2015

current procedural terminology

Professional Edition

Your trusted source!The only official CPT codebook with rules and guidelines from the AMAs CPT Editorial Panel

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Place-of-Service Codes for Professional ClaimsListed below are place-of-service codes and descriptions. These codes should be used on professional claims to specify the entity whereservice(s) were rendered. Check with individual payers (eg, Medicare, Medicaid, other private insurance) for reimbursement policiesregarding these codes. If you would like to comment on a code(s) or description(s), please send your request to posinfo@cms.hhs.gov.

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Place ofServiceCode(s)

Place of ServiceName Place of Service Description

01 Pharmacy A facility or location where drugs and other medically related items and services are sold, dispensed, orotherwise provided directly to patients. (Effective 10/1/05)

02 Unassigned N/A

03 School A facility whose primary purpose is education.

04 Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to homeless individuals (eg,emergency shelters, individual or family shelters).

05 Indian Health ServiceFreeStanding Facility

A facility or location, owned and operated by the Indian Health Service, which provides diagnostic,therapeutic (surgical and nonsurgical), and rehabilitation services to American Indians and AlaskaNatives who do not require hospitalization.

06 Indian Health ServiceProviderBased Facility

A facility or location, owned and operated by the Indian Health Service, which provides diagnostic,therapeutic (surgical and nonsurgical), and rehabilitation services rendered by, or under the supervisionof, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.

07 Tribal 638FreeStanding Facility

A facility or location owned and operated by a federally recognized American Indian or Alaska Nativetribe or tribal organization under a 638 agreement which provides diagnostic, therapeutic (surgical andnonsurgical), and rehabilitation services to tribal members who do not require hospitalization.

08 Tribal 638ProviderBased Facility

A facility or location owned and operated by a federally recognized American Indian or Alaska Nativetribe or tribal organization under a 638 agreement which provides diagnostic, therapeutic (surgical andnonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.

09 Prison/Correctional FacilityA prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by eitherFederal, State, or local authorities for the purpose of confinement or rehabilitation of adult or juvenilecriminal offenders. (Effective 7/1/06)

10 Unassigned N/A

11 OfficeLocation, other than a hospital, skilled nursing facility (SNF), military treatment facility, community healthcenter, State or local public health clinic, or intermediate care facility (ICF), where the health professionalroutinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence.

13 Assisted Living FacilityCongregate residential facility with selfcontained living units providing assessment of each residentsneeds and onsite support 24 hours a day, 7 days a week, with the capacity to deliver or arrange forservices including some health care and other services. (Effective 10/1/03)

14 Group HomeA residence, with shared living areas, where clients receive supervision and other services such as socialand/or behavioral services, custodial service, and minimal services (eg, medication administration).(Effective 10/1/03)

15 Mobile Unit A facility/unit that moves from placetoplace equipped to provide preventive, screening, diagnostic,and/or treatment services.

16 Temporary Lodging A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patientreceives care, and which is not identified by any other POS code. (Effective 4/1/08)

17 Walkin Retail Health ClinicA walkin health clinic, other than an office, urgent care facility, pharmacy, or independent clinic, which isnot described by any other Place of Service code, that is located within a retail operation and provides, onan ambulatory basis, preventive and primary care services. (Effective 5/1/10)

18 Place of EmploymentWorksite

A location, not described by any other POS code, owned or operated by a public or private entity wherethe patient is employed, and where a health professional provides ongoing or episodic occupationalmedical, therapeutic or rehabilitative services to the individual. (This code is available for use effectiveJanuary 1, 2013 but no later than May 1, 2013.)

19 Unassigned N/A

20 Urgent Care FacilityLocation, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnoseand treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.(Effective 1/1/03)

21 Inpatient HospitalA facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical andnonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admittedfor a variety of medical conditions.

22 Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), andrehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 Emergency RoomHospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24 Ambulatory SurgicalCenterA freestanding facility, other than a physicians office, where surgical and diagnostic services areprovided on an ambulatory basis.

25 Birthing Center A facility, other than a hospitals maternity facilities or a physicians office, which provides a setting forlabor, delivery, and immediate postpartum care as well as immediate care of newborn infants.

26 Military Treatment FacilityA medical facility operated by one or more of the Uniformed Services. Military treatment facility (MTF) alsorefers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed ServiceTreatment Facilities (USTF).

2730 Unassigned N/A

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31 Skilled Nursing FacilityA facility that primarily provides inpatient skilled nursing care and related services to patients whorequire medical, nursing, or rehabilitative services but does not provide the level of care or treatmentavailable in a hospital.

32 Nursing FacilityA facility that primarily provides to residents skilled nursing care and related services for therehabilitation of injured, disabled, or sick persons, or, on a regular basis, healthrelated care servicesabove the level of custodial care to other than mentally retarded individuals.

33 Custodial Care Facility A facility that provides room, board, and other personal assistance services, generally on alongterm basis, and which does not include a medical component.

34 Hospice A facility, other than a patients home, in which palliative and supportive care for terminally ill patientsand their families are provided.

3540 Unassigned N/A

41 AmbulanceLand A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick orinjured.

42 AmbulanceAir or Water An air or water vehicle specifically designed, equipped, and staffed for lifesaving and transporting thesick or injured.

4348 Unassigned N/A

49 Independent ClinicA location, not part of a hospital and not described by any other Place of Service code, that is organizedand operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services tooutpatients only. (Effective 10/1/03)

50 Federally QualifiedHealth CenterA facility located in a medically underserved area that provides Medicare beneficiaries preventive primarymedical care under the general direction of a physician.

51 Inpatient Psychiatric Facility A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness ona 24hour basis, by or under the supervision of a physician.

52 Psychiatric FacilityPartial Hospitalization

A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic programfor patients who do not require full time hospitalization, but who need broader programs than arepossible from outpatient visits to a hospitalbased or hospitalaffiliated facility.

53 Community MentalHealth Center

A facility that provides the following services: outpatient services, including specialized outpatient servicesfor children, the elderly, individuals who are chronically ill, and residents of the CMHCs mental healthservices area who have been discharged from inpatient treatment at a mental health facility; 24 hour a dayemergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitationservices; screening for patients being considered for admission to State mental health facilities to determinethe appropriateness of such admission; and consultation and education services.

