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Following are the 2001 Guidelines

Evaluation and Management (E/M) Services Guidelines

In addition to the information presented in the Introduction, several other
items unique to this section are defined or identified here.

Classification of Evaluation and Management (E/M) Services

The E/M section is divided into broad categories such as office visits, hospital
visits, and consultations. Most of the categories are further divided into two
or more subcategories of E/M services. For example, there are two subcategories
of office visits (new patient and established patient) and there are two
subcategories of hospital visits (initial and subsequent). The subcategories of
E/M services are further classified into levels of E/M services that are
identified by specific codes. This classification is important because the
nature of physician work varies by type of service, place of service, and the
patient's status.

The basic format of the levels of E/M services is the same for most categories.
First, a unique code number is listed. Second, the place and/or type of service
is specified, eg, office consultation. Third, the content of the service is
defined, eg, comprehensive history and comprehensive examination. (See "Levels
of E/M Services," page 2, for details on the content of E/M services.) Fourth,
the nature of the presenting problem(s) usually associated with a given level is
described. Fifth, the time typically required to provide the service is
specified. (A detailed discussion of time is provided on page 3.)

Definitions of Commonly Used Terms

Certain key words and phrases are used throughout the E/M section. The following
definitions are intended to reduce the potential for differing interpretations
and to increase the consistency of reporting by physicians in differing
specialties.

New and Established Patient

Solely for the purposes of distinguishing between new and established patients,
professional services are those face-to-face services rendered by a physician
and reported by a specific CPT code(s). A new patient is one who has not
received any professional services from the physician, or another physician of
the same specialty who belongs to the same group practice, within the past three
years.

An established patient is one who has received professional services from the
physician or another physician of the same specialty who belongs to the same
group practice, within the past three years.

In the instance where a physician is on call for or covering for another
physician, the patient's encounter will be classified as it would have been by
the physician who is not available.

No distinction is made between new and established patients in the emergency
department. E/M services in the emergency department category may be reported
for any new or established patient who presents for treatment in the emergency
department.

Chief Complaint

A concise statement describing the symptom, problem, condition, diagnosis or
other factor that is the reason for the encounter, usually stated in the
patient's words.

Concurrent Care

Concurrent care is the provision of similar services, eg, hospital visits, to
the same patient by more than one physician on the same day. When concurrent
care is provided, no special reporting is required. Modifier '-75' has been
deleted.

Counseling

Counseling is a discussion with a patient and/or family concerning one or more
of the following areas:

diagnostic results, impressions, and/or recommended diagnostic studies;
prognosis;
risks and benefits of management (treatment) options;
instructions for management (treatment) and/or follow-up;
importance of compliance with chosen management (treatment) options;
risk factor reduction; and
patient and family education.
(For psychotherapy, see 90804-90857)

Family History

A review of medical events in the patient's family that includes significant
information about:

the health status or cause of death of parents, siblings, and children;
specific diseases related to problems identified in the Chief Complaint or
History of the Present Illness, and/or System Review;
diseases of family members which may be hereditary or place the patient at risk.

History of Present Illness

A chronological description of the development of the patient's present illness
from the first sign and/or symptom to the present. This includes a description
of location, quality, severity, timing, context, modifying factors and
associated signs and symptoms significantly related to the presenting
problem(s).

Levels of E/M Services

Within each category or subcategory of E/M service, there are three to five
levels of E/M services available for reporting purposes. Levels of E/M services
are not interchangeable among the different categories or subcategories of
service. For example, the first level of E/M services in the subcategory of
office visit, new patient, does not have the same definition as the first level
of E/M services in the subcategory of office visit, established patient.

The levels of E/M services include examinations, evaluations, treatments,
conferences with or concerning patients, preventive pediatric and adult health
supervision, and similar medical services, such as the determination of the need
and/or location for appropriate care. Medical screening includes the history,
examination, and medical decision-making required to determine the need and/or
location for appropriate care and treatment of the patient (eg, office and other
outpatient setting, emergency department, nursing facility, etc.). The levels of
E/M services encompass the wide variations in skill, effort, time,
responsibility and medical knowledge required for the prevention or diagnosis
and treatment of illness or injury and the promotion of optimal health. Each
level of E/M services may be used by all physicians.

The descriptors for the levels of E/M services recognize seven components, six
of which are used in defining the levels of E/M services. These components are:
history;
examination;
medical decision making;
counseling;
coordination of care;
nature of presenting problem; and
time.

The first three of these components (history, examination, and medical decision
making) are considered the key components in selecting a level of E/M services.
(See "Determine the Extent of History Obtained," page 5.)

The next three components (counseling, coordination of care, and the nature of
the presenting problem) are considered contributory factors in the majority of
encounters. Although the first two of these contributory factors are important
E/M services, it is not required that these services be provided at every
patient encounter.

Coordination of care with other providers or agencies without a patient
encounter on that day is reported using the case management codes.

The final component, time, is discussed in detail (see page 3).

Any specifically identifiable procedure (ie, identified with a specific CPT
code) performed on or subsequent to the date of initial or subsequent "E/M
Services" should be reported separately.

The actual performance and/or interpretation of diagnostic tests/studies ordered
during a patient encounter are not included in the levels of E/M services.
Physician performance of diagnostic tests/studies for which specific CPT codes
are available may be reported separately, in addition to the appropriate E/M
code. The physician's interpretation of the results of diagnostic tests/studies
(ie, professional component) with preparation of a separate distinctly
identifiable signed written report may also be reported separately, using the
appropriate CPT code with the modifier '-26' appended.

The physician may need to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient's condition required a
significant separately identifiable E/M service above and beyond other services
provided or beyond the usual preservice and postservice care associated with the
procedure that was performed. The E/M service may be caused or prompted by the
symptoms or condition for which the procedure and/or service was provided. This
circumstance may be reported by adding the modifier '-25' to the appropriate
level of E/M service. As such, different diagnoses are not required for
reporting of the procedure and the E/M services on the same date.

Nature of Presenting Problem

A presenting problem is a disease, condition, illness, injury, symptom, sign,
finding, complaint, or other reason for encounter, with or without a diagnosis
being established at the time of the encounter. The E/M codes recognize five
types of presenting problems that are defined as follows:

Minimal: A problem that may not require the presence of the physician, but
service is provided under the physician's supervision.

