Society for Metabolic and Bariatric Surgery Macchew L. Brengman, MD American Socity for Radiation Oncology Corbin R. Johnson, MD Catheryn M. Yashat, MD American Society for Surgery ofthe Hand Steven H, Goldberg, MD, FAAOS F Thomas D. Kaplan, MD American Sociey of Addiction Medicine Joel V. Brill, MD, EACP. AGAF Shawn A. Ryan, MD American Soir of Anesteslgis Padme Gilat, MD Edward R. Mariano, MD American Society of Breast Surgeons Richard E. Fine, MD, FACS. Walton Taylor, MD. American Society of Clinical Oncology Christian A. Thomas, MD Joseph J. Merchant, MD American Society of Colon and Rectal Surgeons William J. Harb, MD, FACS Joshua M. Eberhardt, MD, MBA, FACS, FASCRSt American Society of Gyopathology Carol A. Filomena, MD* American Society of Dermatopathology Jonathan S. Ralston, MD Aleodor A. Andes, MD, MBA American Society of Echocardiography Michael t, Main, MD Susan A. Mayer, MD AMA CPT Advisory Committee American Society of General Surgeons George K. Gillian, MD, FACS Danay G. Lister, MD American Society of Hematology Samuel M. Silver, MD, PhD, MACB, FAHA, FASCO. Chancellor £. Donald, MD American Socity of Interventional Pain Physicians Mahendra Sanapati, Mi Sachin Jha, MD, MS American Society of Nuclear Cardiolegy Friederike Keating, MD American Society of Neuroimaging Ryan Hakimi, DO, MS American Society of Neuroradiology Colin M. Segovis, MD, PhD Gaurang V. Shah, MD American Society of Ophthalmic Plastic and Reconstructive Surgery Neal Freeman, MD, MBA, CCS-P, FACS American Society of Plastic Surgeons Daniel T. Ness, MD Jeffiey H. Kozlow, MD, MS American Society of Retina Specials Gayacei S. Reilly, MD, Christopher R. Henry, MD American Thoracic Sociery Stephen P. Hoffmann, MD ‘Michael E: Nelson, MD, FC p American Urological Ascciation Jonathan R. Rubenstein, MD Jay A. Morola, MD, FACS* American Vein & Lymphatic Society Satish Vayuvegula, MD, MS ‘Michael S. Graves, MD Association of University Radiologists Andrew Degnan, MD Richard Duszak, Js, MD, FACR, College of American Pathologie: Jerry Hussong, MD, DDS, MS, MBA. Ronald W. MeLawhon, MD, PhD Congres of Neurological Surgeons. Henry H. Woo, MD, FACS, EAANS Cheerag D. Upadhyaya, MD, MS, FACS Heart Rhythm Society istopher F Liu, MD, FACC, FHRSt Steven C. Hao, MD, FACC, FHRS Infections Direaser Society of America Steven K. Schmits, MO Ronald &. Devine, MD International Society forthe Advancement of Spine Surgery James J. Yue, MD Morgan L. Lorio, MD, FACS* National Asociation of Medical Examiners Alecia M. Wilson, MD North American Neuromodulation Society Corey W. Hunter, MD Dawood Sayed, MD Pr 2023North American Spine Society William Micchell, MD David R. O'Brien, Je, MD Radiological Society of North America Timothy A. Crummy, MD Shiva Gupta, MD. Renal Physicians Asociation Chester A: Amedia, Jr, MD, FACP Tamathy A. Pflederer, MD Society for Cardiovascular Angiography and Interventions Arthur C. Lee, MD, ESCAL Andrew M. Goldsweig, MD Sociery for Investigative Dermatology Stephen P. Stone, MD Society for Vascular Surgery Sean P. Roddy, MD, FACS Sunita D. Srivastava, MD Society of American Gastrointestinal Endoscopic Surgeons John S. Roth, MD, FACS Kevin £, Wasco, MD, FACS Society of Cardiovascular Computed Tomography Ahmad M. Slim, MD Society of Critical Care Medicine Piyush Mathur, MD. Society of interventional Radiology Ammar Sarwar, MD Ashok Bhanushali, MD Society of Nuclear Medicine and Molecular Imaging Seoet C. Bartley, MD Gaty L.Dillehay, MD, FACNP, FACR Society of Thoracic Surgeons Francis C. Nichols, Il, MD Jeffrey P. Jacobs, MD, FACS, FACC, FCCP The Endocrine Society Vijay Shivaswamy, MD Sandhya Chhabra, MD The Spinal Intervention Society Scott I. Horn, DO The Triologieal Society Richard W. Waguespack, MD, FACS Brian J, McKinnon, MD, MBA United States and Canadian Academy of Pathology Michael O. Idowu, MD, MPH AMA Health Care Professionals Advisory Committee (HCPAC) Mark S, Synovec, MD*, Co-Chair AMA CPT Editorial Panel Douglas C. Mortow, OD, Co-Chair AMA CPT Editorial Panel Academy of Nusition and Dietetis Keith-Thomas Ayoob, FeO. RN, FADA, CSP Jessie M, Pavlinac, MS, RD, CSR, LD American Academy of Audiology Brad A. Stach, PhD Annete A. Burton, AuD American Academy of Physician Asitants Patrick }. Cafferty, MPAS, PA-C Erika Bramletce, PA-C American Association of Naturopathic Physicians Eva Milles, ND Amy E, Hobson, ND American Association for Respiratory Care Susan Rinaldo-Gallo, MEd, RRT, BAARC, CTTS American Chiropractic Association Leo Bronston, DC, MAppSe Kris Anderson, DC, MS American Massage Therapy Association Nancy M. Porambo, BA, MS, LMT, NCTMB “Angela Barker, DCTMB, LMT American Nurses Asociation Jamesetca A. Newland, PhD, RN, FNP-BC, FAANP, DPNAP Jill Olmstead, MSN, NP-C, ANP-BC, FAANP American Occupational Therapy Asociation Lelie F Davidson, PhD, OTR/L. Tippi S. Geron, MS, OTRIL, FAOTA American Optometric Association Rebesea H, Wareman, OD Harvey B. Richman, OD, FAAO American Physical Therapy Asosiation Kathleen M. Picard, PT American Podiatric Medical Association Ira H. Kraus, DPM Sarah M. Abshies, DPM American Prychological Association [Neil H. Pliskin, PhD, ABPP-CN Stephen Gillaspy, PhD American Sociey of Acupuncturists Chanta Sloma, DACM* Jessica Gregory, MSAOM. American Speech Language- Hearing Association Stuart G. Trembath, MA, CCC-A Renee Kinder, MS, CCC-SLP* National Athletic Tainers' Asociation Karen D. Fennell, MS, ATC Joseph J. Greene, MS, ATC National Auociation of Social Workers Mirean F Coleman, LICSW Doris ETames, LCSW, BCD National Sociey of Gene Conelors Karen E. Lewis, MS, MM, CGC Pharmacy Hlealth Information Technology Collaborative Brian J. lets, PhD, BCPS, FAPhA. Melissa A. Somma-McGivney, PharmD ‘American Medical Association ixContents About CP. vi Maintenance and Authorship ofthe CPT Code Set... vi AMA CPT Si vi Introduction. .......+ cote eee Release of CPT Codes, xi Section Numbers and Their Sequences: aiv instructions for Use of the CPT Codebook aiv Format ofthe Terminology iv Requests to Update the CPT Nomenclature... xiv ‘Apaication Submission Requirements Ww General Criteria for Category andi Codes... xv Category Specific Requirements, " Guidelines wi Aon Codes wi Mositiers wi Place af Service and Facility Reporting i Unlisted Procedure or Senice. oe Results, Testing, Interpretation, and Report... xvi Special Report va Time, wil Coce Symbols oi Alphabetical Reference Index. wi Use of Anti-Piracy Technology in CPT Professional 2023 Codebook il CPT 2023 in Electronic Formats. six References to AMA Resources ain {Mlustrated Anatomical and Procedural Review ....... xx Prefixes, Suffixes, and Roots ™ Numbers ™ Surgical Procedu cs Conditions cS Directions and Positions vi Additional References i MedleatOictionaries vi Anatomy References vi List of tlstrations wi Anatomica ilustrations wi Procedural Ilustations vail Evaluation and Management Tabies av Evaluation and Management (E/M) Services Guidelines 4 E/M Guidelines Overview. 