54 Intermediate CareFacility/Mentally Retarded

A facility that primarily provides healthrelated care and services above the level of custodial care tomentally retarded individuals but does not provide the level of care or treatment available in a hospital orSNF.

55 Residential SubstanceAbuse Treatment Facility

A facility which provides treatment for substance (alcohol and drug) abuse to livein residents who donot require acute medical care. Services include individual and group therapy and counseling, familycounseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

56 Psychiatric ResidentialTreatment CenterA facility or distinct part of a facility for psychiatric care which provides a total 24hour therapeuticallyplanned and professionally staffed group living and learning environment.

57 Nonresidential SubstanceAbuse Treatment Facility

A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis.Services include individual and group therapy and counseling, family counseling, laboratory tests, drugsand supplies, and psychological testing. (Effective 10/1/03)

5859 Unassigned N/A

60 Mass Immunization Center

A location where providers administer pneumococcal pneumonia and influenza virus vaccinations andsubmit these services as electronic media claims, paper claims, or using the roster billing method. Thisgenerally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mallbut may include a physician office setting.

61 Comprehensive InpatientRehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician toinpatients with physical disabilities. Services include physical therapy, occupational therapy, speechpathology, social or psychological services, and orthotics and prosthetics services.

62 Comprehensive OutpatientRehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician tooutpatients with physical disabilities. Services include physical therapy, occupational therapy, and speechpathology services.

6364 Unassigned N/A

65 EndStage Renal DiseaseTreatment FacilityA facility other than a hospital, which provides dialysis treatment, maintenance, and/or training topatients or caregivers on an ambulatory or homecare basis.

6670 Unassigned N/A

71 Public Health Clinic A facility maintained by either State or local health departments that provides ambulatory primarymedical care under the general direction of a physician.

72 Rural Health Clinic A certified facility which is located in a rural medically underserved area that provides ambulatoryprimary medical care under the general direction of a physician.

7380 Unassigned N/A

81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or aphysicians office.

8298 Unassigned N/A

99 Other Place of Service Other place of service not identified above.

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Professional EditionMichelle Abraham, MHA, CCS-PJay T. AhlmanAngela J. BoudreauJudy ConnellyRick A. CrosslinBiljana Dimovski, MS, RHM, CDCDesiree D. Evans, AASLauren M. Feldman

DeHandro Hayden, BSNadia Khalid, MJ, RHIA, RMMLia Levreau-Davis, MBA, CPCElizabeth Lumakovska, MPA, RHITJanette Meggs, RHIAMarie L. Mindeman, BA, RHITKaren E. OHara, BS, CCS-PMary R. OHeron, RHIA

Danielle Pavloski, BS, RHIT, CCS-PDesiree Rozell, MPANancy Spector, BSN, MSCLianne Stancik, RHITAsif A. Syed, MD, MPHAda Walker, CCAArletrice Watkins, MHA, RHIARejina L. Young

2015

cptcurrent procedural terminology

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iv

Professional ISBN: 978-1-62202-026-3ISSN: 0276-8283

Current Procedural Terminology (CPT) copyright2014 American Medical Association. All Rights Reserved.

CPT is a registered trademark of the American Medical Association.

Copyright 1966, 1970, 1973, 1977, 1981, 1983-2014 American Medical Association.

1st Edition printed 19662nd Edition printed 19703rd Edition printed 19734th Edition printed 1977Revised: 1978, 1979, 1980, 1981, 1982, 1984, 1985, 1986, 1987, 1988,1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999,2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014

To purchase additional CPT products, contact the American Medical Association Customer Serviceat 800 621-8335 or AMA|Store at amastore.com.Refer to product number EP888815 or EP054115.

To request a license for distribution of products containing or reprinting CPT codes and/or guidelines,please see our website at www.ama-assn.org/go/cpt, or contact the American Medical AssociationCPT/DBP Intellectual Property Services, 330 North Wabash Avenue, Suite 39300, Chicago, IL 60611,312 464-5022.

AC36:EP054115:9/14AC36:EP888815:9/14

Executive Vice President, Chief Executive Officer: James L. Madara, MDChief Operating Officer: Bernard L. HengesbaughSenior Vice President and General Manager, AMA Business Services: Mary G. Henderson, PhDSenior Vice President and Chief Development Officer: Robert A. Musacchio, PhDVice President, Coding and Reimbursement Products Portfolio: Jay AhlmanVice President, Sales and Marketing: Ana EnglishDirector, CPT Coding and Regulatory Services: Marie MindemanDirector, CPT Education and Information Services: Danielle PavloskiDirector, CPT Medical Informatics and Healthcare Strategy: Asif A. Syed, MDDirector, CPT/DBP Intellectual Property Services: Matthew MenningManager, Book and Product Development and Production: Nancy BakerSenior Developmental Editor: Lisa Chin-JohnsonProduction Specialist: Mary Ann AlbaneseDirector, Sales, Key Accounts, Sales and Marketing: Susan WilsonDirector, Key Account Management: Joann SkibaDirector, Marketing: Karen Christensen-AraujoDirector, Channel Programs and Marketing Operations: Erin KalitowskiMarketing Manager: Rachel Dunn

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Eye and Ocular Adnexa / Surgery

American Medical Association v

ForewordCurrent Procedural Terminology (CPT), Fourth Edition, is alisting of descriptive terms and identifying codes for reportingmedical services and procedures performed by physicians. Thepurpose of the terminology is to provide a uniform languagethat will accurately describe medical, surgical, and diagnosticservices, and will thereby provide an effective means for reliablenationwide communication among physicians, patients, andthird parties. CPT 2015 is the most recent revision of a workthat first appeared in 1966.

CPT descriptive terms and identifying codes currently serve awide variety of important functions in the field of medicalnomenclature. The CPT code set is useful for administrativemanagement purposes such as claims processing and for thedevelopment of guidelines for medical care review. The uniformlanguage is also applicable to medical education and outcomes,health services, and quality research by providing a useful basisfor local, regional, and national utilization comparisons. TheCPT code set is the most widely accepted nomenclature for thereporting of physician procedures and services undergovernment and private health insurance programs. In 2000,the CPT code set was designated by the Department of Healthand Human Services as the national coding standard forphysician and other health care professional services andprocedures under the Health Insurance Portability andAccountability Act (HIPAA). This means that for all financialand administrative health care transactions sent electronically,the CPT code set will need to be used.