Self-limited or minor: A problem that runs a definite and prescribed course, is
transient in nature, and is not likely to permanently alter health status OR has
a good prognosis with management/compliance.

Low severity: A problem where the risk of morbidity without treatment is low;
there is little to no risk of mortality without treatment; full recovery without
functional impairment is expected.

Moderate severity: A problem where the risk of morbidity without treatment is
moderate; there is moderate risk of mortality without treatment; uncertain
prognosis OR increased probability of prolonged functional impairment.

High severity: A problem where the risk of morbidity without treatment is high
to extreme; there is a moderate to high risk of mortality without treatment OR
high probability of severe, prolonged functional impairment.

Past History

A review of the patient's past experiences with illnesses, injuries, and
treatments that includes significant information about:
prior major illnesses and injuries;
prior operations;
prior hospitalizations;
current medications;
allergies (eg, drug, food);
age appropriate immunization status;
age appropriate feeding/dietary status.

Social History

An age appropriate review of past and current activities that includes
significant information about:
marital status and/or living arrangements;
current employment;
occupational history;
use of drugs, alcohol, and tobacco;
level of education;
sexual history;
other relevant social factors.

System Review (Review of Systems)

An inventory of body systems obtained through a series of questions seeking to
identify signs and/or symptoms which the patient may be experiencing or has
experienced. For the purposes of CPT the following elements of a system review
have been identified:
Constitutional symptoms (fever, weight loss, etc.)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

The review of systems helps define the problem, clarify the differential
diagnosis, identify needed testing, or serves as baseline data on other systems
that might be affected by any possible management options.

Time

The inclusion of time in the definitions of levels of E/M services has been
implicit in prior editions of CPT. The inclusion of time as an explicit factor
beginning in CPT 1992 is done to assist physicians in selecting the most
appropriate level of E/M services. It should be recognized that the specific
times expressed in the visit code descriptors are averages, and therefore
represent a range of times which may be higher or lower depending on actual
clinical circumstances.

Time is not a descriptive component for the emergency department levels of E/M
services because emergency department services are typically provided on a
variable intensity basis, often involving multiple encounters with several
patients over an extended period of time. Therefore, it is often difficult for
physicians to provide accurate estimates of the time spent face-to-face with the
patient.

Studies to establish levels of E/M services employed surveys of practicing
physicians to obtain data on the amount of time and work associated with typical
E/M services. Since "work" is not easily quantifiable, the codes must rely on
other objective, verifiable measures that correlate with physicians' estimates
of their "work". It has been demonstrated that physicians' estimations of
intraservice time (as explained below), both within and across specialties, is a
variable that is predictive of the "work" of E/M services. This same research
has shown there is a strong relationship between intra-service time and total
time for E/M services. Intra-service time, rather than total time, was chosen
for inclusion with the codes because of its relative ease of measurement and
because of its direct correlation with measurements of the total amount of time
and work associated with typical E/M services.

Intra-service times are defined as face-to-face time for office and other
outpatient visits and as unit/floor time for hospital and other inpatient
visits. This distinction is necessary because most of the work of typical office
visits takes place during the face-to-face time with the patient, while most of
the work of typical hospital visits takes place during the time spent on the
patient's floor or unit.

Face-to-face time (office and other outpatient visits and office consultations):
For coding purposes, face-to-face time for these services is defined as only
that time that the physician spends face-to-face with the patient and/or family.
This includes the time in which the physician performs such tasks as obtaining a
history, performing an examination, and counseling the patient.

Physicians also spend time doing work before or after the face-to-face time with
the patient, performing such tasks as reviewing records and tests, arranging for
further services, and communicating further with other professionals and the
patient through written reports and telephone contact.

This non-face-to-face time for office services-also called pre- and post-
encounter time-is not included in the time component described in the E/M codes.
However, the pre- and post-face-to-face work associated with an encounter was
included in calculating the total work of typical services in physician surveys.

Thus, the face-to-face time associated with the services described by any E/M
code is a valid proxy for the total work done before, during, and after the
visit.

Unit/floor time (hospital observation services, inpatient hospital care, initial
and follow-up hospital consultations, nursing facility): For reporting purposes,
intra-service time for these services is defined as unit/floor time, which
includes the time that the physician is present on the patient's hospital unit
and at the bedside rendering services for that patient. This includes the time
in which the physician establishes and/or reviews the patient's chart, examines
the patient, writes notes and communicates with other professionals and the
patient's family.

In the hospital, pre- and post-time includes time spent off the patient's floor
performing such tasks as reviewing pathology and radiology findings in another
part of the hospital.

This pre- and post-visit time is not included in the time component described in
these codes. However, the pre- and post-work performed during the time spent off
the floor or unit was included in calculating the total work of typical services
in physician surveys.

Thus, the unit/floor time associated with the services described by any code is
a valid proxy for the total work done before, during, and after the visit.

Unlisted Service

An E/M service may be provided that is not listed in this section of CPT. When
reporting such a service, the appropriate "Unlisted" code may be used to
indicate the service, identifying it by "Special Report", as discussed in the
following paragraph. The "Unlisted Services" and accompanying codes for the E/M
section are as follows:

99429 Unlisted preventive medicine service
99499 Unlisted evaluation and management service

Special Report

An unlisted service or one that is unusual, variable, or new may require a
special report demonstrating the medical appropriateness of the service.
Pertinent information should include an adequate definition or description of
the nature, extent, and need for the procedure; and the time, effort, and
equipment necessary to provide the service. Additional items which may be
included are complexity of symptoms, final diagnosis, pertinent physical
findings, diagnostic and therapeutic procedures, concurrent problems, and
follow-up care.

Clinical Examples

Clinical examples of the codes for E/M services are provided to assist
physicians in understanding the meaning of the descriptors and selecting the
correct code. The clinical examples are listed in Appendix D. Each example was
developed by physicians in the specialties shown.

The same problem, when seen by physicians in different specialties, may involve
different amounts of work. Therefore, the appropriate level of encounter should
be reported using the descriptors rather than the examples.

The examples have been tested for validity and approved by the CPT Editorial
Panel. Physicians were given the examples and asked to assign a code or assess
the amount of time and work involved. Only those examples that were rated
consistently have been included in Appendix D.

Instructions for Selecting a Level of E/M Service

Identify the Category and Subcategory of Service

The categories and subcategories of codes available for reporting E/M services
are shown in Table 1 on the following page.

