In medical billing, CPT codes are the standard to describe a medical procedure. They’re also called International Classification of Diseases (ICD) codes or Current Procedural Terminology (CPT) codes. So it is because CPT codes and modifiers were created by the American Medical Association (AMA). The ICD-9 and ICD-10 systems are used for coding procedures and diseases in hospitals throughout the United States, but other countries use different methods for billing purposes.
What are CPT codes?
CPT stands for Current Procedural Terminology, a system developed by the American Medical Association (AMA) that describes all things related to patient care. It includes surgical procedures like open heart surgery, knee replacement surgery, and brain cancer treatment (which is why it’s called “procedural”). Orthopedic surgeries involve injuries or problems within bones—like broken legs or shoulders—and can be performed on both adults and children.
Types of CPT codes
The CPT codes have been divided into three categories. They are as below:
CPT® Category I
CPT® Category II
CPT® Category III
Best CPT codes for medical billing tasks:
Here are the top codes and modifiers for pathology and orthopedics.
You’ve got your list of the most commonly used code and modifier combinations for pathology and orthopedics, but what about the rest? We’ve compiled a list of the field’s top CPT codes and modifiers that you might want to consider when working on your next medical billing project.
Codes used in Pathology Billing and Coding:
CPT codes (dermatologists)- 88300 to 88332
Level III surgical pathology (abscess, anus, hematoma, etc.)- 88304
Level IV surgical pathology or microscopic examination (lip, skin, tongue, etc.)- 88305
CPT New Codes:
- Obstetric panel (including HIV testing) – 80081
- Molecular Pathology Procedures – Gene Specific and Genome procedures- 81170, 81162, 81218, 81219, 81272, 81273, 81276, 81311, 81314.
- Cytogenetic microarray analyses- 81228, 81229, 81405, 81406
- Lengthy QT syndrome gene analyses- 81280, 81282
- Genomic Sequencing Procedures and other Molecular Multianalyte Assays- 81412, 81432, 81433, 81434, 81437, 81438, 81442
- Multianalyte Assays with MAAAs- 81490, 81493, 81525, 81528, 81535, +81536, 81538, 81540, 81545, 81595, 0009M, 0010M
- Immunofluorescence Stains- +88350
CPT Revised Codes:
- Molecular Pathology- 81210, 81275, 81355, 81401, 81402, 81403, 81404, 81405, 81406
- Genomic Sequencing Procedures and other Molecular Multianalyte Assays- 81435, 81436, 81445, 81450, 81455
- Chemistry– 82542, 83789
- Immunology– 86708, 86709
- Microbiology– 87301, 87305, 87320, 87324, 87327, 87328, 87329, 87332, 87335, 87336, 87337, 87338, 87339, 87340, 87341, 87350, 87380, 87385, 87389, 87390, 87391, 87400, 87420, 87425, 87427, 87430, 87449, 87450, 87451, 87502, +87503
- Surgical Pathology- 88346
Top CPT codes and modifiers codes used in Orthopaedics billing:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine: 90281 – 99199; 99500 – 99607
Hand Surgery
- CPT – 11760 – Repair of Nail Bed
- CPT – 25215 – Carpectomy; all bones of the proximal row
- CPT – 64721 – Neuroplasty (carpal tunnel release)
Carpal Tunnel Release – 64721
- “Neuroplasty and/or transposition; median nerve at the carpal tunnel.”
- Endoscopic Carpal Tunnel Release – 29848
What is a modifier in medical billing?
A service, technique, or item may be modified for remuneration in certain circumstances using a modifier. For example, modifiers for CPT may add details or change the therapy description or procedure to make it more particular following the medical records. Therefore, it may be successful in responding to reimbursement with the proper modifier.
In addition, modifiers are essential to ensuring that the patient receives the medical care they need at the right time and in the right way. Physicians and therapists use modifiers to clarify precisely what they did during a procedure or treatment session. Modifiers are necessary to ensure patients get the proper care at the right time.