4 Classification of Evaluation end Management M) Services 4 > Lovols of E/M Services 6 Unlisted Service Z Special Report 12 Evaluation and Management. 13 Otfce ar Gther Outpatient Services 3 Hospital Observation Services 15 > Flsrital Inpatient and Observation Care Services ...15 Consultations 1B Emergency Department Services, 0 Critical Care Services a Nursing Facility Services 2 Domiciiary, Rest Home eg, Boarding Home), ‘or Custoial Care Services B Domiciliary, Rest Home (eg, Assisted Living Facility, or Home Care Plan Oversight Senvies 6 Home or Residence Services 8 Prolonged Services 2 Coase Management Senices. 30 Care Plan Oversight Sevices 31 Preventive Medicine Services 2 Nore foce-to-Fece Services % Special Evaluation and Management Services 40 Newborn Care Services 0 Delvery/Biiing Room Attendance and Resuscitation Seni a Inpatient Neonatal Intensive Cae Services and Pediatric and Neonatal Critical Care Services a Cognitive Assessment and Care Plan Services 48 Care Management Services. a7 Psychiatric Collaborative Care Management Services ...52 Transitional Care Management Services 58 ‘Advance Care Pianning. a7 General Behavioral Health Integration Care Management 58 Other Evaluation and Management Services 88 Anesthesia Guidelines .... Time Reporting Anesthesia Serves Supalied Materials. 60 ‘Separate or Multiple Procedures 60 Unlisted Service or Procedure 60 Special Report 51 Anesthesia Modifiers 61 Qualifying Circumstances 61 Amesthesi@............. «2 Head 62 Neck 62 Thorax (Chest Wal! and Shoulder Girdle} 63 lnvrathoracic 63 Spine and Spinal Cord 68 Upper Abdamen 64 Lower Abdomen 64 Perineum, 65 Pelvis (Except Hip) 66 x Contents cr 2023Surgery Guidelines Surgery. Upper Leg (Except Knee). Kee and Popiteal Area Lower Lg Below Knee, Includes Anke and Foot) Shoulder and Axila Ups Armand Elbow Forearm, Wist, and Kand Radiological Procedures Burn Excisions or Debridement Obstetric. Other Procedures Semvices CPT Surgical Package Definition for Diagnostic Procedwes for Therapeutic Surgical Procedures Follow-Up Follow-Up Car Supplied Materials Reporting More Than One Procedure/Servce Separate Procedure Unlisted Service or Procedure Special Report imaging Guidance Surgical Destruction Foreign Body/implant Definition General Integumentary System Musculoskeletal System Respiratory System, Cardiovascular System Hemic and Lymphatic Systems, Mediastinum and Diaphragm Digestive System Urinary System Male Genital System Reproductive System Procedures. Intersex Surgery Female Genital System. Maternity Care and Delivery Endocrine System, Nervous System Eye and Ocular Adnexa Auditory System Operating Microscope Radiology Guidelines (Including Nuclear Medicine and Diagnostic Ultrasound). Subject Listings Separate Procedures Unlisted Service or Procedure Special Report 66 68 67 6 67 68 68 @ 69 69 nm n 2 2 n n 72 2 73 m4 74 74 74 n 7 78 123 205 233 307 333 395 421 az 427 431 482 406 452 4g 510 515 2D 520 520 520 521 Contents EE ‘Supervision and Interpretation, Imaging Guidance ‘Administration of Contrast Materials) Witten Reports) Foreign BodyyImplant Definition Radiology.......... oe Diagnostic Radiology (Diagnostic Imaging} Diagnostic Ultrasound Radiologic Guidance Breast, Mammography Bone/Jint Ssies Aaciation Oncology Nuclear Medicine Pathology and Laboratory Guidelines ......... Services in Pathology nd Laboratory Separate or Multiple Procedures Unlisted Service or Procedure Special Report Pathology and Laboratory....... Organ or Disease-Oriented Panels. Drug Assay Therapeutic Drug Assays Evocative/Suporession Testing Pathology Clinical Consultations Urinalysis ‘Molecular Pathology. Genomic Sequencing Procedures and Other Molecular Multianalyte Assays Multianaiyte Assays with Algorithmic Analyses Chemistry Hematology and Coaguiation immunology Transfusion Mesicine Microbiology. ‘Anatomic Pathology Cytopathology. Cytogenetic Stucies Surgical Pathology In Vivo (ea, Transcutaneous) Laboratory Procedures. Other Procedures Reproductive Medicine Procedures Proprietary Laboratory Analyses Modicine Guidelines. .... Add-on Codes Separate Procedures Unlisted Service or Procedure Special Report Imaging Guidance Supplied Materials Foreign Body/Implant Definition 521 521 521 521 522 5a 581 552 563 54 562 595 595 595 596 608 609 61 614 64 8 649 652 664 8o7 674 675 684 684 685 687 693 oat 698 696 78 ng 19 ng 720 720 720 70 >< Contain ne revised text ‘American Medical AssociationContents Medicine... cesessseccssecesersnesesecese@l Pationt Sefety 877 Immune Blobulns, Serum or Recombinant Products, ...721 Strctural Measures, 87a Immunization Administration for Vaccines/Toxoids. 722 Nonmeasure Cade Listing 878 Vaccines, Toxoids 75 Category Il Codes 88 Poychiaty. a Appendix A—Modifiers il Biofeedback 736 rf ‘Appendix B—Summary of Additions, Deletions, pe 6 and Revisions a) Gastroenterology 79 Cptthalnalogy a Appendix C—Clinical Examples .. Special Otorhinolayngologic Services. m9 ‘Appendix D—Summary of CPT Add-on Codes. Cardiovascular 752 Appendix E—Summary of CPT Codes Noninvasive Vascular Diagnostic Stuies 788 Exempt from Modifier... +958 Pulmonary. 782 ‘Appendix F—Summary of CPT Codes ‘Allergy and Clinical Immunology 796 Exempt from Modifier 63. . Endocrinology 798 ‘Appendix G—Summary of CPT Codes Neurology and Neuramuscula: Procedures 798 That Include Moderate (Conscious) Sedation 960 Medical Genetics and Genetic Counseling Services. ..618 ‘Appendix H—Alphabetical Clinical Topics Listing Adaptive Behavior Services 818 {AKA ~ Alphabetical Listing) oo 960 Central Nervous System Assessments/Tests {eg, Neuro-Cognitive, Mental Status, Speech Testing). .821 Appendix I—Genetic Testing Code Modifiers. Appendix J—Electrodiagnostic Medicine Listing 960 Heaith Behavior Assessment and Intervention 825 of Sensory, Motor, and Mixed Nerves...... 961 > Behavior Management Senices 82 i Hydration, Therapeutic, Prophylactic, Diagnostic Injections Appendix K—Product Pending FDA Approval. 964 and Infusions, and Chemotherapy and Other Highly ‘Appendix L—Vascular Families +965 Coa ae a Appendix M—Renumbered CPT Codes-Citations Crosswalk . ate eeeeeeanen S15 Photodynamic Therapy. 