The changes that appear in this revision have been prepared bythe CPT Editorial Panel with the assistance of physiciansrepresenting all specialties of medicine, and with importantcontributions from many third-party payers and governmentalagencies.

The American Medical Association trusts that this revision willcontinue the usefulness of its predecessors in identifying,describing, and coding medical, surgical, and diagnosticservices.

AcknowledgmentsPublication of the annual CPT codebook represents manychallenges and opportunities. From reconciling the manydifferences of opinion about the best way to describe aprocedure, to the last details on placement of a semicolon, manyindividuals and organizations devote their energies and expertiseto the preparation of this revision.

The editorial staff wishes to express sincere thanks to the manynational medical specialty societies, health insuranceorganizations and agencies, and individual physicians and otherhealth professionals who have made contributions.

Thanks are due to Robert A. Musacchio, PhD, Sr VP, AmericanMedical Association; Claudia Bonnell, Blue Cross and BlueShield Association; Nelly Leon-Chisen, American HospitalAssociation; Sue Bowman, RHIA, American HealthInformation Management Association; and Raemarie Jiminez,CPC, American Academy of Professional Coders, for theirinvaluable assistance in enhancing the CPT code set.

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vi CPT Editorial Panel/Advisory Committee CPT 2015

AMA CPT Editorial PanelChairPeter A. Hollmann, MD*Vice-ChairKenneth P. Brin, MD, PhD, FACC*

Albert E. Bothe, Jr, MD, FACSBoyd R. Buser, DO, FACOFPLeslie F. Davidson, PhD, OTR/LFrank J. Dubeck, Jr, MD, FACP*Richard Duszak, Jr, MD, FACR*David A. Ellington, MDRonald A. Gabel, MDEdith Hambrick, MD, JDChristopher L. Jagmin, MDKatharine Krol, MDVictor L. Lewis, Jr, MD, FACSBernard A. Pfeifer, MD

Julia M. Pillsbury, DO, FAAP, FACOPAntonio E. Puente, PhDMark S. Synovec, MD*

SecretaryMarie L. Mindeman, BA, RHIT

*Member of the CPT Executive CommitteeNew Panel MemberNew Advisors

AMA CPT Advisory CommitteeAmerican Academy of Allergy, Asthma and ImmunologyDonald W. Aaronson, MD, JD, MPH

American Academy of Child & Adolescent PsychiatryBenjamin N. Shain, MD, PhDDavid I. Berland, MD

American Academy of DermatologyAlexander Miller, MDAnn F. Haas, MD

American Academy of Disability Evaluating PhysiciansDouglas W. Martin, MD, FAADEP, FACOEMJames B. Talmage, MD

American Academy of Family PhysiciansRobert J. Carr, Jr, MDGretchen M. Dickson, MD, MBA

American Academy of NeurologyMarc R. Nuwer, MD, PhD, FAAN, FACPBruce H. Cohen, MD, FAAN

American Academy of OphthalmologyMichael X. Repka, MD, MBAJohn M. Haley, MD

American Academy of Orthopaedic SurgeonsRichard J. Friedman, MD, FACSCM. Bradford Henley, MD, MBA

American Academy of Otolaryngic AllergyPaul T. Fass, MD, FACS

American Academy of Otolaryngology Head and Neck SurgeryBradley F. Marple, MD, FAAOALawrence M. Simon, MD, FAAP

American Academy of Pain MedicineEduardo M. Fraifeld, MD

American Academy of PediatricsJoel F. Bradley, Jr, MD, FAAPSanjeev Y. Tuli, MD, MEd, FAAP

American Academy of Physical Medicine and RehabilitationJeffrey S. Brault, DOAnnie D. Purcell, DO

American Academy of Sleep MedicineAmy J. Aronsky, DO, FAASM, FCCP, CBSMWilliam C. Sherrill, Jr, MD

American Association for Clinical ChemistryWilliam A. Clark, PhD, DABCC, FACB

American Association for Thoracic SurgeryKirk R. Kanter, MDStephen J. Lahey, MD

American Association of Clinical EndocrinologistsEric A. Orzeck, MD, FACP, FACE

American Association of Neurological SurgeonsR. Patrick Jacob, MDHenry H. Woo, MD, FAANS

American Association of Neuromuscular and ElectrodiagnosticMedicineAndrea J. Boon, MD

American Clinical Neurophysiology SocietyMarc R. Nuwer, MD, PhD, FAAN, FACPRonald G. Emerson, MD

American College of Allergy, Asthma and ImmunologyGary N. Gross, MD

American College of CardiologyRobert N. Piana, MD, FACCRandall C. Thompson, MD

American College of Chest PhysiciansSteve G. Peters, MDMichael E. Nelson, MD, FCCP

American College of Emergency PhysiciansKenneth L. DeHart, MD, FACEPJacob Mark J. Meredith, III, MD, MMM, FACEP

American College of GastroenterologyChristopher Y. Kim, MD, MBA, FACG, FASGE, AGAF, FACPDaniel C. DeMarco, MD, FACG

American College of Medical Genetics and GenomicsDavid B. Flannery, MD

American College of Medical QualityJoel Grossman, MD

American College of Mohs SurgeryDavid B. Pharis, MD, PC

American College of Nuclear MedicineScott C. Bartley, MD

American College of Occupational and Environmental MedicineLee S. Glass, MD, JD

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Eye and Ocular Adnexa / Surgery

American Medical Association vii

American Society for Reproductive MedicineDrew V. Moffitt, MD

American Society for Surgery of the HandDaniel J. Nagle, MDLeo S. Benson, MD

American Society of AnesthesiologistsPeter A. Goldzweig, DOKevin E. Vorenkamp, MD

American Society of Cataract and Refractive SurgeryStephen S. Lane, MD

American Society of Clinical OncologyChristian A. Thomas, MD

American Society of Colon and Rectal SurgeonsStephen M. Sentovich, MD, MBA, FCS, FASCRSWilliam J. Harb, MD, FACS