Review the Reporting Instructions for the Selected Category or Subcategory

Most of the categories and many of the subcategories of service have special
guidelines or instructions unique to that category or subcategory. Where these
are indicated, eg, "Inpatient Hospital Care," special instructions will be
presented preceding the levels of E/M services.

Review the Level of E/M Service Descriptors and Examples in the Selected
Category or Subcategory

The descriptors for the levels of E/M services recognize seven components, six
of which are used in defining the levels of E/M services. These components are:
history;
examination;
medical decision making;
counseling;
coordination of care;
nature of presenting problem; and
time.

The first three of these components (ie, history, examination, and medical
decision making) should be considered the key components in selecting the level
of E/M services. An exception to this rule is in the case of visits which
consist predominantly of counseling or coordination of care (See numbered
paragraph 3, page 6.)

The nature of the presenting problem and time are provided in some levels to
assist the physician in determining the appropriate level of E/M service.

Determine the Extent of History Obtained

The extent of the history is dependent upon clinical judgment and on the nature
of the presenting problems(s). The levels of E/M services recognize four types
of history that are defined as follows:

Problem focused: chief complaint; brief history of present illness or problem.

Expanded problem focused: chief complaint; brief history of present illness;
problem pertinent system review.

Detailed: chief complaint; extended history of present illness; problem
pertinent system review extended to include a review of a limited number of
additional systems; pertinent past, family, and/or social history directly
related to the patient's problems.

Comprehensive: chief complaint; extended history of present illness; review of
systems which is directly related to the problem(s) identified in the history of
the present illness plus a review of all additional body systems; complete past,
family, and social history.

The comprehensive history obtained as part of the preventive medicine evaluation
and management service is not problem-oriented and does not involve a chief
complaint or present illness. It does, however, include a comprehensive system
review and comprehensive or interval past, family, and social history as well as
a comprehensive assessment/history of pertinent risk factors.

Determine the Extent of Examination Performed

The extent of the examination performed is dependent on clinical judgment and on
the nature of the presenting problem(s). The levels of E/M services recognize
four types of examination that are defined as follows:

Problem focused: a limited examination of the affected body area or organ
system.

Expanded problem focused: a limited examination of the affected body area or
organ system and other symptomatic or related organ system(s).

Detailed: an extended examination of the affected body area(s) and other
symptomatic or related organ system(s).

Comprehensive: a general multi-system examination or a complete examination of a
single organ system. Note: The comprehensive examination performed as part of
the preventive medicine evaluation and management service is multisystem, but
its extent is based on age and risk factors identified.

For the purposes of these CPT definitions, the following body areas are
recognized:
Head, including the face
Neck
Chest, including breasts and axilla
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
For the purposes of these CPT definitions, the following organ systems are
recognized:
Eyes
Ears, Nose, Mouth, and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunologic

Determine the Complexity of Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis
and/or selecting a management option as measured by:

the number of possible diagnoses and/or the number of management options that
must be considered;
the amount and/or complexity of medical records, diagnostic tests, and/or other
information that must be obtained, reviewed, and analyzed; and
the risk of significant complications, morbidity, and/or mortality, as well as
comorbidities, associated with the patient's presenting problems(s), the
diagnostic procedure(s) and/or the possible management options.

Four types of medical decision making are recognized: straightforward; low
complexity; moderate complexity; and high complexity. To qualify for a given
type of decision making, two of the three elements in Table 2 on the following
page must be met or exceeded.

Comorbidities/underlying diseases, in and of themselves, are not considered in
selecting a level of E/M services unless their presence significantly increases
the complexity of the medical decision making.

Select the Appropriate Level of E/M Services Based on the Following

1. For the following categories/subcategories, all of the key components, ie,
2. history, examination, and medical decision making, must meet or exceed the
3. stated requirements to qualify for a particular level of E/M service: office,
4. new patient; hospital observation services; initial hospital care; office
5. consultations; initial inpatient consultations; confirmatory consultations;
6. emergency department services; comprehensive nursing facility assessments;
7. domiciliary care, new patient; and home, new patient.

2. For the following categories/subcategories, two of the three key components
(ie, history, examination, and medical decision making) must meet or exceed the
stated requirements to qualify for a particular level of E/M services: office,
established patient; subsequent hospital care; follow-up inpatient
consultations; subsequent nursing facility care; domiciliary care, established
patient; and home, established patient.

3. When counseling and/or coordination of care dominates (more than 50%) the
physician/
patient and/or family encounter (face-to-face time in the office or other
outpatient setting or floor/unit time in the hospital or nursing facility), then
time may be considered the key or controlling factor to qualify for a particular
level of E/M services. This includes time spent with parties who have assumed
responsibility for the care of the patient or decision making whether or not
they are family members (eg, foster parents, person acting in locum parentis,
legal guardian). The extent of counseling and/or coordination of care must be
documented in the medical record.

Table 1
Categories and Subcategories of Service

Category/Subcategory					Code Number
Office or Other Outpatient Service
New Patient						99201-99205
Established Patient					99211-99215
Hospital Observation Discharge Services			99217
Hospital Observation Services				99218-99220
Hospital Observation or Inpatient Care
Services (Including Admission and
Discharge Services)					99234-99236
Hospital Inpatient Services				
Initial Hospital Care					99221-99223
Subsequent Hospital Care				99231-99233
Hospital Discharge Services				99238-99239
Consultations						
Office Consultations					99241-99245
Initial Inpatient Consultations				99251-99255
Follow-up Inpatient Consultations			99261-99262
Confirmatory Consultations				99271-99275
Emergency Department Services				99281-99288
Critical Care Services					99291-99292
Neonatal Intensive Care					99292-99298
Nursing Facility Services
Comprehensive Nursing Facility
Assessments						99301-99393
Subsequent Nursing Facility Care			99311-99313
Nursing Facility Discharge Services			99315-99316
Domiciliary, Rest Home or 
Custodial Care Services
New Patient						99321-99323
Established Patient					99331-99333
Home Services						
New Patient						99341-99345
Established Patient					99347-99350
Prolonged Services
With Direct Patient Contact				99354-99357
Without Direct Patient Contact				99358-99359
Standby Services					99360
Case Management Services				
Team Conferences					99361-99362
Telephone Calls						99371-99373
Care Plan Oversight Services					
Preventative Medicine Services				
New Patient						99381-99387
Established Patient					99391-99379
Individual Counseling					99401-99404
Group Counseling					99411-99412
Other							99420-99429
Newborn Care						99431-99440
Special E/M Services					99450-99456
Other E/M Services					99499

Table 2
Complexity of Medical Decision Making

Number of Diagnoses or Management Options
minimal
limited
multiple
extensive

Amount and/or Complexity of Data to be Reviewed
Minimal or none
limited
moderate
extensive

Risk of Complications and/or Morbidity or Mortality
minimal
low
moderate
high

Type of Decision Making
straightforward
low complexity
moderate complexity
high complexity

Anesthesia Guidelines

Services involving administration of anesthesia are reported by the use of the
anesthesia five digit procedure code (00100-01999) plus modifier codes (defined
under "Anesthesia Modifiers" later in these guidelines).