834 Special Dermatological Procedures 834 Appendix N—Summary of Resequenced CPT Codes... .981 Physical Medicine and Rehabilitation 895 ‘Appendix 0—Multianalyte Assays with Algorithmic Medical Nurtion Therapy 843 ‘Analyses and Proprietary Laboratory Analyses. .......986, Acupuncture 843, Appendix P—CPT Codes That May Be Used For Osteopathic Manipulative Treatment om Synchronous Telemedicine Services. 1033 Chiropractic Manipulative Treatment. B45 ee Se eaRr! Pare ratory Bind Education and Training for Patient Self-Management. ..245 joronavirus 2 -CoV-2} (coronavirus disease Non-Face-to-Face Nonphysician Services B46 MeL AE Lop vee ae Special Services, Procedures and Repors. 349 ‘Appendix R—Digitel Medicine-Services Taxonomy. 1037 (Qualifying Circumstances for Anesthesia 51 > Appendix S—Antficial Imeligence Taxonomy Moderate (Conscious) Sedation 1 for Medical Services and Procedures 4. 1041 Other Services and Pocedutes 853 > Appendix T—CPT Codes That May Be Used For 5 Synchronous Real-Time Interactive Audio-Only Home Health Procedures/Services 864 poeple dalled eiakemtadamediondall rey Medication Therapy Management Services 855 Index. 1003 Category Il Codes ve severe ST Meditirs 858 Composite Codes 859 Patient Management 99 Patient History 260 Prysial Examination 863 Diagnosto/Screening Processes or Results 864 Therapeutic, Preventive, or Othe Interventions .......871 Follow-up or Other Outcomes a7 xii Contents cr 2023Introduction Current Procedural Terminology (CPT®), Fourth Edition, isa set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other qualified health care professionals, or entities, Each procedute or service is identified with a five-digit code. The use of CPT codes simplifies the reporting of procedures and services. In the CPT code set, the term “procedute” is used to describe services, including diagnostic tests. Inclusion of a descriptor and its associated five-digit code number in the CPT Category I code set is based on whether the procedure or service is consistent with contemporary ‘medical practice and is performed by many practitioners in clinical practice in multiple locations. Inclusion in the CPT. code set of procedure or service, or proprietary name, does not represent endorsement by the American Medical Association (AMA) of any particular diagnostic or therapeu tic procedure or service or proprictary test or manufactures. Inclusion or exclusion of a procedure or service, ox propric- tary name, does not imply any health insurance coverage oF reimbursement policy. The main body of the Category I section is listed in six sec- tions. Each section is divided into subsections with anatomic, procedural, condition, or descriptor subheadings. The procedures and services with ther identifying codes are presented in numeric order with the exception of the sese- quenced codes and the entire Evaluation and Management section (99202-99499), which appears ac the beginning of the listed procedures. The evaluation and management codes are used by most physicians in reporting a significant portion of their services. Release of CPT Codes ‘The CPT code set is published annually in late summer oF carly fall as both electronic data files and books. The release of CPT data files occurs annually between August 31 and che first week of September. The release of che CPT Professional publication comes several weeks later. Howeves, co meet the needs ofa rapidly changing health care environment, the CPT code set is periodically updated throughout the year on aaset schedule. Each update has both a release date and an effective date. The interval between the release of the update and the effective date is considered an implememeation peri- cod and is intended co allow physicians and other providers, payers, and vendors to incorporate CPT changes into their systems. Changes to the CPT code set are meant to be applied prospectively from the effective date. The following, table outlines the complete CPT code set update calendar. New CPT codts have been created to streamline services related to the novel coronavirus. [tis imperative to check the AMA CPT public website at hteps:/Avwwama-assn.org/ practice-management/ept/covid-19-coding-and-guidance throughout the year to obtain the necessary frequent updates to the CPT code set. CPT Code Set Update Calendar CPT Category/Section Category | Category I Category il yt Immune Globutins, Serum, or Recombinant Products, January Naccines, Toxoids Molecular Pathology Te uy Administrative MARA October January PA Ail yi October? ¢=Contsns new or raved txt ‘American Medical Association xiIntroduction Section Numbers and Their Sequences Eraluation and Management, 9920299499 Anesthesiology 00700-01999, 9910099140 Sarge cesses 10004-69990 Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) . 70010-79999 Pathology and Laboratory. 80047-89398, 0001U-0354U Medicine (except Anesthesiology) 90281-99199, 99500-99607, 00014-01128 ‘The first and last code numbers and the subscction name of the icems appear at the top margin of most pages (eg, 10004-11005 Surgery/Integumentary System"). The con- tinuous pagination of the CPT codebook is found on the lower margin of each page along with explanation of any code symbols that are found on that page. Instructions for Use of the CPT Codebook Select the name of the procedure or service that accurately identifies the service performed, Do not seleet a CPT code that merely approximates the service provided. Ifo such specific code exists, then report the service using the appro- priate unlisted procedure or service code. In surgery, it may bean operation; in medicine, a diagnostic or therapeutic procedure; in radiology, a radiograph. Other additional pro- cedures performed or pertinent special services are also list- ed. When necessary, any modifying or extenuating, circumstances are added. Any service or procedure should be adequately documented in the medical record. Ieis equally important to recognize that as techniques in med- icine and surgery have evolved, new types of services, incud- ing minimally invasive surgery, as well as endovasculat, percutaneous, and endoscopic interventions have challenged the raditional distinction of Surgery vs Medicine. Thus, the listing of a servic or procedure ina specific section of this, book should not be interpreted as strictly classifying the ser vice or procedure as “surgery” or “nor surgery” for insurance or other purposes. The placement ofa given service in a specific section of the book may reflect historical or other consider- ations (eg, placement of the percutaneous peripheral vascular endovascular interventions in the Surgery/Cardiovascular System section, while the