In this article I’m going to talk about the CPT-4 manuals and what you’ll usually get from them. As far as I know, there are only two organizations putting these together, but I could be incorrect since I only know two vendors. One is the American Medical Association, the organization that’s responsible for creating and modifying the codes yearly, and the other is Optum360, the manual I’ve been buying for the last 4 years. I also buy my HCPCS books from Optum360; the costs of both books is lower than those bought directly from the AMA.
cover of the Optum360 CPT manual
Before I go further, because the images in this article are difficult to see, I recommend downloading this pdf file with the images so you can view them easier. You can either download the file or open it, which will open in your browser (at least for most people). I apologize for how the images look; it’s hard to scan pictures when you have to deal with the spiral.
I’m also using the 2022 manual to show and explain everything I’m covering. This will be important to know further down in this article.
First, both books are pretty comprehensive. They may do things differently in spots, but overall you’re going to get the same information. The general breakdown of the information is pretty much the same and in the same place. The one major exception is that in the AMA CPT manual the evaluation and management codes, which I also call outpatient services or room codes, are at the beginning of the manual, whereas in the Optum book they’re at the back of the book. If all codes were kept in numerical order they’d follow Optum; in order of importance, they probably should be at the beginning. It’s not a big deal, but it needed to be noted. Also, just so you know, this year’s Optum book is nearly 950 pages!
anatomical image 1
anatomical image 2
Second, there will be anatomical illustrations of the body with the proper terms that will match up to certain medical procedures within the manual. Notice the two images I’m sharing here. Both are of the full body, but one’s highlighting the bones while the other is highlighting the arterial system. If you have a medical background you’ll already know all of this; if you come from a finance background like me, it’s nice to have a reference just in case questions come up regarding procedures that you don’t understand.
heart catheterization images
In the Optum book, you’ll find all the large body illustrations in one section. You’ll also find illustrations throughout the manual based on types of services being performed to help give you an idea of how a treatment is supposed to be performed. These will be helpful to everyone, medical or finance background, because you’ll be able to corroborate with whoever is performing the procedure if they’re doing it according to the image or a different way.
The most important section in both books is the index. This will help you find what you’re looking for fast and easy… most of the time. Every once in a while you might be looking for a term that you can’t find, which probably means the department or charge master is using its own terminology that only they understand. You’ll either need to ask them what the actual terms are or look them up on a search engine.
Index page 1
The index section is comprehensive. In the long term you’ll appreciate how detailed it is. You’ll also need to learn that sometimes you’ll have to go through a lot of information to find what you need, even though some of it is in alphabetical order. For instance, look at Ablation, near the top of the 1st column (3rd column if you’re looking at the pdf file). It’s in alpha order on the first page of the A’s, and the categories underneath it are also in alphabetical order. Then the specific types of ablation are in alpha order under each category.
But if you were looking for stomach endoscopy, you wouldn’t find it unless you knew to look under “endoscopic” (note the terminology) first and then see stomach. If you looked under endoscopy pages after, you wouldn’t find anything about stomach there and you might get confused. That’s the thing about health care terms; just because the manual or the AMA defines something one way doesn’t mean hospital departments will do the same.
Back in the early days, in general terminology, the CPT book was broken up into 5 specific categories when it came to “regular codes” or “Category I” codes (I’ll come back to this later) based on terminology. They were: E&M codes, invasive procedure codes, radiology, lab and everything else. That sounds pretty simplistic, but it was actually more confusing. The range of numbers for invasive codes runs from 10004 through 69990, which was overwhelming. Later on, more categories were created to help out, which turned out to be a good thing once more defined lab tests were developed and it was decided to create numbers that began with 0 and to add them to the end of the lab section (which begins with 8).
Because of this, the manuals now come with inserts that can be added (that’s why it’s best to purchase the spiral manuals) with more specific terminology that will help you find what you’re looking for quicker (that is, once you get used to most of the general terminology and how to use the index properly). In 2022, using the Optum manual, those titles are:
* Path and Lab
look at the right side
The inserts help you get to where you want to go quicker than in the past. Even if you don’t understand some of the terminology, the edge of the first page you come to after each tab will highlight the range of codes listed in there, and you’ll know which direction to go if the code you’re searching for isn’t there.