The reporting of anesthesia services is appropriate by or under the responsible
supervision of a physician. These services may include but are not limited to
general, regional, supplementation of local anesthesia, or other supportive
services in order to afford the patient the anesthesia care deemed optimal by
the anesthesiologist during any procedure. These services include the usual
preoperative and postoperative visits, the anesthesia care during the procedure,
the administration of fluids and/or blood and the usual monitoring services (eg,
ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry).
Unusual forms of monitoring (eg, intra-arterial, central venous, and Swan-Ganz)
are not included.

Items used by all physicians in reporting their services are presented in the
Introduction. Some of the commonalities are repeated here for the convenience of
those physicians referring to this section on Anesthesia. Other definitions and
items unique to anesthesia are also listed.

To report sedation with or without analgesia (conscious sedation) provided by a
physician also performing the service for which conscious sedation is being
provided, see codes 99141, 99142.

To report regional or general anesthesia provided by a physician also performing
the services for which the anesthesia is being provided, see mod ifier '-47,'
Anesthesia by Surgeon, in Appendix A.

Time Reporting

Time for anesthesia procedures may be reported as is customary in the local
area. Anesthesia time begins when the anesthesiologist begins to prepare the
patient for the induction of anesthesia in the operating room or in an
equivalent area and ends when the anesthesiologist is no longer in personal
attendance, that is, when the patient may be safely placed under postoperative
supervision.

Physician's Services

Physician's services rendered in the office, home, or hospital, consultation,
and other medical services are listed in the section entitled Evaluation and
Management Services (99200 series) found in the front of the book, beginning on
page 1. "Special Services and Reporting" (99000 series) are presented in the
Medicine section.

Materials Supplied by Physician

Supplies and materials provided by the physician (eg, sterile trays, drugs) over
and above those usually included with the office visit or other services
rendered may be listed separately. List drugs, tray supplies, and materials
provided. Identify as 99070.

Separate or Multiple Procedures

It is appropriate to designate multiple procedures that are rendered on the same
date by separate entries. This can be reported by using the multiple procedure
modifier '-51'. See "Anesthesia Modifiers" for modifier definitions.

Special Report

A service that is rarely provided, unusual, variable, or new may require a
special report in determining medical appropriateness of the service. Pertinent
information should include an adequate definition or description of the nature,
extent, and need for the procedure; and the time, effort, and equipment
necessary to provide the service. Additional items which may be included are:
complexity of symptoms;
final diagnosis;
pertinent physical findings;
diagnostic and therapeutic procedures;
concurrent problems;
follow-up care.

Anesthesia Modifiers

All anesthesia services are reported by use of the anesthesia five digit
procedure code (00100-01999) plus the addition of a physical status modifier.
The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by
a single digit from 1 to 6 defined below.

P1-A normal healthy patient.
P2-A patient with mild systemic disease.
P3-A patient with severe systemic disease.
P4-A patient with severe systemic disease that is a constant threat to life.
P5-A moribund patient who is not expected to survive without the operation.
P6-A declared brain-dead patient whose organs are being removed for donor
purposes.

The above six levels are consistent with the American Society of
Anesthesiologists (ASA) ranking of patient physical status. Physical status is
included in CPT to distinguish among various levels of complexity of the
anesthesia service provided.

Example: 00100-P1

Qualifying Circumstances

More than one may be selected.

Many anesthesia services are provided under particularly difficult
circumstances, depending on factors such as extraordinary condition of patient,
notable operative conditions, and/or unusual risk factors. This section includes
a list of important qualifying circumstances that significantly impact on the
character of the anesthesia service provided. These procedures would not be
reported alone but would be reported as additional procedure numbers qualifying
an anesthesia procedure or service.

99100 Anesthesia for patient of extreme age, under one year and over seventy
(List separately in addition to code for primary anesthesia procedure)

99116 Anesthesia complicated by utilization of total body hypothermia (List
separately in addition to code for primary anesthesia procedure)

99135 Anesthesia complicated by utilization of controlled hypotension (List
separately in addition to code for primary anesthesia procedure)

99140 Anesthesia complicated by emergency conditions (specify) (List separately
in addition to code for primary anesthesia procedure)

(An emergency is defined as existing when delay in treatment of the patient
would lead to a significant increase in the threat to life or body part.)

Surgery Guidelines

Items used by all physicians in reporting their services are presented in the
Introduction. Some of the commonalities are repeated here for the convenience of
those physicians referring to this section on Surgery. Other definitions and
items unique to Surgery are also listed.

Physicians' Services

Physicians' services rendered in the office, home, or hospital, consultations,
and other medical services are listed in the section entitled Evaluation and
Management Services (99200 series) found in the front of the book, beginning on
page 9. "Special Services and Reports" (99000 series) is presented in the
Medicine section.

Listed Surgical Procedures

Listed surgical procedures include the operation per se, local infiltration,
metacarpal/digital block or topical anesthesia when used, and normal,
uncomplicated follow-up care. This concept is referred to as a "package" for
surgical procedures. To report a postoperative follow-up visit for documentation
purposes only, use 99024.

Follow-Up Care for Diagnostic Procedures

Follow-up care for diagnostic procedures (eg, endoscopy, arthroscopy, injection
procedures for radiography) includes only that care related to recovery from the
diagnostic procedure itself. Care of the condition for which the diagnostic
procedure was performed or of other concomitant conditions is not included and
may be listed separately.

Follow-Up Care for Therapeutic Surgical Procedures

Follow-up care for therapeutic surgical procedures includes only that care which
is usually a part of the surgical service. Complications, exacerbations,
recurrence, or the presence of other diseases or injuries requiring additional
services should be reported with the identification of appropriate procedures.