percutaneous coronary interventions appear in the Medicine/ Cardiovascular section). > When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. ‘A “physician or other qualified health care professional” is an individual who is qualified by education, trainin, licensure! regulation (when applicable), and facility privileging (when applicable) who performs a professional service wichin his! her scope of practice and independently reports that profes sional service. These professionals are distinct ftom “clinical staff A clinical staff member isa person who works under the supervision of a physician or other qualified health care ‘professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service. Other policies may also allece who may report specific services. ‘Throughout the CPT code set the use of rerms such as “pl sician,” “qualified health care professional,” or “individual” is not intended to indicate chat other entities may not report the service. In selected instances, specific instructions may define a service as limited to professionals or limited to other entities (eg, hospital or home health agency) Instructions, ypically included as parenthetical notes with selected codes, indicate that a code should not be reported with another code or codes. These instructions are incended Co prevent errors of significant probability and are nor al inclusive, For example, the code with such instructions may bbe a component of anocher code and therefore it would be incorrect ro ceport both codes even when the component service is performed. These instructions are not intended as a listing of all possible code combinations that should not be reported, nor do they indicate all possible code combina- tions that are appropriately reported. When reporting codes for services provided, itis important to assure the accuracy and quality of coding through verification of the intent of the code by use of the related guidelines, parenthetical instructions, and coding resources, including CPT Asistane and other publications resulting from collaborative efforts of the American Medical Association with the medical specialty societies (ie, Clinical Examples in Radiology). Format of the Terminology The CPT code set has been developed as stand-alone descriptions of medical procedures. Howeves, some of the procedures in the CPT codebook are not printed in their entirety but refer back ro a common portion of the proce- dure listed in a preceding entry. This is evident when an entry is followed by one or more indentations. This is done in an effort to conserve space Example 25100 Athrotomy, wrist joint; with biopsy 25105 with synovectomy ‘Note thar the common part of code 25100 (the part before the semicolon) should also be considered part of code 25105. Therefore, the full proceduse represented by code 25105 should read: 25105 —Arhrotomy, wrist joint; with synovectomy Requests to Update the CPT Nomenclature The effectiveness of the CPT nomenclature depends on con- stant updating co reflect changes in medical practice. This can only be accomplished through the interest and timely suggestions of practicing physicians and other qualified health care professionals, specialty professional societies, state medical associations, organizations, agencies, individual users of the CPT code set, and other stakeholders. xiv Introduction cer 073Introduction Accordingly, the AMA welcomes correspondence, inquiries, and suggestions concerning CPT coding and nomenclature for old and new procedures and services, as well as any mat- ters relating to the CPT code set. For information on submission of an application to add, delete, or revise codes contained in che CPT code set, please see wirw.ama-assn.org/golept-processfaq oF contact: CPT Editorial Research & Development ‘American Medical Association 330 North Wabash Avenue Suite 39300 Chicago IL 60611-5885 Code change applications are available at the AMA’s CPT website a https://wiw.ama-assn.org/practice-management! eptlepe-code-change-applications. All proposed changes to the CPT code set will be considered by the CPT Eéitorial Panel in consultation with medical specialty societies as represented by the CPT Advisory Commince, other health care professional societies as repre- sented by the Health Care Professionals Advisory Commitice (HCPAC), and other interested parties. Application Submission Requirements All complete CPT code change applications are reviewed and evaluated by the CPT staf, che CPT/HCPAC Advisory Committee, and che CPT Editorial Pane. Strict confor mance with the following is required for review of a code change application: + Submission of a complete application, including all ‘necessary supporting documents; + Adherence to all posted deadlines; * Cooperation with requests from the CPT staff and/or Editorial Panel members for clarification and information; and + Compliance with CPT Lobbying Policy. General Criteria for Category I, Il, and III Codes All Category I II, and III code change applications must sat- isfy each of the following criteria: + The proposed descriptor is unique, well-defined, and describes a procedure or service that isclealy identified and distinguished from existing procedures and services already in the CPT code set: The descriptor structuse, guidelines, and instructions are consistent with the current CPT Editorial Panel standards for maintenance of the code set The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by one or more existing codes (with the exclusion of unlisted codes). However, procedures and services frequently performed together may require new at revised codes; + The structure and content of the proposed code descriptor accurately reflects the procedure ot service as typically per formed. IFalways or Frequently performed with one or more other procedures or services, the descriptor structse and content will reflec the typical combination or com: plete procedure or service: + The descriptor for the procedure or service is not proposed 45 a means to report extraordinary circumstances related £0 the performance of a procedure or service already described in the CPT code set; and + The procedure or service satisfies the category-specific criteria set forth below. ements Category-Speci Category | Criteria [A proposal for a new or revised Category I code must satisly all ofthe following criteria: Req + All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or serviees + The procedure oF service is performed by many physicians or other qualified health care professionals across the United States: + The procedure or service