Here is a precise table showing when to use modifiers in Orthopaedic procedures:
| Modifier | Procedure | Unit (ASC/P) |
| -50 | Bilateral procedures | Both |
| -51 | Multiple procedures | (P) |
| -52 | Reduced services | – |
| -58 | Staged or related procedure or service by the same physician during the postoperative period | Both |
| -59 | Distinct procedural service | Both |
| -73 | Discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia | (A) |
| -74 | Discontinued outpatient hospital/ASC procedure after the administration of anesthesia | (A) |
| -76 | Repeat procedure or service by the same physician | Both |
| -77 | Repeat procedure or service by another physician | Both |
| -78 | Return to the OR for a related procedure during the postoperative period | Both |
| -79 | Unrelated procedure or service by the same physician during the postoperative period | Both |
| -RT & -LT | Right Side and Left Side | Both |
| -TC | Technical component | Both |
Modifiers in Pathology Billing:
| Modifier TC | Technical Component |
| -26 | Professional Component |
| Global Billing | Billing pathology services with no modifiers |
| Surgery or E/M visits during the postoperative period | -24 or -79 modifier |
| Benign diagnosis | 88304 |
| malignant | 88305 |
| Entries 175 among five codes; 230 different types of tissue or specimen scenario | |
| Non-incidental appendix CPT code | 88304 |
| Gross and microscopic code | 88302-88309 |
CPT codes and modifiers— why are they game changers?
Modifiers indicate additional services performed, the complexity of a procedure, and its severity. They also can be used in office settings when there is no need for hospitalization or sedation. Moreover, modifiers are added to CPT codes to help providers bill accurately. They should be included on your patient’s bills since they will increase the amount you receive from insurance companies by $0-$10 per modifier.
The modifiers are two-digit codes with two levels:
Level I Modifiers: Usually known as CPT Modifiers and have two numeric digits. Level I modifiers are added to the information or adjusted care descriptions to give extra details about a procedure or specific provided service to a patient.
Level II Modifiers: Level II modifiers are HCPCS Modifiers consisting of two digits (Alpha / Alphanumeric characters) in the range AA to VP. These modifiers are annually updated by CMS – Centers for Medicare and Medicaid Services.
How do you know if a CPT code needs a modifier?
Coding modifiers are used to further define the code that was billed. For example, they can indicate a different type of procedure, a different site, or a different service date. Moreover, modifiers are also used to bill for functions not listed in the CPT book.
How do you find the CPT Codes and modifiers?
To find the CPT modifier, you can use several resources.
- The CMS website has a search function that allows you to enter a CPT code and view its modifiers. You can also use this tool if you want to search for all modifiers associated with one or more codes.
- There is a long list of things that the American Medical Association modifier values on its website. A reference guide is also available in print form from the AMA. You can also have a look at it to get the CPT modifiers.
What are the most commonly used CPT code modifiers?
A modifier is a code that describes the nature of the service provided. For example, modifiers can tell the type of procedure performed, who performed it, and why it was done.
For example, if you have an appendectomy for a ruptured appendix in a patient with an acute abdomen and hemodynamic instability, your CPT code will be:
- PC0144 (Surgery – Anorectal/Pelvic Floor)
The first number refers to “an” or “to,”—meaning that this procedure involves the removal of both rectum and sigmoid colon. The second number relates to procedure type: PC indicates pathology/pathology-related; 0144 means appendectomy with removing both rectum and the sigmoid colon. So PC0144, in this case, would mean the removal of both organs along with sigmoidectomies (sigmoid removed). The third field refers to what level we are referring to. Pelvic floor repair should include repair only if damaged or destroyed by accident/trauma while performing other surgical procedures involving the gastrointestinal tract, such as colorectal surgeries, etc. However, there may be cases when another entity performs certain types.
Conclusion:
We believe that this article has improved your comprehension of what is required for billing your orthopedic procedures. When you work in pathology and orthopedics, you’re probably already familiar with the unique needs of your billing department. After all, it’s a field that requires a lot of attention to detail and meticulous record-keeping. And when your lab’s billing process involves thousands of patients, it can be challenging to keep track of everything.
At U Control Billing Services, we understand how vital your billing team is to your business—and we want to help! Our state-of-the-art medical billing services offer high-quality services at an affordable price.