Materials Supplied by Physician

Supplies and materials provided by the physician (eg, sterile trays/drugs), over
and above those usually included with the office visit or other services
rendered may be listed separately. List drugs, trays, supplies, and materials
provided. Identify as 99070.

Reporting More Than One Procedure/Service

When a physician performs more than one procedure/service on the same date, same
session or during a post-operative period (subject to the "surgical package"
concept), several CPT modifiers may apply. (See Appendix A for definition.)

-51 Multiple Procedures

When multiple procedures/services (other than evaluation and management) are
performed at the same session, report the most significant procedure first, with
all other procedures listed with the '-51' modifier appended. For a list of
procedures exempt from the use of the '-51' modifier, see Appendices E and F.

-58 Staged or Related Procedure or Service by the Same Physician During the
Postoperative Period
When a procedure(s) is prospectively planned as a staged procedure, or when the
secondary and subsequent procedure(s) is more extensive, or to indicate therapy
following a diagnostic surgical procedure, use the '-58' modifier with the
staged procedure(s).

-59 Distinct Procedural Service

For procedure(s)/service(s) not ordinarily performed or encountered on the same
day by the same physician, but appropriate under certain circumstances (eg,
different site or organ system, separate excision or lesion), use the '-59'
modifier.

-76 Repeat Procedure by Same Physician

When a procedure or service is repeated by the same physician subsequent to the
original service, use the '-76' modifier.

-77 Repeat Procedure by Another Physician

When a procedure is repeated by another physician subsequent to the original
service, use the '-77' modifier.

-78 Return to the Operating Room for a Related Procedure During the
Postoperative Period
When a procedure, related to the initial procedure, requires a return to the
operating room during the postoperative period of that initial procedure, use
the '-78' modifier.

-79 Unrelated Procedure or Service by the Same Physician During the
Postoperative Period
When a procedure, unrelated to the initial procedure, is performed by the same
physician during the postoperative period of the initial procedure, use the '-
79' modifier.

Add-on Codes

Some of the listed procedures are commonly carried out in addition to the
primary procedure performed. These additional or supplemental procedures are
designated as "add-on" codes with a "?" symbol, and are listed in Appendix E of
CPT. Add-on codes in CPT can be readily identified by specific descriptor
nomenclature which includes phrases such as "each additional" or "(List
separately in addition to primary procedure)."

The "add-on" code concept in CPT applies only to add-on procedures/services
performed by the same physician. Add-on codes describe additional intra-service
work associated with the primary procedure (eg, additional digit(s), lesion(s),
neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s)).

Add-on codes are always performed in addition to the primary service/procedure,
and must never be reported as a stand-alone code. All add-on codes found in CPT
are exempt from the multiple procedure concept (see modifier '-51' definition of
Surgery Guidelines).

Separate Procedure

Some of the procedures or services listed in CPT that are commonly carried out
as an integral com ponent of a total service or procedure have been identified
by the inclusion of the term "separate procedure." The codes designated as
"separate procedure" should not be reported in addition to the code for the
total procedure or service of which it is considered an integral component.

However, when a procedure or service that is designated as a "separate
procedure" is carried out independently or considered to be unrelated or
distinct from other procedures/services provided at that time, it may be
reported by itself, or in addition to other procedures/services by appending the
modifier '-59' to the specific "separate procedure" code to indicate that the
procedure is not considered to be a component of another procedure, but is a
distinct, independent procedure. This may represent a different session or
patient encounter, different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion, or separate injury (or area
of injury in extensive injuries).

Subsection Information

Several of the subheadings or subsections have special needs or instructions
unique to that section. Where these are indicated (eg, "Maternity Care and
Delivery"), special "Notes" will be presented preceding those procedural
terminology listings, referring to that subsection specifically. If there is an
"Unlisted Procedure" code number (see below) for the individual subsection, it
will also be shown. Those subsections within the Surgery section that have
"Notes" are as follows:

Removal of Skin Tags				11200-11201
Shaving of Lesions				11300-11313
Excision-Benign Lesions				11400-11471
Excision-Malignant Lesions			11600-11646
Repair (Closure)				12001-13160
Adjacent Tissue Transfer or Rearrangement	14000-14350
Free Skin Grafts				15000-15400
Flaps (Skin and/or Deep Tissue)			15570-15999
Burns, Local Treatment				16000-16042
Destruction, Benign Lesions			17000-17250
Destruction, Malignant Lesions 			17260-17286
Mohs Micrographic Surgery			17304-17310
Musculoskeletal					20000-29909
Wound Exploration-Trauma			20100-20103
Grafts (or Implants)				20900-20999
Spine: Excision					22100-22116
Spine: Osteotomy				22210-22226
Spine: Fracture/Dislocation			22305-22328
Arthrodesis					22548-22812
Spinal Instrumentation				22840-22855
Casting and Strapping				29000-29750
Cardiovascular System				33010-37799
Pacing Cardioverter-Pacemaker or Defibrillator	33200-33249
Venous-CABG					33510-33516
Arterial-Venous-CABG				33517-33530
Arterial-CABG					33533-33545
Transluminal Angioplasty			35450-35476
Transluminal Atherectomy			35480-35495
Composite Grafts				35681-35683
Arteries and Veins				34001-35907
Vascular Injection Procedures: Intravenous	36000-36015
Endoscopy					31505-31579, 32601-32665, 43200-43272,
						44360-44394, 45300-45385,
						46600-46615, 47550-47556
Herniotomy					49495-49611
Urodynamics					51725-51797
Endoscopy					52000-52318
Ureter and Pelvis				52320-52339
Maternity Care and Delivery			59000-59899
Surgery of Skull Base				61580-61619
Neurostimulators (Intracranial)			61850-61888
Neurostimulators (Spinal)			63650-63688
Neurostimulators (Peripheral Nerve)		64553-64595
Secondary Implants(s)				65125-65175
Removal Cataract				66830-66999
Prophylaxis					67141-67145
Operating Microscope				69990

Unlisted Service or Procedure

A service or procedure may be provided that is not listed in this edition of
CPT. When reporting such a service, the appropriate "Unlisted Procedure" code
may be used to indicate the service, iden tifying it by "Special Report" as
discussed in the section below. The "Unlisted Procedures" and accompanying codes
for Surgery are as follows:

15999 Unlisted procedure, excision pressure ulcer
17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19499 Unlisted procedure, breast
20999 Unlisted procedure, musculoskeletal system, general
21089 Unlisted maxillofacial prosthetic procedure
21299 Unlisted craniofacial and maxillofacial procedure
21499 Unlisted musculoskeletal procedure, head
21899 Unlisted procedure, neck or thorax
22899 Unlisted procedure, spine
22999 Unlisted procedure, abdomen, musculoskeletal system
23929 Unlisted procedure, shoulder
24999 Unlisted procedure, humerus or elbow
25999 Unlisted procedure, forearm or wrist
26989 Unlisted procedure, hands or fingers
27299 Unlisted procedure, pelvis or hip joint
27599 Unlisted procedure, femur or knee
27899 Unlisted procedure, leg or ankle
28899 Unlisted procedure, foot or toes
29799 Unlisted procedure, casting or strapping
29909 Unlisted procedure, arthroscopy
30999 Unlisted procedure, nose
31299 Unlisted procedure, accessory sinuses
31599 Unlisted procedure, larynx
31899 Unlisted procedure, trachea, bronchi
32999 Unlisted procedure, lungs and pleura
33999 Unlisted procedure, cardiac surgery
36299 Unlisted procedure, vascular injection
37799 Unlisted procedure, vascular surgery
38129 Unlisted laparoscopy procedure, spleen
38589 Unlisted laparoscopy procedure, lymphatic system
38999 Unlisted procedure, hemic or lymphatic system
39499 Unlisted procedure, mediastinum
39599 Unlisted procedure, diaphragm
40799 Unlisted procedure, lips
40899 Unlisted procedure, vestibule of mouth
41599 Unlisted procedure, tongue, floor of mouth
41899 Unlisted procedure, dentoalveolar structures
42299 Unlisted procedure, palate, uvula
42699 Unlisted procedure, salivary glands or ducts
42999 Unlisted procedure, pharynx, adenoids, or tonsils
43289 Unlisted laparoscopy procedure, esophagus
43499 Unlisted procedure, esophagus
43659 Unlisted laparoscopy procedure, stomach
43999 Unlisted procedure, stomach
44209 Unlisted laparoscopy procedure, intestine (except rectum)
44799 Unlisted procedure, intestine
44899 Unlisted procedure, Meckels diverticulum and the mesentery
44979 Unlisted laparoscopy procedure, appendix
45999 Unlisted procedure, rectum
46999 Unlisted procedure, anus
47399 Unlisted procedure, liver
47579 Unlisted laparoscopy procedure, biliary tract
47999 Unlisted procedure, biliary tract
48999 Unlisted procedure, pancreas
49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum
49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999 Unlisted procedure, abdomen, peritoneum and omentum
50549 Unlisted laparoscopy procedure, renal
50949 Unlisted laparoscopy procedure, ureter
53899 Unlisted procedure, urinary system
54699 Unlisted laparoscopy procedure, testis
55559 Unlisted laparoscopy procedure, spermatic cord
55899 Unlisted procedure, male genital system
58578 Unlisted laparoscopy procedure, uterus
58579 Unlisted hysteroscopy procedure, uterus
58679 Unlisted laparoscopy procedure, oviduct, ovary
58999 Unlisted procedure, female genital system (nonobstetrical)
59898 Unlisted laparoscopy procedure, maternity care and delivery
59899 Unlisted procedure, maternity care and delivery
60659 Unlisted laparoscopy procedure, endocrine system
60699 Unlisted procedure, endocrine system
64999 Unlisted procedure, nervous system
66999 Unlisted procedure, anterior segment of eye
67299 Unlisted procedure, posterior segment
67399 Unlisted procedure, ocular muscle
67599 Unlisted procedure, orbit
67999 Unlisted procedure, eyelids
68399 Unlisted procedure, conjunctiva
68899 Unlisted procedure, lacrimal system
69399 Unlisted procedure, external ear
69799 Unlisted procedure, middle ear
69949 Unlisted procedure, inner ear
69979 Unlisted procedure, temporal bone, middle fossa approach

Special Report

A service that is rarely provided, unusual, variable, or new may require a
special report in determining medical appropriateness of the service. Pertinent
information should include an adequate definition or description of the nature,
extent, and need for the procedure, and the time, effort, and equipment
necessary to provide the service. Additional items which may be included are:

complexity of symptoms;
final diagnosis;
pertinent physical findings (such as size, locations, and number of lesion(s),
if appropriate);
diagnostic and therapeutic procedures (including major and supplementary
surgical procedures, if appropriate);
concurrent problems;
follow-up care.

Starred (*) Procedures or Items
Certain relatively small surgical services involve a readily identifiable
surgical procedure but include variable preoperative and postoperative services
(eg, incision and drainage of an abscess, injection of a tendon sheath,
manipulation of a joint under anesthesia, dilation of the urethra). Because of
the indefinite pre- and postoperative services the usual "package" concept for
surgical services (see above) cannot be applied. Such procedures are identified
by a star (*) following the procedure code number.

When a star (*) follows a surgical procedure code number, the following rules
apply:
1. The service as listed includes the surgical procedure only. Associated pre-
and postoperative services are not included in the service as listed.

2. Preoperative services are considered as one of the following:
When the starred (*) procedure is carried out at the time of an initial visit
(new patient) and this procedure constitutes the major service at that visit,
procedure number 99025 is listed in lieu of the usual initial visit as an
additional service.

When the starred (*) procedure is carried out at the time of an initial or
established patient visit involving significant identifiable services, the
appropriate visit is listed with the modifier '-25' appended in addition to the
starred (*) procedure and its follow-up care.
When the starred (*) procedure requires hospitalization, an appropriate hospital
visit is listed in addition to the starred (*) procedure and its follow-up care.

3. All postoperative care is added on a service-by-service basis (eg, office or
hospital visit, cast change).

4. Complications are added on a service-by-service basis (as with all surgical
procedures).

Surgical Destruction

Surgical destruction is a part of a surgical procedure and different methods of
destruction are not ordinarily listed separately unless the technique
substantially alters the standard management of a problem or condition.
Exceptions under special circumstances are provided for by separate code
numbers.

Radiology Guidelines (Including Nuclear Medicine and Diagnostic Ultrasound)

Items used by all physicians in reporting their services are presented in the
Introduction. Some of the commonalities are repeated here for the convenience of
those physicians referring to this section on Radiology (Including Nuclear
Medicine and Diagnostic Ultrasound). Other definitions and items unique to
Radiology are also listed.