is performed with frequency consistent with the intended clinical use (ie, a service for a common condition should have high volume, whereas 2 service commonly performed for a rare condition may have low volume); ‘The procedure of service is consistent with current medi- cal practice; and ‘The clinical efficacy of the procedure or service is docu- ‘mented in literature that meets the requirements set forth i the CPT code change application. Category Il Criteria The following criteria are used by the CPT/HICPAC and the CPT Editorial Panel for evaluating Category Il code applications: + Measurements that were developed and tested by 2 national organization; + Evidence-based measurements with established ties to health outcomes: + Measurements that address clinical conditions of high prevalence, high ris, or high cost; and + Wellestablished measurements that are currently being used by large segments of the health care industry across the country. In addition, all of che following are required: *+ Definition or purpose of the measuse is consistent with ies intended use (qualicy improvement and accountabilicy, or solely quality improvement) * Aspect of care measured is substantially influenced by the physician (or other qualified health care professional or entity For which the code may be relevant) ‘American Medical Association xWIntroduction *+ Reduces data collection burden on physicians (or other qualified health care professionals or entities) + Significane o Affect large segment of health care community 6 Tied to health outcomes © Addresses clinical condicions of high prevalence, high costs, high risks + Bvidence-based Agreed upon 0 Definable © Measurable + Riskcadjustment specifications and instructions forall out- come meases submitted or compelling evidence a 0 ‘why risk adjustment is nor rlevane + Sufficiently detailed to make ic useful for multiple purposes + Facilitates reporting of performance measure(s) + Inclusion of select patient history, testing (eg, glycohemo- globin), other process measures, cognitive or procedure ser- vices within CPT, or physiologic measures (eg, blood pressure) to support performance measurements + Performance measure-development process chat includes © Nationally recognized expert panel © Multidisciplinary 1 Vetting process Category III Ci ‘The following criteria are used by the CPT/HCPAC Advisory Commie and the CPT Editorial Panel for evalu- ating Category III code applications: * The procedure or service is currently oF recently per- formed in humans; and ‘At least one of the following additional eriteria has been met: * The application is supported by atleast one CPT or HCPAC advisor representing practitioners who would use this procedure or service: or * The actual or potential clinical efficacy of the specific pro- cedure of service is supported by peer reviewed literature, which is available in English for examination by the CPT Edicorial Panel; or + There is (2) at least one Institutional Review Boaed: approved protocol ofa study of the pracedute or service being performed; (b) a description of a current and ongo- ing Unied States tral outlining the efficacy of the proce dure or service; or (¢) other evidence of evolving clinical utilization. Guidelines Specific guidelines are presented ac the beginning of each of the sections. These guidelines define items that are necessary o appropriately interpret and report the procedures and ser- viees contained in that section. For example, in the Medicine section, specific insteuctions are provided for handling unlisted services or procedures, special reports, and supplies and materials provided. Guidelines also provide explanations regarding terms that apply only to a particular section. For instance, Radiology Guidelines provide a defi- nition of the unique term, ‘tadiological supervision and interpretation.” While in Anesthesia, a discussion of report- ing time is included. Avwritcen report (eg, handvaicten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation. Please see the guidelines regarding Imaging Guidance in each individual section. Add-on Codes Some of the listed procedures are commonly carried out in addition to the primary procedure performed. These addi- tional or supplemental procedures are designated as add-on codes with the + symbol and they are listed in Appendix D of the CPT codebook. Add-on codes in CPT 2023 can be readily identified by specific descriptor nomenclature that includes phrases such as “cach additional” or “(Lise separately in addition to primary procedure).” ‘The add-on code concept in CPT 2023 applies only to add- ‘on procedures or services performed by the same physician. ‘Add-on codes describe additional inera-service work associat- ced with the primary procedure, eg. addicional digit(s), lesion(), neurorchaphy(s), vercebralsegment(s), rendon(s), Joins) » Add-on codes are always performed in addition tothe pri- sary service or procedure and must never be reported as a stand-alone code. The inclusionary parenthetical noces fo: lowing the add-on codes are designed to include the typical base code(s) and not every possible reportable code combi- nation. When che add-on proceduse can be reported bilater- ally and is performed bilaterally, the appropriate add-on code is reported twice, unless the code descriptor, guidelines, or parenthetical instructions for that particular add-on code instructs otherwise. Do not report modifier 50, Bilateral Procedures, in conjunction with add-on codes. All add-on ‘odes in the CPT code set are exempr from the multiple pro- cedure concept. See the definitions of modifier 50 and 51 in Appendix A. Modifiers ‘A modifier provides the means to report or indicate that a service or procedure that has been performed has been akered by some specific circumstance but not changed in its definition or code. Modifiers also enable heakh care profes- sionals to effectively respond co payment policy requirements established by other entities. The judicious application of modifiers obviates the necessity for separate procedure list- ings that may describe the modifying circumstance. xvi Introduction ort 2023Introduction Modifiers may be used to indicate to the recipient of report that: + Aservice or procedure had both a professional and techni cal component. + Aservice or procedure was performed by more than one physician or other health eare professional and/or in more than one location + A service or procedure was increased or reduced. *+ Only part ofa service was performed. + An adjunctive service was performed. + A bilateral procedure was performed. + A service or procedure was provided more than once. + Unusual events occurred. Example A physician providing diagnostic or therapeutic radiology services, ultrasound, or nuclear medicine services in a hospital would add modifier 26 to report the professional component. 