American Society of CytopathologyCarol A. Filomena, MD

American Society of General SurgeonsGeorge K. Gillian, MD, FACS

Christopher C. Smith, MD

American Society of HematologySamuel M. Silver, MD, PhD, FACP, FAHARobert Weinstein, MD

American Society of Interventional Pain PhysiciansFrank J.E. Falco, MD

Sachin Jha, MD, MS

American Society of NeuroradiologyRaymond K. Tu, MDJacqueline A. Bello, MD, FACR

American Society of Ophthalmic Plastic and Reconstructive SurgeryL. Neal Freeman, MD, MBA, CCS-P, FACS

American Society of Plastic SurgeonsRaymond V. Janevicius, MDDeborah S. Bash, MD

American Thoracic SocietyStephen P. Hoffmann, MD

American Urological AssociationJeffrey A. Dann, MD, MBARonald P. Kaufman, Jr, MD, FACS

Association of University RadiologistsRobert K. Zeman, MD, FACR

College of American PathologistsMichael D. McEachin, MD

Congress of Neurological SurgeonsJoseph S. Cheng, MD

Heart Rhythm SocietyOussama M. Wazni, MDJoseph E. Marine, MD

Infectious Disease Society of AmericaSteven K. Schmitt, MDLyssette L. Cardona, MD, MPH, MSHA

International Spinal Intervention SocietyScott I. Horn, DOClaire Tibiletti, MD

American College of PhysiciansJeannine Z. Engel, MD, FACPR. Scott Hanson, MD, MPH, FACP

American College of Radiation OncologyAndy W. Su, MDPaul E. Wallner, DO, FACR, FAOCR, FASTRO, FACRO

American College of RadiologyDaniel Picus, MD, FACR, RCCTimothy A. Crummy, MD, RCC

American College of RheumatologyGerald M. Eisenberg, MD, FACP, FACRRobert J. Lloyd, MD, FACP, FACR

American College of SurgeonsLinda M. Barney, MD, FACSMark T. Savarise, MD, FACS

American Congress of Obstetricians and GynecologistsJordan G. Pritzker, MD, MBA, FACOGJudith K. Volkar, MD

American Dental AssociationAnthony M. Spina, DDS, MDJoshua E. Everts, DDS, MD

American Gastroenterological AssociationJoel V. Brill, MD, AGAF, FASGE, FACG, CHCQM

American Geriatric SocietyRobert A. Zorowitz, MD, MBA, FACP, AGSF, CMD

American Institute of Ultrasound in MedicineHarvey L. Nisenbaum, MD

American Medical Directors AssociationDennis L. Stone, MD, MBA

American Orthopaedic AssociationBlair C. Filler, MD

American Orthopaedic Foot and Ankle SocietyWalter J. Pedowitz, MD

David I. Pedowitz, MD

American Osteopathic AssociationJudith A. OConnell, DO, FAAOBrian E. Kaufman, DO

American Psychiatric AssociationDavid K. Nace, MDJeremy S. Musher, MD

American Roentgen Ray SocietyMark D. Alson, MD, FACR, RCC

American Society for Aesthetic Plastic Surgery, Inc.Paul R. Weiss, MD

American Society for Clinical PathologyLee H. Hilborne, MD, MPH, FASCP

American Society for Dermatologic SurgeryMurad Alam, MDJeremy S. Bordeaux, MD, MPH

American Society for Gastrointestinal EndoscopyGlenn D. Littenberg, MD, FACP

American Society for Radiation OncologyDavid C. Beyer, MD, FACR, FACRO, FASTROWilliam F. Hartsell, MD

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viii CPT Editorial Panel/Advisory Committee CPT 2015

American Academy of Physician AssistantsPatrick J. Cafferty, MPAS, PA-C

American Association of Naturopathic PhysiciansWendell B. Milliman, NDEva Miller, ND

American Association for Respiratory CareSusan Rinaldo-Gallo, MEd, RRT, FAARC

American Chiropractic AssociationCraig S. Little, DC, FACOLeo Bronston DC, MappSC

American Massage Therapy AssociationSusan B. Rosen, LPMNancy M. Porambo, BA, MS, LMT, NCTMB

American Nurses AssociationJamesetta A. Newland, PhD, RN, FNP-BC, FAANP, DPMAP

Leslie C. Verucci, RN, MSN, CNS, CRNP, APRN-BC

American Occupational Therapy AssociationMary Jo McGuire, MS, OTR/L, FAOTADoris J. Shriver, OTR, FAOTA, QRC, CLCP

American Optometric AssociationDouglas C. Morrow, ODRebecca H. Wartman, OD

American Physical Therapy AssociationHelene M. Fearon, PTKathleen M. Picard, PT

American Podiatric Medical AssociationPhillip E. Ward, DPMIra H. Kraus, DPM

American Psychological AssociationNeil H. Pliskin, PhD, ABPP-CNRandy E. Phelps, PhD

American Speech Hearing AssociationStuart G. Trembath, MA, CCC-AR. Wayne Holland, EdD, CCC-SLP

National Athletic Trainers AssociationKaren D. Fennell, MS, ATC, LATWilliam T. Griffin, MA, LAT, ATC

National Association of Social WorkersMirean F. Coleman, LICSW

National Society of Genetic CounselorsLeslie H. Cohen, MS, CGC

Pharmacy Health Information Technology CollaborativeDaniel E. Buffington, PharmD, MBA

National Association of Medical ExaminersJohn S. Denton, MD

North American Spine SocietyWilliam Mitchell, MDDavid R. OBrien, Jr, MD

Radiological Society of North AmericaTimothy A. Crummy, MD

Renal Physicians AssociationChester A. Amedia, Jr, MD, FACPTimothy A. Pflederer, MD

Society for Cardiovascular Angiography and InterventionsArthur C. Lee, MD, FSCAI

Society for Investigative DermatologyStephen P. Stone, MD

Society for Vascular SurgerySean P. Roddy, MD, FACS

Society of American Gastrointestinal Endoscopic SurgeonsJohn S. Roth, MD, FACSKevin E. Wasco, MD, FACS

Society of Critical Care MedicineGeorge A. Sample, MD, FCCP

Society of Interventional RadiologyDonald F. Denny, Jr, MDTimothy L. Swan, MD

Society of Nuclear Medicine and Molecular ImagingGary L. Dillehay, MD, FACNP, FACR