Subject Listings

Subject listings apply when radiological services are performed by or under the
responsible supervision of a physician.

Multiple Procedures

It is appropriate to designate multiple procedures that are rendered on the same
date by separate entries. This can be reported by using the multiple procedure
modifier '-51'. See Appendix A for modifier definitions.

Separate Procedures

Some of the procedures or services listed in CPT that are commonly carried out
as an integral component of a total service or procedure have been identified by
the inclusion of the term "separate procedure." The codes designated as
"separate procedure" should not be reported in addition to the code for the
total procedure or service of which it is considered an integral component.

However, when a procedure or service that is designated as a "separate
procedure" is carried out independently or considered to be unrelated or
distinct from other procedures/services provided at that time, it may be
reported by itself, or in addition to other procedures/services by appending the
modifier '-59' to the specific "separate procedure" code to indicate that the
procedure is not considered to be a component of another procedure, but is a
distinct, independent pro cedure. This may represent a different session or
patient encounter, different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion, or separate injury (or area
of injury in extensive injuries).

Subsection Information

Several of the subheadings or subsections have special needs or instructions
unique to that section. Where these are indicated (eg, "Radiation Oncology")
special "Notes" will be presented preceding those procedural terminology
listings, referring to that subsection specifically. If there is an "Unlisted
Procedure" code number (see section below) for the individual subsection, it
will be shown. Those subsections with "Notes" are as follows:

Diagnostic Radiology (Diagnostic Imaging)		70010-76499
Aorta and Arteries					75600-75790
Diagnostic Ultrasound					76506-76999
Radiation Oncology					77261-77799
Clinical Treatment Planning				77261-77299
RadiationTreatment Management				77427-77499
Proton Beam Treatment Delivery				77520-77523
Hyperthermia						77600-77620
Clinical Brachytherapy					77750-77799
Nuclear Medicine					78000-78299
Musculoskeletal System					78300-78399
Cardiovascular System					78414-78499

Unlisted Service or Procedure

A service or procedure may be provided that is not listed in this edition of
CPT. When reporting such a service, the appropriate "Unlisted Procedure" code
may be used to indicate the service, identifying it by "Special Report" as
discussed below. The "Unlisted Procedures" and accompanying codes for Radiology
(Including Nuclear Medicine and Diagnostic Ultrasound) are as follows:

76499 Unlisted diagnostic radiologic procedure
76999 Unlisted ultrasound procedure
77299 Unlisted procedure, therapeutic radiology clinical treatment planning
77399 Unlisted procedure, medical radiation physics, dosimetry and treatment
devices, and special 	services
77499 Unlisted procedure, therapeutic radiology treatment management
77799 Unlisted procedure, clinical brachytherapy
78099 Unlisted endocrine procedure, diagnostic nuclear medicine
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure,
diagnostic nuclear medicine
78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine
78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine
78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine
78599 Unlisted respiratory procedure, diagnostic nuclear medicine
78699 Unlisted nervous system procedure, diagnostic nuclear medicine
78799 Unlisted genitourinary procedure, diagnostic nuclear medicine
78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine
79999 Unlisted radiopharmaceutical therapeutic procedure

Special Report

A service that is rarely provided, unusual, variable, or new may require a
special report in determining medical appropriateness of the service. Pertinent
information should include an adequate definition or description of the nature,
extent, and need for the procedure; and the time, effort, and equipment
necessary to provide the service. Additional items which may be included are:

complexity of symptoms;
final diagnosis;
pertinent physical findings;
diagnostic and therapeutic procedures;
concurrent problems;
follow-up care.

Supervision and Interpretation

When a procedure is performed by two physicians, the radiologic portion of the
procedure is designated as "radiological supervision and interpretation." When a
physician performs both the procedure and provides imaging supervision and
interpretation, a combination of procedure codes outside the 70000 series and
imaging supervision and interpretation codes are to be used.
(The Radiological Supervision and Interpretation codes are not applicable to the
Radiation Oncology subsection.)

Administration of Contrast Material(s)

Some of the listed procedures are commonly carried out without the use of
contrast material for imaging enhancement. For those codes that may or may not
be performed using contrast material for imaging enhancement, the phrase "with
contrast" represents contrast material administered intravascularly or intra-
articularly (for intra-articular injection use appropriate joint injection code
and, if used, appropriate imaging guidance code).

For spine examinations using computerized tomography, magnetic resonance
imaging, magnetic resonance angiography, "with contrast" includes intrathecal or
intravascular injection. For intrathecal injection, use also 61055 or 62284.

Injection of contrast material is part of the "with contrast" CT, MRI, MRA
procedure.
Oral and/or rectal contrast administration alone does not qualify as a study
"with contrast."

Written Report(s)

A written report, signed by the interpreting physician, should be considered an
integral part of a radiologic procedure or interpretation.

Pathology and Laboratory Guidelines

Items used by all physicians in reporting their services are presented in the
Introduction. Some of the commonalities are repeated here for the convenience of
those physicians referring to this section on Pathology and Laboratory. Other
definitions and items unique to Pathology and Laboratory are also listed.

Services in Pathology and Laboratory

Services in Pathology and Laboratory are provided by a physician or by
technologists under responsible supervision of a physician.

Separate or Multiple Procedures

It is appropriate to designate multiple procedures that are rendered on the same
date by separate entries.

Subsection Information

Several of the subheadings or subsections have special needs or instructions
unique to that section. Where these are indicated, (eg, "Panel Tests"), special
"Notes" will be presented preceding those procedural terminology listings
referring to that subsection specifically. If there is an "Unlisted Procedure"
code number (see section below) for the individual subsection, it will be shown.
Those subsections with "Notes" are as follows:

Organ or Disease Panels			80048-80090
Drug Testing				80100-80103
Therapeutic Drug Assays			80150-80299
Evocative/Suppression Testing		80400-80440
Consultations (Clinical Pathology)	80500-80502
Urinalysis				81000-81099
Chemistry				82000-84999
Molecular Diagnostics			83890-83912, 87470-87799
Infectious Agent Antibodies		86602-86804
Microbiology Infectious Agent Detection	87260-87799
Anatomic Pathology			88000-88099
Cytopathology				88141-88167
Surgical Pathology			88300-88399