73090 with modifier 26 = Professional componenc only for an X say of the forearm Example Two surgeons may be required to manage a specific surgical problem. When two surgcons work together as primary sux- ‘geons performing distinct part(s) of a procedure, each sur- geon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgesy once using the same procedure code. Modifier 62 would be applicable. For instance, a neurologi- cal surgeon and an otolaryngologist are working as cd-sur ons in performing tansphenoial excision of pany neoplasm. ‘The first surgeon would report 61548 62 = Hypophysectomy or excision of pituitary tumor, ceansnasal or transseptal approach, nonstereotactic + two surgeons modifier and the second surgeon would repatt: 61548 62 = Hypophysectomy or excision of pituitary tmos, cransnasal or ranssepral approach, nonstereotactic + cwo surgeons modifier Ifadditional procedure(s) (including add-on procedure(s)) are performed during the same surgical session, separate code(s} may also be reported wich modifier 62 added. I should be noted that if co-surgeon acts as an assistant in the performance of additions) procedure(s) dusing the same surgical session, those services may be reported using sepa~ rate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. A complete listing of modifiers is found in Appendix A. Place of Service and Facility Reporting Some codes have specified places of service (eg, evaluation and management codes are specific to a setting). Other ser- vices and procedures may have instructions specific to the place of service (eg, therapeutic, prophylactic, and diagnostic injections and infusions). The CPT code set is designated for reporting physician and other qualificd health care profes- sional services. Icis also the designated code set for reporting services provided by organizations or fails (cg, hospitals) in specific circumstances. Throughout the CPT code set, che use of terms such as “physician,” “qualified health care pro- fessional,” or “individual” is not intended to indicate that other entities may not report the service. tn selected instane- ¢s, specific instructions may define a service as limited v0 professionals or limited to other entities (eg, hospital or home health agency). The CPT code set uses the term “facil- ity” to describe such providers and the term “nonfacilty” to describe services sertngs or citewmstances in which no facil- ty reporting may occur. Services provided in the home by an agency are facility services. Services provided in the home by 2 physician or other qualified lalth care professional who is not a representative of che agency are nonfuclcy services. Unlisted Procedure or Service Ie is recognized chat there may be services or procedures per- formed by physicians or other qualified health care profes- sionals thac are not found in che CPT code set. Therefore, a number of specific code nunibers have been designated for reporting unlisted procedures. When an unlisted procedure number is used, the service or procedate should be described (Gee specific section guidelines). Each of these unlisted proce- dural code numbers (with che appropriate accompanying topical entry) relates toa specific section of the book and is presented in the guidelines of that section. In some cases, alternative coding and procedural nomencla- tute as contained in other code sets may allow appropriate reporting of a mote specific code. CPT references ro use an unlisted procedure code do not preclude the reporting of an appropriate code that may be found in ether code sts. Results, Testing, Interpretation, and Report Results ate the technical component of a service. Testing leads to results; results lead to interpretation, Reports are the work product of the interpretation of rest resules. Certain procedures or services described in CPT involve a technical ‘component (eg, tests), which produces “resules” (eg, data, images, slides). For clinical use, some of these results require incenpretaion. Some CPT descriptors specifically require interpretation and reporting in order to report that code. Special Report A service that is rately provided, unusual, variable, or new ‘may require a special report. Pertinent information should include an adequate definition or description of the nature, extent, and need forthe procedure and the time, effort, and equipment necessary to provide the service. > ¢= Contains new or revised txt American Medical AssociationIntroduction Time ‘The CPT code set contains many codes with a time basis for code selection, The following standards shal apply to time rmeasirement, unless there are code ar code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary. Time is the face-to-face time with the patient. Phrases such as “interpretation and report” in the code descriptor are not intended ro indicat in all cases that report writing is part ofthe reported time. A unit of time is attained when the mid-point is passed. For exam- ple, an hour is atained when 31 minutes have elapsed (more than midway berween zero and 60 minutes). A second hour is attained when a total of 91 minutes has elapsed. When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest ro the actual time is used. See also the Evaluation and Management (E/M) Services Gui When another service is performed concurrently with a time-based service, the cime associated with the concusrent sevice should not be included in the time used for reporting the time-based service. Some services measured in units other than days extend across calendar dates. When this ‘occurs a continuous service does nor reset and create a first hour. However, any disruption in the service does create a new initial service. For example, if intravenous hydration (96360, 96361) is given from 11 Px to 2 aMt, 96360 would. be reported once and 96361 twice. For facility reporting on a single date of service or for continuous services that last beyond midnigh (ie, over a range of dates), report che total unit of time provided continuously. Code Symbols ‘A summary listing of additions, deletions, and revisions applicable to the CPT codebook is found in Appendix B. New procedure numbers added to the CPT codebook are identified throughout the text withthe @ symbol placed before the code number, In instances where a code revision