Let’s talk about resequenced codes. What sometimes happens is the AMA decides to break down a procedure into multiple codes because it can be done multiple ways. This helps quickly define how it was performed, and sometimes changes the amount of reimbursement on the back end. Let’s take a look at this page as an example; there’s a lot here that we’re going to look at that will help you on other pages.
Look at 10021, Fine needle aspiration biopsy, around the middle of the left column. Notice there are numbers highlighted in green both in front and after that code. Notice they’re the same numbers, but those following the original code come before the one for the needle aspiration. The initial goal of the AMA is to keep codes within their categories as they were created. Sometimes it doesn’t work like that and they’ll move an entire group of codes elsewhere if there’s enough number space. In this case, 10021 has been the first CPT code for a great many years, which means many people are used to it being there.
So the AMA has created codes that are going to lead off this category within the next year to 4 years. The new first code will eventually be 10004, and 10021 will be left, but it’ll be at the end of the rest of the codes. It will probably have its description modified somewhat, but it’ll give instructions for how to use it and how to capture how many additional lesions were performed. The other codes will start with the main process being used to do the biopsy, then have a secondary code for identifying each additional lesion being performed, just like 10021, but they’ll eventually be ahead of 10021.
In the Optum book, the explanation of additional instructions and alterations are in blue. Numbers 10004, 10006, 10008, 10010 and 10012 tells you that those charges need the number in front of them to properly code and bill those claims. Some of them also tell you other codes not within the department that need to be captured as part of the procedure, and others that shouldn’t be included. I know it looks confusing, but it gets the job done properly.
Here’s an interesting sidebar. These same codes in this same order are in both the 2020 and 2021 CPT manuals. The reason they do that is because studies have shown that many hospitals update their charge masters between 3 and 7 years; that’s a shame. Therefore, they’ll share the same information for a certain number of years hoping everyone makes the proper modifications within this time period.
However, the information in blue print might change more quickly. For instance, on this page, the blue area leading this section has the same information as 2021, but different information than 2020. That’s why I always keep at least 3 years of this manual and the HCPCS manual. I used to keep all of them, but they’re big and take up a lot of space so I finally changed that process.
In any case, you need to get used to this kind of thing because it happens throughout the manual in all departments. They didn’t used to give you this much information, which made things a bit more difficult to figure out. The question might be is too much information easier to decipher than too little. Trust me, you’ll always appreciate there being more information, no matter what it is you’re doing.
bottom of every procedure page
I want to quickly bring your attention to the bottom of the page, which is on every page where there are CPT codes. You see both symbols and line colors. That’s a way to determine whether something’s been listed a long time or if there’s been some kind of change to make you aware of. It’s hard to say which codes are more important than the others, but I’ll go out on a limb for a couple of these. The two I’d ignore are those regarding web releases. Those won’t do you any good or harm, so don’t worry about them.
All of the other codes are important, but for different reasons. New codes are always important to know about, and so are reinstated codes. However, revised codes are the most comprehensive to know about because these could be long time codes whose descriptions have changed that could totally revamp what they used to be about.
An entire department could have had their descriptions changed along with having new codes added. That’s a big deal because the departments using those codes will need to have a primer on what those codes represent and match it up with what they’re presently using those codes for, and it might change how they’ve been using those codes. This is a reason why I’ve always advocated trying to create code descriptions that come close to what the manual calls them.
The second row of comments I usually skip as they’re basically just informational. However, after what we went through in 2020, where more services were provided via telemedicine, it might be more helpful for entities like physician and clinic offices to know about these codes. When it comes to non-FDA drugs, this might indicate that an insurance company might not pay for it and phone calls might need to be made to verify that.
Next I’ll touch quickly upon the E&M codes, which I mentioned earlier in this article. The manuals these days give you a lot of information on how these codes should be used and gives us more information on each of these codes before being used. There are two problems you might end up being with when it comes these codes.
The first is that there’s no rule that says hospital and physician codes for the same service have to use the same code. That was the standard everyone used to shoot for about 30 years ago, but those days are gone. In today’s world, the “supposed” determination is how much did each contribute to the care of the patient and to what degree.