Unlisted Service or Procedure

A service or procedure may be provided that is not listed in this edition of
CPT. When reporting such a service, the appropriate "Unlisted Procedure" code
may be used to indicate the service, identifying it by "Special Report" as
discussed below. The "Unlisted Procedures" and accompanying codes for Pathology
and Laboratory are as follows:

80299 Quantitation of drug, not elsewhere specified
81099 Unlisted urinalysis procedure
84999 Unlisted chemistry procedure
85999 Unlisted hematology and coagulation procedure
86586 unlisted antigen, each
86849 Unlisted immunology procedure
86999 Unlisted transfusion medicine procedure
87999 Unlisted microbiology procedure
88099 Unlisted necropsy (autopsy) procedure
88199 Unlisted cytopathology procedure
88299 Unlisted cytogenetic study
88399 Unlisted surgical pathology procedure
89399 Unlisted miscellaneous pathology test

Special Report

A service that is rarely provided, unusual, variable, or new may require a
special report in determining medical appropriateness of the service. Pertinent
information should include an adequate definition or description of the nature,
extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service. Additional items which may be included are:

complexity of symptoms;
final diagnosis;
pertinent physical findings;
diagnostic and therapeutic procedures;
concurrent problems;
follow-up care.

Medicine Guidelines

In addition to the definitions and commonly used terms presented in the
Introduction, several other items unique to this section on Medicine are defined
or identified here.

Multiple Procedures

It is appropriate to designate multiple procedures that are rendered on the same
date by separate entries. For example: If individual psychotherapy (90804) is
rendered in addition to subsequent hospital care (eg, 99231), the psychotherapy
would be reported separately from the hospital visit. In this instance, both
99231 and 90804 would be reported.

Add-on Codes

Some of the listed procedures are commonly carried out in addition to the
primary procedure performed. All add-on codes found in CPT are exempt from the
multiple procedure concept. They are exempt from the use of the modifier '-51',
as these procedures are not reported as stand-alone codes. These additional or
supplemental procedures are designated as "add-on" codes. Add-on codes in CPT
can be readily identified by specific descriptor nomenclature which includes
phrases such as "each additional" or "(List separately in addition to primary
procedure)."

Separate Procedures

Some of the procedures or services listed in CPT that are commonly carried out
as an integral component of a total service or procedure have been identified by
the inclusion of the term "separate procedure." The codes designated as
"separate procedure" should not be reported in addition to the code for the
total procedure or service of which it is considered an integral component.

However, when a procedure or service that is designated as a "separate
procedure" is carried out independently or considered to be unrelated or
distinct from other procedures/services provided at that time, it may be
reported by itself, or in addition to other procedures/services by appending the
modifier '-59' to the specific "separate procedure" code to indicate that the
procedure is not considered to be a component of another procedure, but is a
distinct, independent procedure. This may represent a different session or
patient encounter, different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion, or separate injury (or area
of injury in extensive injuries).

Subsection Information

Several of the subheadings or subsections have special instructions unique to
that section. These special instructions will be presented preceding those
procedural terminology listings, referring to that subsection specifically. If
there is an "Unlisted Procedure" code number (see section below) for the
individual subsection, it will also be shown. Those subsections within the
Medicine section that have special instructions are as follows:

Immune Globulins 					90281-90399
Immunization Administration for Vaccines/Toxoids	90471-90472
Vaccines, Toxoids  					90476-90749
Therapeutic or Diagnostic Infusions			90780-90781
Psychiatry						90801-90899
Dialysis 						90918-90999
Ophthalmology						92002-92499
Otorhinolaryngology					92502-92599
Echocardiography					93303-93350
Cardiac Catheterization					93501-93556
Peripheral Arterial Disease Rehabilitation		93668
Non-Invasive Vascular Diagnostic Studies		93875-93990
Pulmonary						94010-94799
Allergy and Clinical Immunology				95004-95199
Neurology and Neuromuscular				95805-95999
Neurostimulators, Analysis-Programming			95970-95975
Central Nervous System Assessments/Tests		96100-96117
Chemotherapy Administration				96400-96549
Dermatological Procedures				96900-96999
Physical Medicine and Rehabilitation
Modalities						97010-97028
Constant Attendance					97032-97039
Therapeutic Procedures					97110-97546
Active Wound Care Management				97601-97602
Osteopathic Manipulative Treatment			98925-98929
Chiropractic Manipulative Treatment			98940-98943
Special Services, Procedures and Reports 		99000-99090
Conscious Sedation					99141-99142

Unlisted Service or Procedure

A service or procedure may be provided that is not listed in this edition of
CPT. When reporting such a service, the appropriate "Unlisted Procedure" code
may be used to indicate the service, identifying it by "Special Report" as
discussed on this page. The "Unlisted Procedures" and accompanying codes for
Medicine are as follows:

90399 Unlisted immune globulin
90749 Unlisted vaccine/toxoid
90799 Unlisted therapeutic, prophylactic or diagnostic injection
90899 Unlisted psychiatric service or procedure
90999 Unlisted dialysis procedure, inpatient or outpatient
91299 Unlisted diagnostic gastroenterology procedure
92499 Unlisted ophthalmological service or procedure
92599 Unlisted otorhinolaryngological service or procedure
93799 Unlisted cardiovascular service or procedure
94799 Unlisted pulmonary service or procedure
95199 Unlisted allergy/clinical immunologic service or procedure
95999 Unlisted neurological or neuromuscular diagnostic procedure
96549 Unlisted chemotherapy procedure
96999 Unlisted special dermatological service or procedure
97039 Unlisted modality (specify type and time if constant attendance)
97139 Unlisted therapeutic procedure (specify)
97799 Unlisted physical medicine/rehabilitation service or procedure
99199 Unlisted special service, procedure or report

Special Report

A service that is rarely provided, unusual, variable, or new may require a
special report in determining medical appropriateness of the service. Pertinent
information should include an adequate definition or description of the nature,
extent, and need for the procedure; and the time, effort, and equipment
necessary to provide the service. Additional items which may be included are:
complexity of symptoms;
final diagnosis;
pertinent physical findings;
diagnostic and therapeutic procedures;
concurrent problems;
follow-up care.

Materials Supplied by Physician

Supplies and materials provided by the physician (eg, sterile trays/drugs), over
and above those usually included with the office visit or other services
rendered may be listed separately. List drugs, trays, supplies, and materials
provided. Identify as 99070.