hhas resulted in a substantially altered procedure descriptor, the dk. symbol i placed before the code number. The B symbols ae used to indicate new and revised text other than the procedure descriptors, These symbols indicate CPT Editorial Panel actions. The AMA reserves the tight to cor- rect typographical errors and make stylistic improvements > CPT add-on codes are annotated by the + symbol and are listed in Appendix D. The symbol © is used to identify codes that are exempt from the use of modifier 5! but hhave not been designated as CPT add-on procedures or se vices, A list of codes exempt from modifier 51 usage is included in Appendix E. The M symbol is used to identify ‘codes for vaccines that are pending FDA approval (see Appendix K). The # symbol is used to identify codes that are listed out of numerical sequence (see Appendix N). The 1% symbol is used to identify codes that may be used 0 report telemedicine services when appended by modifier 95 (see Appendix P). The 4 symbol is used to identify codes that may be used to report audio-only telemedicine services when appended by modifier 93 (sce Appendix T).4 Resequenced codes that are not placed numerically ae iden- tified with the # symbol, and a reference placed numerically (ie, Code is out of numerical sequence. See...) as a naviga- tional alert co direct the user to the location of the out-of- sequence code (see Appendix N). Resequencing is utilized to allow placement of related concepts in appropriate locations within che families oF codes regardless of the availability of| ‘numbers for sequential numerical placement. Duplicate proprietary laboratory analyses (PLA) tests are annotated by the ¥€ symbol. PLA codes describe proprietary clinical nboratory analyses and can be either provided by a single (“sole-source”) laboratory or licensed or marketed to zaltiple providing laboratories (eg, cleared or approved by the Food and Drug Administration [FDA]). All codes chat are included in the PLA section are also included in Appendix O, wich che procedure’ proprietary name. In some instances, the descriptor language of PLA codes may be identical and the code may only be differentiated by the lisced proprietary name in Appendix O. When more than cone PLA test hasan identical desctiptos, the codes will be denoted by the symbol € Unless specifically noted, even though the Proprietary Laboratory Analyses section of the code set is located atthe end of the Pathology and Laboratory sectian of che code set, PLA code does not Fulfil Category I code criteria. A PLA code(a) chat has Category I status is annotated by the 1 symbol. Alphabetical Reference Index This codebook features an expanded alphabetical index that includes listings by procedure and anatomic sie, Procedures and services commonly known by their eponyms or other designations are also included. Use of Anti-Piracy Technology in CPT Professional 2023 Codebook ‘The AMA takes the act of and/or the prospect of piracy of its books and copyrighted content very seriously, and is com- mitted to providing the most effective anti-piracy service to its authors and readers. To help combat print piracy and pro- tect our intellectual properties and customers’ right to AMA- certified content, the AMA has adopted aaci-piracy technology in the CPT Profesional 2023 codebook. To protect the copyrighted content and prevent counterfet- ing of the CPT Profesional 2023 codebook using color copi- cs, this book is protected and equipped with state-of-the-art anti-piracy technology within its pages. Therefore, you will notice light-yellow dots atthe bottom of most pages in this book. Asa result of che implementation of this anti-piracy technology, you will notice that the pages inthis codebook cannot be reproduced by photocopy or scan in accordance with current copyright rules and laws. Introduction or 2023Intyoduction In addition to stopping counterfeit book production and protecting the copyrighted content of this manual, the wse of anti-piracy technology is designed specifically to protect you, the end-user, by ensuring that you are using an accurate, high- quality, and authentic AMA-ceetifed version of the reference manual. We appreciate your efforts and cooperation in reducing content piracy and improving copyright protections CPT 2023 in Electronic Formats CPT 2023 procedure codes and descriptions are available as downloadable data files. The CPT daca files are available in ASCII and EBCDIC formats and provide a convenient way to import the 2023 CPT codes and descriptions into existing documentation or into any billing and claims reporting software that accepts a text (.TXT) file format. ‘The data files contain the complete official AMA CPT guidelines, descriprot package, and new descriptors for consumers and clinicians. ‘The CPT Profesional codebook is also available as an e-book. For more information about CPT electronie formats, call 800 621-8335 or visit amastore.com. References to AMA Resources The sybals & & and appear afier many codes throughout this codebook, which indicate that the AMA has published reference macerial regarding that particular code, ‘The symbol © refers to the CPT Changes: An Insider View, an annual book with all of the coding changes for the current year, the & refers co the CPT Assistant monthly rnewsletct. The symbol & refers tothe quarterly newsletter Clinical Examples in Radiology Example 36598 Contrast injections) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report 9 CPT Changes: An insider's View 2008, £9 Clinica! Examples in Radiology Winter 06:15, In this example, the blue reference symbol indicates that in the 2006 edition of CPT Changes: An Insiders View informa- tion is available that may assist in understanding the applica- tion of the code. The ted reference symbol indicates that the 2006 Winter issue of Clinical Examples in Radiology (page 15) should be consulted. CPT Assistant and Clinical Examples in Radiology are avail- able online. Benefits exclusive to the online versions include: + Monthly (CPT Asistant) and quarterly (Clinical Examples in Radiology) updates! The home screen notifies you when ‘anew issue is available, and you can review the latest issue in its entirery + Unlimited access to every archived issue and article dating bck to when the newsletters first published. + Ahistorical CPT code list chat references when a code was added, deleted, and/or revised since 1990. + Simple search capabilities, including intuitive menus and a cumulative index of article tiles. A fall archive of CPT Auistant articles (1990-2022) is also available in