This is more pertinent in hospitals, such as the emergency room, since most of the time physicians aren’t employees of the hospital, but contracted help. Even if the hospital agrees to handle the physician billing, that doesn’t mean the codes will be the same. Most of the time both parties just let it go, as it’s rare for insurance companies to come back and complain about it, and no physician or hospital has been accused of fraud because of it.
The second is that, just because the manual gives us a determination on how codes should be reviewed and decided upon doesn’t mean physicians will accept those rules. As an example, code 99214 states that the evaluation should be between 30 and 39 minutes. As the video below will indicate, which highlights an issue I had with my physician, it rarely goes that way; check out this video:
Once again, unless there’s an aberration in coding where every account being charged is always at the highest category level, there’s little to be done to sway physicians on this unless an insurance company determines it wants to audit them… which does happen occasionally. The best you can do is mention it at least once a year, put it into your compliance notes if you have that department, and move on with life.
The last two types of codes I’m going to highlight are Category II and Category III codes.
Category II codes are basically extension codes that track how certain procedures worked or not. It’s considered as an indication that certain services they’d be matched up with were more or less comprehensive than the norm. All the codes end with the letter F and may or may not be reimbursed. They’re almost never used, so they’re not considered a big deal.
Category III codes are a different animal. They’re either brand new or experimental codes that were brought to the attention of the AMA, and these are used in tracking how and when they’re being used with a 5 year window, to determine if they’ll become full time CPT codes or determine that they don’t qualify as something that will be accepted on its merit. These codes end with the letter T, and if your facility is doing any of these types of services, the codes should be included on the bill.
Don’t bother contacting insurance companies about these codes because they won’t be reimbursed until or at least until they’ve been added as regular CPT codes. What’s more important is the documentation for these codes so that the insurance companies and the AMA can review the information from many entities and make their decision based on those records and details.
The last thing to talk about are the appendixes in the back area of the manuals. Some are crucial to both billing and quickly learning about all the specific code changes for the year quickly. You won’t get as much detail on each change as you will by looking the codes up individually, but you will find out whether certain codes have been eliminated or moved to other areas, as well as if a batch of new codes have shown up in a particular department. This is the area I go to before any other place because it could lead to the beginning of a lot of comprehensive work in a department or let you know that you can ease into the new year and only have modifications to deal with.
The main thing to know about the appendixes is that most of the information back there isn’t going to be useful to you, so there’s a lot to skip in general terms, but might need to look through in case something unusual comes up that you’re being asked about. The appendixes in both manuals used to be in the same order, but I’m not guaranteeing that since I haven’t seen the AMA manual in quite a few years. So I’m going to give you the categories in order as they’re arranged by the Optum manual:
* Appendix A – Modifiers
* Appendix B – New, Revised and Deleted Codes
* Appendix C – Evaluation and Management Extended Guidelines
* Appendix D – Crosswalk of Deleted Codes (this not only gives you eliminated codes but will tell you what they’ve been replaced with. You’ll also see which Category III codes have been accepted and newly coded
* Appendix E – Resequenced Codes
* Appendix F – Add-on Codes, Optum Modifier 50 Exempt, Modifier 51 Exempt, Optum Modifier 51 Exempt, Modifier 63 Exempt, and Modifier 95 Telemedicine Services
* Appendix G – Medicare Internet-only Manuals
* Appendix H – Quality Payment Program
* Appendix I – Medically Unlikely Edits (almost no one will ever need to look at this)
* Appendix J – Inpatient-Only Procedures
* Appendix K – Place of Service and Type of Service
* Appendix L – Multianalyte Assays with Algorithmic Analyses
* Appendix M – Glossary (very helpful for us non-medical terminology geniuses)
* Appendix N – Listing of Sensory, Motor, and Mixed Nerves
* Appendix O – Vascular Families
This covers pretty much everything that’s included in CPT manuals. There’s lots of information and I wouldn’t expect anyone to try to remember most of these codes unless they pertain to an area of the hospital or clinic or the specialty of the physician you’re working for uses them often. It’s always important that these codes match up to the proper revenue codes, as claims will be denied if they don’t. At the very least, get used to the structure of this manual and the HCPCS manual (which I’ll cover in a different article) so you won’t be confused if you ever have to look through one.