Society of Thoracic SurgeonsFrancis C. Nichols, III, MDJeffrey P. Jacobs, MD, FACS, FACC, FCCP

The Endocrine SocietyAllan R. Glass, MD

The Triological SocietyRichard W. Waguespack, MD, FACS

United States and Canadian Academy of PathologyDavid S. Wilkinson, MD, PhD

AMA Health Care ProfessionalsAdvisory Committee (HCPAC)Peter A. Hollmann, MD*, Co-ChairAMA CPT Editorial PanelAntonio E. Puente, PhD, Co-ChairAMA CPT Editorial Panel

Academy of Nutrition and DieteticsKeith-Thomas Ayoob, EdD, RN, FADA, CSPJessie M. Pavlianc, MS, RD, CSR, LD

American Academy of AudiologyBrad A. Stach, PhDPaul M. Pessis, AuD

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American Medical Association ix Contains new or revised text

ContentsEvaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . .11

Office or Other Outpatient Services . . . . . . . . . . . . . . . . . .11

Hospital Observation Services . . . . . . . . . . . . . . . . . . . . . .13

Hospital Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . .15

Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Emergency Department Services . . . . . . . . . . . . . . . . . . . .22

Critical Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Nursing Facility Services . . . . . . . . . . . . . . . . . . . . . . . . . .25

Domiciliary, Rest Home (eg, Boarding Home),or Custodial Care Services . . . . . . . . . . . . . . . . . . . . . . . . .28

Domiciliary, Rest Home (eg, Assisted Living Facility),or Home Care Plan Oversight Services . . . . . . . . . . . . . . .29

Home Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Prolonged Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Case Management Services . . . . . . . . . . . . . . . . . . . . . . . .33

Care Plan Oversight Services . . . . . . . . . . . . . . . . . . . . . . .34

Preventive Medicine Services . . . . . . . . . . . . . . . . . . . . . .35

Non-Face-to-Face Services . . . . . . . . . . . . . . . . . . . . . . . . .37

Special Evaluation and Management Services . . . . . . . . .39

Newborn Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Delivery/Birthing Room Attendance andResuscitation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Inpatient Neonatal Intensive Care Services andPediatric and Neonatal Critical Care Services . . . . . . . . . .41

Care Management Services . . . . . . . . . . . . . . . . . . . .45

Transitional Care Management Services . . . . . . . . . . . . . .48

Advance Care Planning . . . . . . . . . . . . . . . . . . . . . . . .49

Other Evaluation and Management Services . . . . . . . . . .50

Anesthesia Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Time Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Anesthesia Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Separate or Multiple Procedures . . . . . . . . . . . . . . . . . . . .52

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Anesthesia Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Qualifying Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . .53

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Thorax (Chest Wall and Shoulder Girdle) . . . . . . . . . . . . . .54

Intrathoracic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Spine and Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Lower Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

Section Numbers and Their Sequences . . . . . . . . . . . . . . . xii

Instructions for Use of the CPT Codebook . . . . . . . . . . . . . xii

Format of the Terminology . . . . . . . . . . . . . . . . . . . . xiii

Requests to Update the CPT Nomenclature . . . . . . xiii

Application Submission Requirements . . . . . . . . . xiii

General Criteria for Category I and Category III Codes . xiii

Category-Specific Requirements . . . . . . . . . . . . . . . xiv

Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Add-on Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Place of Service and Facility Reporting . . . . . . . . . . . xv

Unlisted Procedure or Service . . . . . . . . . . . . . . . . . . xv

Results, Testing, Interpretation, and Report . . . . . . . xv

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Code Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi

Alphabetical Reference Index . . . . . . . . . . . . . . . . . xvi

CPT 2015 in Electronic Formats . . . . . . . . . . . . . . . . xvi

References to AMA Resources . . . . . . . . . . . . . . . . xvi

Illustrated Anatomical and Procedural Review . . . . . . xvii

Prefixes, Suffixes, and Roots . . . . . . . . . . . . . . . . . . . . . . xvii

Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Directions and Positions . . . . . . . . . . . . . . . . . . . . xviii

Additional References . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

Medical Dictionaries . . . . . . . . . . . . . . . . . . . . . . . xviii

Anatomy References . . . . . . . . . . . . . . . . . . . . . . . xviii

Lists of Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

Anatomical Illustrations . . . . . . . . . . . . . . . . . . . . xviii

Procedural Illustrations . . . . . . . . . . . . . . . . . . . . . . xix

Evaluation and Management Tables . . . . . . . . . . . . . . . . xxii

Evaluation and Management (E/M) Services Guidelines .4

Classification of Evaluation and Management(E/M) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Definitions of Commonly Used Terms . . . . . . . . . . . . . . . . .4

Unlisted Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Clinical Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Instructions for Selecting a Level of E/M Service . . . . . . . .9

31449_CPT Prof 2015_FM iv-xvi.indd 9 7/31/14 11:18 AM

x Contents CPT 2015

Contents

Pelvis (Except Hip) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Upper Leg (Except Knee) . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Knee and Popliteal Area . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Lower Leg (Below Knee, Includes Ankle and Foot) . . . . . .58

Shoulder and Axilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Upper Arm and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Forearm, Wrist, and Hand . . . . . . . . . . . . . . . . . . . . . . . . .59

Radiological Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Burn Excisions or Debridement . . . . . . . . . . . . . . . . . . . . .60

Obstetric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Surgery Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

CPT Surgical Package Definition . . . . . . . . . . . . . . . . . . . .62

Follow-Up Care for Diagnostic Procedures . . . . . . . . . . . .62

Follow-Up Care for Therapeutic Surgical Procedures . . . .62

Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Reporting More Than One Procedure/Service . . . . . . . . . .62

Separate Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . . .63

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Surgical Destruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . .98

Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165

Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . .185

Hemic and Lymphatic Systems . . . . . . . . . . . . . . . . . . . . .245

Mediastinum and Diaphragm . . . . . . . . . . . . . . . . . . . . . .249

Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255

Urinary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .305

Male Genital System . . . . . . . . . . . . . . . . . . . . . . . . . . . .325

Reproductive System Procedures . . . . . . . . . . . . . . . . . . .330

Intersex Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .330

Female Genital System . . . . . . . . . . . . . . . . . . . . . . . . . . .333

Maternity Care and Delivery . . . . . . . . . . . . . . . . . . . . . .342

Endocrine System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .346

Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .352

Eye and Ocular Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . .383

Auditory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .398

Operating Microscope . . . . . . . . . . . . . . . . . . . . . . . . . . .401

Radiology Guidelines (Including Nuclear Medicineand Diagnostic Ultrasound) . . . . . . . . . . . . . . . . . . . . . . . . .406