the CPT Profesional Print ard Digital app bun- dle (see the following information about the CPT QuickRef app). ‘The CPT QuickRefapp is available for (OS (Apple) and. Android devices (smate phones and tablets). The QuickRef app contains important coding and billing tools, including: + The entixe CPT 2023 code set (Full codes, descriptions, icons, illustrations, and parenthetical notes), plus the entire 2022 code se to facilitate the yearend code set Facility and non-faciliry RVUs and Global Days. Medicare Physician Fee Schedule calculator that can be set toa specific geographic region (GPCI) + CPT Asistant Archive: all content and every issue of CPT. Assistant from 1990 through 2022, linked to the pertinent CPT codes and available for browsing. Official AMA CPT coding guideline linked to each CPT code. + More than 200 AMA-created colorized procedural and. anatomical illustrations + Modifiers *+ Keyword and code number search Favorites capable, to store most frequently used codes or ‘modifiers for easy access For more information, call 800 621-8335. atsins now or vised txt American Medical Association xixIllustrated Anatomical and Procedural Review Ieis essential chat coders have a thorough understanding of medical terminology and anatomy to cade accurately. The following section reviewing the basics of vocabulary and anatomy’ can be used as quick reference eo help you with your coding. Iv is not intended 2s a replacement for up-to-date medical dictionaries and anatomy texts, which ae essential tools for accurate coding. Prefixes, Suffixes, and Roots Although medical terminology may scem comples, many ‘medical rerms can be broken into component parts, which makes chem easier to understand, Many of these terms are derived ftom Latin ot Greek words, but some include the names of physicians Prefixes are word parts that appear at the beginning of a word and modify its meaning; suffixes are found atthe end of words. By learning what various prefixes and sufixes mean, ics possible o decipher the meaning of a word quickly. The following lists are a quick reference for some common prefixes and suffixes Numbers Profix Meaning Example mond, un one monocyte, unilateral bi ‘two bilateral ti thee iad quad four quadriplegia hex, sex six hexose diplo double diplopia Surgical Procedures Suffix Meaning Example ccentesis puncture a cavity to remove fluid amniocentesis, -ectomy —_sugical removal exision) appendectomy ostomy anew permanent opening colostomy -otomy cutting nt nisin} tracheotomy -orthapty surgical repar/suture hemionhaphy -opery surgical fixation nephropexy ‘plasty surgical repair thinoplasty ‘tipsy crushing, destroying lithotripsy Conditions Prefix Meaning ambi- bath ariso- unequal ais: bod, painful citficut eu ‘900d, normal hetero- different homo same hyper excessive, above hypo- deficient, below iso- equal, same imal Bad, poor imegalo large Suffix Meaning -algia pain -asthenia weakness emia blood -iasis caneiton of “itis inflammation sis destruction, break down Wve estoy, break down oid tke oma tumor -opathy disease of -orthagia emorthage -orrea flow or discharge -osis abnormal condition of “paresis weakness -plasia growth -plegia paralysis. ea breathing Example ambidextrous anisocoria dysphoria euthanasia heterogeneous homogeneous hypergastric hhypogestrie isotonic malaise megalocardia Example neuralgia myasthenia anemia amebiasis appendicitis, hemolysis hhemahtic tipoic arthropathy rmenorthagia ‘amenorthea tuberculosis hemiparesis hyperplasia paraplegia 2X _illstrated Anatomical and Procedural Review cranesLists of Illustrations Directions and Positions Prefix Meaning Example ab ‘away from ‘abction ad toward adduction ecto, ex0- outside ectopic, exocrine endo- within endoscope eri upon enigastric intra below, under infrastructure ips. same ipsitteral meso: middle mesopexy meta- after, beyond, transformation metastasis peri- ‘strounding pericardium retro behind, back retvoversion trans- across, through ‘ranevaginal Word Meaning at or near the front surface ofthe body at or near the back surface ofthe body anterior or ventral posterior or dorsal superior above inferior below lateral side distal farthest from center proximal nearest to center medial middle supine face up or palm up prone face down or palm down sagittal vericat body plane, divides the body into equal right and left sides transverse horizontal body plane, divides the body imto top and bottom sections coronal vertical body plane, divides the body into front and back sections Additional References For best coding results, you will ned to use other ference rmacerial in adition so your CPT® coding books. These references include medical dictionaries and anaromy books. Medical Dictionaries Darland’ Mtated Medical Dicionary, 33rd ed Philadelphia, Ps Ehevier, 2020, Stedman’: CPT® Dictionary, 2nd ed. Chicago, IL: American Medical Association; 2000. (0P:300609 Stedman's Medical Dictionary. 28th ed. Philadelphia, PA: Lippincott; 2005. Anatomy References Bernard, SP. Netter Alas of Human Anatomy for CPT® Surgery Chicago, IL: American Medical Association; 2015, P495015 Kirschner, CG, Newer’ Atlas of Human Anatomy for CPT® Coding, 3d ed (Chicago, IL: American Medical Association; 2019. 07490619 Newt, FH. Atlas of Htoman Anatomy, 6th ed Philadelphia, PA; Blevir; 2014 ops3674 Lists of Illustrations “To further aid coders in properly assigning CPT codes, the codebook contains a number of anatomical and procedural llustations. Anatomical Illustrations ‘Thirty-five anacomical illustrations are located on the following pages: Page Mlustration Tile nxiv Body Planes—3/4 View av Body Aspects—Side View viv Body Planes—Front View 8 Structure of Skin 115 ‘Skeletal System 116 ‘Skull—Front and Lateral Views "6 ‘Thoracic Vertebra—~Superior View 16 Lumber Vertetra—Superior View 16 umivar Vertebrae—tateral View 18 Bones, Muscles, and Tendons of Hard 19 Bones and Muscles of Foot 12 Muscular System—Front we Muscular System—Back 148 Visual Definitions of Spinal Anatomy and Procedures A Vertebral interspace (non-tony] and segment (oon) B. Foraminotomy and facetectomy 149 ©. \minotomy, hemilaminectomy, and laminectomy 0. Corpectomy Paranasal Sinuses Respiratory System Aortic Anatomy Cardiac Anatomy, Heart Blood Flow Circulatory System, Arteries Circulatory System, Veins Brachial Artery Lymrintic System Digestive System Urinary System Mole Genital System Female Gerital System Nervous System Brain Anatomy Sagittal Section of Brain ard Brain Stem ye Anatomy Anterior Segment of the Eye Ear Anatomy Endocrine System Cranial Nerves ‘American Medical Association xxi