We worked with the industry’s best pathologists, labs, and clinics to provide you with the tools you need to maximize revenue while providing an excellent patient experience. If you’re looking for someone who can help get your billing operations running smoothly again and help them grow even faster than they have been in the past, look no further than U Control Billing Services is here! If you are still unsure about any CPT codes and modifiers, feel free to contact us anytime! We are willing to help with any inquiries or concerns regarding billing medical services.
FAQs
What are the CPT codes for pathology? ›
Gross examination of a specimen is an integral component of pathology consultation during surgery (CPT codes 88329-88334) and surgical pathology gross and microscopic examination (CPT codes 88302-88309).
Does CPT 88305 require a modifier? ›Since 88305 has a professional component, the -76 modifier is the correct modifier.
What is the modifier for the pathology service? ›When billing for only the professional component, use modifier 26. When billing for only the technical component, use modifier TC. using one line without a modifier. The facility reimburses the pathologist/pathology group for the professional component per their mutual agreements.
What is the CPT code for orthopedic evaluation? ›Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.
What are the 4 types of pathology? ›The American Osteopathic Board of Pathology also recognizes four primary specialties: anatomic pathology, dermatopathology, forensic pathology, and laboratory medicine. Pathologists may pursue specialised fellowship training within one or more subspecialties of either anatomical or clinical pathology.
What are the three types of pathology? ›The 3 main and broad subtypes of pathology are anatomical pathology, clinical pathology & molecular pathology.
Does CPT 88342 need a modifier? ›It's helpful to have this resource available for review to verify when you have a situation like this that requires a modifier when certain CPTs are billed together. CPTs 88342 & 88341 require a modifier to be billed with 88360.
Can 88305 be billed with TC modifier? ›Modifier –TC is appended to the code indicating the technical component and modifier –26 indicates the professional component. The proper coding would be: 88304 –26 and 88304 –TC; or 88305 –26 and 88305 –TC.
Does 80305 need a modifier? ›CMS MLN Matters MM9956 states that effective with dates of service April 1, 2017 and after, CPT code 80305 was approved by the FDA as a waived test under CLIA and must be billed with the modifier QW.
What is modifier 59 for pathology? ›Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
What is 26 modifier for pathology? ›
Modifier 26 is defined as the professional component (PC). The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report. Use modifier 26 when a physician interprets but does not perform the test.
Should I use modifier 59 or XS? ›The use of modifier 59 or -XS is appropriate for different anatomic sites during the same encounter only when procedures (which aren't ordinarily performed or encountered on the same day) are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in ...
How and why modifiers are used in orthopedic surgery? ›Modifiers are added to the main procedure code to indicate that the procedure has been altered by a distinct factor. Modifiers can increase or decrease reimbursement. They can also cause claims not to play properly or deny if used incorrectly or not used, when necessary.
What does CPT code 73721 mean? ›Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material.
What is CPT code E0149? ›A heavy duty walker (E0148, E0149) is one which is labeled as capable of supporting beneficiaries who weigh more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding.
What are the common terms used in pathology? ›- Anatomic Pathology. ...
- Pathology. ...
- Pathologist. ...
- Diagnosis. ...
- Cancer. ...
- Lesion. ...
- Benign. ...
- Malignant.
Typical examples include cervical smear, sputum and gastric washings. Forensic pathology involves the post mortem examination of a corpse for cause of death using a process called autopsy. Dermatopathology concerns the study of skin diseases.
What is the medical terminology for pathology? ›pathology - the branch of medicine that deals with the essential nature of disease and the changes in body tissues and organs which cause or are caused by disease; the structural and functional manifestations of disease. pathogen - a disease-causing microorganism or agent.
What are the basic pathology tests? ›Pathology tests cover blood tests, and tests on urine, stools (faeces) and bodily tissues. If you're sick, many of the decisions about your care will be based on the results of your blood and pathology tests. Some common tests in Australia include a full blood count, liver function tests, and urinalysis.
What are the 2 types of general tests in pathology and laboratory? ›There are two types of general tests in Path and Lab: qualitative and quantitative. Quantitative tests how much of a certain thing is in the body (say, calcium or alcohol), while qualitative tests for the presence of a substance, period.