Subject Listings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .406

Separate Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .406

Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . .406

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .407

Supervision and Interpretation . . . . . . . . . . . . . . . . . . . . .407

Administration of Contrast Material(s) . . . . . . . . . . . . . .407

Written Report(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .407

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .408

Diagnostic Radiology (Diagnostic Imaging) . . . . . . . . . . .408

Diagnostic Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . .427

Radiologic Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .432

Breast, Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . .433

Bone/Joint Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .434

Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .435

Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .442

Pathology and Laboratory Guidelines . . . . . . . . . . . . . . . .465

Services in Pathology and Laboratory . . . . . . . . . . . . . . .465

Separate or Multiple Procedures . . . . . . . . . . . . . . . . . . .465

Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . .465

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465

Pathology and Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . .466

Organ or Disease-Oriented Panels . . . . . . . . . . . . . . . . . .466

cDrug Assayb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .467

Therapeutic Drug Assays . . . . . . . . . . . . . . . . . . . . . . . . .476

Evocative/Suppression Testing . . . . . . . . . . . . . . . . . . . .478

Consultations (Clinical Pathology) . . . . . . . . . . . . . . . . . .479

Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .479

Molecular Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .480

cGenomic Sequencing Procedures and Other MolecularMultianalyte Assaysb . . . . . . . . . . . . . . . . . . . . . . . . . . .503

Multianalyte Assays with Algorithmic Analyses . . . . . . .505

Chemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506

Hematology and Coagulation . . . . . . . . . . . . . . . . . . . . . .518

Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .520

Transfusion Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .526

Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .527

Anatomic Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534

Cytopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534

Cytogenetic Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .536

Surgical Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .537

In Vivo (eg, Transcutaneous) Laboratory Procedures . . . .543

Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .543

Reproductive Medicine Procedures . . . . . . . . . . . . . . . . .543

Medicine Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .548

Add-on Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .548

Separate Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .548

Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . .548

31449_CPT Prof 2015_FM iv-xvi.indd 10 8/1/14 9:37 AM

American Medical Association xi Contains new or revised text

Contentsery

Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549

Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549

Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .550

Immune Globulins, Serum or Recombinant Products . . . .550

Immunization Administration for Vaccines/Toxoids . . . . .550

Vaccines, Toxoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .551

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .555

Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .560

Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .560

Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .563

Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .564

Special Otorhinolaryngologic Services . . . . . . . . . . . . . . .569

Cardiovascular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .573

Noninvasive Vascular Diagnostic Studies . . . . . . . . . . . .599

Pulmonary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .602

Allergy and Clinical Immunology . . . . . . . . . . . . . . . . . . .605

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .608

Neurology and Neuromuscular Procedures . . . . . . . . . . .608

Medical Genetics and Genetic Counseling Services . . . .619

Central Nervous System Assessments/Tests(eg, Neuro-Cognitive, Mental Status, Speech Testing) . .619

Health and Behavior Assessment/Intervention . . . . . . . .620

Hydration, Therapeutic, Prophylactic, DiagnosticInjections and Infusions, and Chemotherapy andOther Highly Complex Drug or Highly ComplexBiologic Agent Administration . . . . . . . . . . . . . . . . . . . . .621

Photodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . .626

Special Dermatological Procedures . . . . . . . . . . . . . . . . .627

Physical Medicine and Rehabilitation . . . . . . . . . . . . . . .627

Medical Nutrition Therapy . . . . . . . . . . . . . . . . . . . . . . . .630

Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .630

Osteopathic Manipulative Treatment . . . . . . . . . . . . . . . .631

Chiropractic Manipulative Treatment . . . . . . . . . . . . . . . .631

Education and Training for Patient Self-Management . . .632

Non-Face-to-Face Nonphysician Services . . . . . . . . . . . .633

Special Services, Procedures and Reports . . . . . . . . . . . .633

Qualifying Circumstances for Anesthesia . . . . . . . . . . . .635

Moderate (Conscious) Sedation . . . . . . . . . . . . . . . . . . . .635

Other Services and Procedures . . . . . . . . . . . . . . . . . . . .636

Home Health Procedures/Services . . . . . . . . . . . . . . . . .637

Medication Therapy Management Services . . . . . . . . . .638

Category II Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .639

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640

Composite Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640

Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . .641

Patient History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .642

Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . .644

Diagnostic/Screening Processes or Results . . . . . . . . . .645

Therapeutic, Preventive, or Other Interventions . . . . . . .651

Follow-up or Other Outcomes . . . . . . . . . . . . . . . . . . . . .657

Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .657

Structural Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .658

Nonmeasure Code Listing . . . . . . . . . . . . . . . . . . . . . . . .658

Category III Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .659

Appendix AModifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . .679

Appendix BSummary of Additions,Deletions, and Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . .685

Appendix C Clinical Examples . . . . . . . . . . . . . . . . . . . .694

Office or Other Outpatient Service . . . . . . . . . . . . . . . . . .694

Hospital Inpatient Services . . . . . . . . . . . . . . . . . . . . . . .704

Subsequent Hospital Care . . . . . . . . . . . . . . . . . . . . . . . .707

Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .710

Emergency Department Services . . . . . . . . . . . . . . . . . . .716

Critical Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .717

Prolonged Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .717

Care Plan Oversight Services . . . . . . . . . . . . . . . . . . . . . .718

Inpatient Neonatal Intensive Care Service andPediatric and Neonatal Critical Care Services . . . . . . . . .718

Appendix DSummary of CPT Add-on Codes. . . . . . . . .719

Appendix ESummary of CPT CodesExempt from Modifier 51. . . . . . . . . . . . . . . . . . . . . . . . . . . .720

Appendix FSummary of CPT CodesExempt from Modifier 63. . . . . . . . . . . . . . . . . . . . . . . . . . . .721

Appendix GSummary of CPT CodesThat Include Moderate (Conscious) Sedation . . . . . . . . .722