What is CPT 88341 and 88342 modifier? ›
CPT code 88342 is a primary procedure code and includes “per specimen” in the description. You should report it for the initial single antibody stain procedure on each separate specimen. Add-on CPT code 88341 would be used for each additional single probe stain procedure per specimen.
What modifier do I use for 65222? ›It is important to note that CPT code 65222 is a per eye code, so the other case to consider is if you have a corneal foreign body in the right eye and the left eye at the same time. In this case, you can bill for the corneal foreign body removal in each eye using the -RT and the -LT modifiers with the procedure code.
Does 88141 need a modifier? ›CPT code 88141 (cytopathology, cervical or vaginal [any reporting system]; requiring interpretation by physician) is used to report smears that require separate interpretation by a physician. This code is not split-billed and must not be billed with modifier 26, TC or 99.
What is the difference between 88304 and 88305? ›Using 88304 when the diagnoses are benign and 88305 when the diagnosis is malignant.
How many times can 88305 be billed? ›A maximum of eight (8) units of 88305 shall be considered for reimbursement for all other diagnoses not listed above for the same patient on the same date of service.
What is modifier TC and 26? ›Modifier 26 is used by a physician who performs the professional component of a service, and Modifier TC is used when only the technical component of a service is performed. There are times when it is important to specify these separate services.
Does 82962 need a modifier? ›LAB TESTS REQUIRING MODIFIER QW
Certain codes describe only CLIA-waived tests and therefore are exempt from the requirement to add the QW modifier. The CPT codes for the tests currently exempt from the requirement are 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651.
CPT 80305 is drug screening by dipsticks, cups, cards or cartridges read visually. CPT 80306 is drug screening by dipsticks, cups, cards or cartridges read on an instrument reader. CPT 80307 is drug screening on a chemistry analyzer.
When should you use modifier QW? ›Modifier QW is used to indicate that the diagnostic lab service is a Clinical Laboratory Improvement Amendment (CLIA) waived test and that the provider holds at least a Certificate of Waiver. The provider must be a certificate holder in order to legally perform clinical laboratory testing.
What is modifier 51 used for? ›Modifier 51 is defined as multiple surgeries/procedures. Multiple surgeries performed on the same day, during the same surgical session. Diagnostic Imaging Services subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider.
What is modifier 54 used for? ›
Modifier 54
Surgical Care Only. When a physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding this modifier to the usual procedure code.
Modifier 79 is used to indicate that the service is an unrelated procedure that was performed by the same physician during a post-operative period. Modifier 79 is a pricing modifier and should be reported in the first position. A new post-operative period begins when the unrelated procedure is billed.
What is a 77 modifier? ›CPT modifier 77 is used to report a repeat procedure by another physician. Guidelines and Instructions. Submit this modifier to indicate that a basic procedure or service performed by another physician had to be repeated.
What is a 27 modifier? ›The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001.
What is modifier 21 used for? ›21 Prolonged Evaluation and Management Services: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation a.
What are examples of modifier Xe? ›Modifier -XE is used to indicate a separate surgical operative session on the same date of service or a distinct encounter after the patient has left the hospital or changed status or locations within the facility. Example: 8 a.m. outpatient surgery and 8 p.m. outpatient surgery.
What modifier do I use for 97140? ›The 97140 CPT code is appended with the modifier -59 or the appropriate -X modifier.
What is the XP modifier? ›Modifier XP - A patient has a cardiovascular stress test and is then referred to a different provider to do a rhythm ECG. Modifier XP must be appended to the rhythm ECG CPT code to indicate it was performed by a different provider than the cardiovascular stress test.
What is the modifier for orthopedic surgeon? ›Orthopedic surgeons utilize the 22-modifier when billing for complex procedures under the American Medical Association's Current Procedural Terminology (CPT) for reasons such as excessive blood loss, anatomic abnormality, and morbid obesity, cases that would ideally be reimbursed at a higher rate to compensate for ...
What is the correct order for modifiers? ›The general order of sequencing modifiers is (1) pricing (2) payment (3) location. Location modifiers, in all coding situations, are coded “last”.
What are the four types of modifiers? ›
- Signed.