Appendix HAlphabetical Clinical Topics Listing(AKA Alphabetical Listing) . . . . . . . . . . . . . . . . . . . . . . . .724

Appendix IGenetic Testing Code Modifiers . . . . . . . . .724

Appendix JElectrodiagnostic Medicine Listingof Sensory, Motor, and Mixed Nerves . . . . . . . . . . . . . . . .725

Appendix KProduct Pending FDA Approval . . . . . . . . .728

Appendix LVascular Families . . . . . . . . . . . . . . . . . . . . .729

Appendix MRenumbered CPT CodesCitationsCrosswalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .732

Appendix NSummary of Resequenced CPT Codes . . .738

Appendix OMultianalyte Assays withAlgorithmic Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .739

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .743

31449_CPT Prof 2015_FM iv-xvi.indd 11 8/1/14 9:51 AM

xii Introduction CPT 2015

Introduction

Current Procedural Terminology (CPT), Fourth Edition, is aset of codes, descriptions, and guidelines intended todescribe procedures and services performed by physiciansand other health care professionals, or entities. Each proce-dure or service is identified with a five-digit code. The use ofCPT codes simplifies the reporting of procedures and servic-es. In the CPT code set, the term procedure is used todescribe services, including diagnostic tests.

Inclusion of a descriptor and its associated five-digit codenumber in the CPT Category I code set is based on whetherthe procedure or service is consistent with contemporarymedical practice and is performed by many practitioners inclinical practice in multiple locations. Inclusion in the CPTcode set does not represent endorsement by the AmericanMedical Association (AMA) of any particular diagnostic ortherapeutic procedure or service. Inclusion or exclusion of aprocedure or service does not imply any health insurancecoverage or reimbursement policy.

The CPT code set is published annually in the late summeror early fall as both electronic data files and books. Therelease of CPT data files on the Internet typically precedesthe book by several weeks. In any case, January 1 is the effec-tive date for use of the update of the CPT code set. Theinterval between the release of the update and the effectivedate is considered the implementation period and is intend-ed to allow physicians and other providers, payers, and ven-dors to incorporate CPT changes into their systems. Theexceptions to this schedule of release and effective dates areCPT Category III and vaccine product codes, which arereleased twice a year on January 1 or July 1 with effectivedates for use six months later, and CPT Category II codes.Changes to the CPT code set are meant to be applied pro-spectively from the effective date.

The main body of the Category I section is listed in six sec-tions. Each section is divided into subsections with anatom-ic, procedural, condition, or descriptor subheadings. Theprocedures and services with their identifying codes are pre-sented in numeric order with one exceptionthe entireEvaluation and Management section (99201-99499)appears at the beginning of the listed procedures. Theseitems are used by most physicians in reporting a significantportion of their services.

Section Numbers and TheirSequencesEvaluation and Management . . . . . . . . . . . . 99201-99499

Anesthesiology . . . . . . . . . . . . 00100-01999, 99100-99140

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10021-69990

Radiology (Including Nuclear Medicineand Diagnostic Ultrasound) . . . . . . . . . 70010-79999

Pathology and Laboratory. . . . . . . . . . . . . . . 80047-89398

Medicine (exceptAnesthesiology) . . . . . . . 90281-99199, 99500-99607

The first and last code numbers and the subsection name ofthe items appear at the top margin of most pages (eg,11010-11306 Surgery/Integumentary System). The con-tinuous pagination of the CPT codebook is found on thelower margin of each page along with explanation of anycode symbols that are found on that page.

Instructions for Use of the CPTCodebookSelect the name of the procedure or service that accuratelyidentifies the service performed. Do not select a CPT codethat merely approximates the service provided. If no suchspecific code exists, then report the service using the appro-priate unlisted procedure or service code. In surgery, it maybe an operation; in medicine, a diagnostic or therapeuticprocedure; in radiology, a radiograph. Other additional pro-cedures performed or pertinent special services are also list-ed. When necessary, any modifying or extenuatingcircumstances are added. Any service or procedure should beadequately documented in the medical record.

It is equally important to recognize that as techniques inmedicine and surgery have evolved, new types of services,including minimally invasive surgery, as well as endovascular,percutaneous, and endoscopic interventions have challengedthe traditional distinction of Surgery vs Medicine. Thus, thelisting of a service or procedure in a specific section of thisbook should not be interpreted as strictly classifying the ser-vice or procedure as surgery or not surgery for insuranceor other purposes. The placement of a given service in a spe-cific section of the book may reflect historical or other con-siderations (eg, placement of the percutaneous peripheralvascular endovascular interventions in the Surgery/Cardiovascular System section, while the percutaneous coro-nary interventions appear in the Medicine/Cardiovascularsection).

When advanced practice nurses and physician assistants areworking with physicians, they are considered as working inthe exact same specialty and exact same subspecialties as thephysician. A physician or other qualified health care profes-sional is an individual who is qualified by education, train-ing, licensure/regulation (when applicable), and facilityprivileging (when applicable) who performs a professionalservice within his/her scope of practice and independentlyreports that professional service. These professionals are dis-tinct from clinical staff. A clinical staff member is a personwho works under the supervision of a physician or otherqualified health care professional and who is allowed by law,regulation, and facility policy to perform or assist in the per-formance of a specified professional service, but who doesnot individually report that professional service. Other poli-cies may also affect who may report specific services.

Throughout the CPT code set the use of terms such as phy-sician, qualified health care professional, or individual isnot intended to indicate that other entities may not reportthe service. In selected instances, specific instructions may

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Introduction

American Medical Association xiii Contains new or revised text

define a service as limited to professionals or limited to otherentities (eg, hospital or home health agency).

Instructions, typically included as parenthetical notes withselected codes, indicate that a code should not be reportedwith another code or codes. These instructions are intendedto prevent errors of significant probability and are not allinclusive. For example, the code with such instructions maybe a component of another code and therefore it would beincorrect to report both codes even when the componentservice is performed. These instructions are not intended as alisting of all possible code combinations that should not bereported, nor do they indicate all possible code combina-tions that are appropriately reported. When reporting codesfor services provided, it is important to assure the accuracyand quality of coding through verification of the intent ofthe code by use of the related guidelines, parentheticalinstructions, and coding resources, including CPT Assistantand other publications resulting from collaborative efforts ofthe American Medical Association with the medical specialtysocieties (ie, Clinical Examples in Radiology).