- Unsigned.
- Short.
- Long.
73718 x 1 for the lower leg and femur. CPT description is "lower extremity, other than joint", which would include thigh to ankle long bones. There is no separation of the code for "upper leg" and "lower leg". 73721 x 1 for the foot, "joint of lower extremity".
What does CPT code 25607 mean? ›CPT code 25607 as “ Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation.”
What is the CPT 27130? ›| Code | Description |
|---|---|
| 27130 | ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT |
HCPCS code E0135 for Walker, folding (pickup), adjustable or fixed height as maintained by CMS falls under Walking Aids and Attachments .
What is E0776? ›HCPCS code E0776 for IV pole as maintained by CMS falls under Infusion Pumps and Supplies .
What is code E0147? ›HCPCS Code for Walker, heavy duty, multiple braking system, variable wheel resistance E0147.
What does CPT code 88305 mean? ›Definitions: CPT Code 88305: Level IV - Surgical pathology, gross and microscopic examination. These examinations would be ordered as a gross and microscopic pathology exam or a gross and microscopic tissue exam.
What is CPT code 88104 and 88108? ›Code 88104 is reported for fluids, washings or brushings, except cervical or vaginal; smears with interpretation. Code 88108 is reported for concentration technique; smears with interpretation.
What is CPT code 883051? ›Standard biopsies - any biopsy (e.g. CPT 883051) received on a patient in which special handling is not required. b. Special handling - cases requiring further fixation, decalcification, ancillary testing (such as special stains, immunohistochemistry, and molecular studies), or deeper sections.
What is the difference between CPT code 88304 and 88305? ›
Skin Specimens
A skin cyst, skin tag, or skin debridement is coded 88304 regardless of the size. All other skin specimens, including complex tissues such as excisions of melanoma and basal cell carcinoma with assessment of margins, fall under 88305, skin other than cyst, tag, debridement, or plastic repair.
Under the surgical pathology section of the CPT code manual, code 88305 identifies a level IV gross and microscopic exam while code 88307 identifies a level V gross and microscopic exam. When it is necessary to evaluate margins, note the following distinctions in coding of breast tissue.
What is CPT code 88342 used for? ›88342 – Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure. CPT code 88342 is a primary procedure code and includes “per specimen” in the description. You should report it for the initial single antibody stain procedure on each separate specimen.
What is CPT code 87426 used for? ›What is CPT Code 87426 Antigen Testing Code? Furthermore, the code, 87426, represents antigen tests using an immunofluorescent or immunochromatographic technique for the detection of biomolecules produced by the SAR-CoV-2 virus (COVID-19).
Does 88185 need a modifier? ›There are two codes to report the technical side, the work done to prepare the specimen and run the test, 88184 and add-on code 88185. For billing this component, you are allowed to bill “per marker.” One unit of 88184 and one unit of 88185 for each additional marker. Modifier -TC is not required.
What is the description of CPT code 86923? ›CPT® Code 86923 - Transfusion Medicine Procedures - Codify by AAPC.
What is CPT code 88333? ›Code 88333 is reported for the first touch prep and 88334 x 2 for the two additional margins. Performing a touch prep and a frozen section on the same specimen as part of a intraoperative consult is not uncommon. A CPT note confirms that billing for cytology and a frozen section together may be appropriate.
What does CPT code 88341 mean? ›Code. Description. 88341. IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
What is CPT code 88331? ›A. Use code 88331, Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen, for the first frozen section on the two specimens submitted separately.
What is CPT code 88360 and 88361? ›CPT codes 88360 and 88361 include the IHC staining and the initial qualitative slide exam. CPT copyright 2021 American Medical Association. All rights reserved.
What is CPT code 88325? ›
Code 88325 Consultation, comprehensive, with review of records and specimens, with report on referred material. slides/material are considered by the consultant to make the diagnosis. other special procedure slides and test data prepared and initially examined at the referring facility.
Who can bill CPT code 88305? ›Basics of CPT code 88305. Surgical pathology involves the gross and microscopic examination by surgical (e.g., dermatologists) and non-surgical providers (e.g., pathologists) of surgical or biopsy specimens.