Format of the TerminologyThe CPT code set has been developed as stand-alonedescriptions of medical procedures. However, some of theprocedures in the CPT codebook are not printed in theirentirety but refer back to a common portion of the proce-dure listed in a preceding entry. This is evident when anentry is followed by one or more indentations. This is donein an effort to conserve space.

Example

25100 Arthrotomy, wrist joint; with biopsy

25105 with synovectomy

Note that the common part of code 25100 (the part beforethe semicolon) should also be considered part of code25105. Therefore, the full procedure represented by code25105 should read:

25105 Arthrotomy, wrist joint; with synovectomy

Requests to Update the CPTNomenclatureThe effectiveness of the CPT nomenclature depends on con-stant updating to reflect changes in medical practice. Thiscan only be accomplished through the interest and timelysuggestions of practicing physicians and other qualifiedhealth care professionals, specialty/professional societies,state medical associations, organizations, agencies, individualusers of the CPT code set, and other stakeholders.Accordingly, the AMA welcomes correspondence, inquiries,and suggestions concerning CPT coding and nomenclaturefor old and new procedures and services, as well as any mat-ters relating to the CPT code set.

For information on submission of an application to add,delete, or revise codes contained in the CPT code set, pleasesee www.ama-assn.org/go/cpt-processfaq or contact:

CPT Editorial Research & DevelopmentAmerican Medical Association330 North Wabash AvenueSuite 39300Chicago IL 60611-5885

Code change applications are available at the AMAs CPTwebsite: www.ama-assn.org/go/cpt-application.

All proposed changes to the CPT code set will be consideredby the CPT Editorial Panel, in consultation with medicalspecialty societies as represented by the CPT AdvisoryCommittee, other health care professional societies as repre-sented by the Health Care Professionals Advisory Committee(HCPAC), and other interested parties.

Application SubmissionRequirementsAll complete CPT code change applications are reviewedand evaluated by the CPT staff, the CPT/HCPAC AdvisoryCommittee, and the CPT Editorial Panel. Strict confor-mance with the following is required for review of a codechange application:

Submission of a complete application, including all neces-sary supporting documents

Adherence to all posted deadlines

Cooperation with requests from the CPT staff and/orEditorial Panel members for clarification and information;and

Compliance with CPT Lobbying Policy

General Criteria for Category I andCategory III CodesAll Category I or Category III code change applicationsmust satisfy each of the following criteria:

The proposed descriptor is unique, well-defined, anddescribes a procedure or service that is clearly identifiedand distinguished from existing procedures and servicesalready in the CPT code set.

The descriptor structure, guidelines, and instructions areconsistent with the current CPT Editorial Panel standardsfor maintenance of the code set.

The proposed descriptor for the procedure or service isneither a fragmentation of an existing procedure or servicenor currently reportable as a complete service by one ormore existing codes (with the exclusion of unlisted codes).However, procedures and services frequently performedtogether may require new or revised codes.

The structure and content of the proposed code descriptoraccurately reflects the procedure or service as typically per-formed. If always or frequently performed with one ormore other procedures or services, the descriptor structureand content will reflect the typical combination or com-plete procedure or service.

The descriptor for the procedure or service is not proposedas a means to report extraordinary circumstances related tothe performance of a procedure or service alreadydescribed in the CPT code set; and

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The procedure or service satisfies the category-specific cri-teria set forth below.

Category-Specific RequirementsCategory I CriteriaA proposal for a new or revised Category I code must satisfyall of the following criteria:

All devices and drugs necessary for performance of theprocedure or service have received FDA clearance orapproval when such is required for performance of theprocedure or service.

The procedure or service is performed by many physiciansor other qualified health care professionals across theUnited States.

The procedure or service is performed with frequency con-sistent with the intended clinical use (ie, a service for acommon condition should have high volume, whereas aservice commonly performed for a rare condition mayhave low volume).

The procedure or service is consistent with current medi-cal practice.

The clinical efficacy of the procedure or service is docu-mented in literature that meets the requirements set forthin the CPT code change application.

Category III Criteria The following criteria are used by the CPT/HCPACAdvisory Committee and the CPT Editorial Panel for evalu-ating Category III code applications:

The procedure or service is currently or recently per-formed in humans; and

At least one of the following additional criteria has been met:

The application is supported by at least one CPT orHCPAC advisor representing practitioners who would usethis procedure or service; or

The actual or potential clinical efficacy of the specific pro-cedure or service is supported by peer reviewed literature,which is available in English for examination by the CPTEditorial Panel; or

There is (a) at least one Institutional Review Boardapproved protocol of a study of the procedure or servicebeing performed; (b) a description of a current and ongo-ing United States trial outlining the efficacy of the proce-dure or service; or (c) other evidence of evolving clinicalutilization.

GuidelinesSpecific guidelines are presented at the beginning of each ofthe sections. These guidelines define items that are necessaryto appropriately interpret and report the procedures and ser-vices contained in that section. For example, in theMedicine section, specific instructions are provided for han-dling unlisted services or procedures, special reports, andsupplies and materials provided. Guidelines also provideexplanations regarding terms that apply only to a particularsection. For instance, Radiology Guidelines provide a defi-nition of the unique term, radiological supervision and

Introduction

xiv Introduction CPT 2015

interpretation. While in Anesthesia, a discussion of report-ing time is included.

Add-on CodesSome of the listed procedures are commonly carried out inaddition to the primary procedure performed. These addi-tional or supplemental procedures are designated as add-oncodes with the symbol and they are listed in Appendix Dof the CPT codebook. Add-on codes in CPT 2015 can bereadily identified by specific descriptor nomenclature thatincludes phrases such as each additional or (List separatelyin addition to primary procedure).

The add-on code concept in CPT 2015 applies only to add-on procedures or services performed by the same physician.Add-on codes describe additional intra-service work associat-ed 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 pri-mary service or procedure and must never be reported as astand-alone code. All add-on codes found in the CPT code-book are exempt from the multiple procedure concept (seethe modifier 51 definition in Appendix A).

ModifiersA modifier provides the means to report or indicate that aservice or procedure that has been performed has beenaltered by some specific circumstance but not changed in itsdefinition or code. Modifiers also enable health care profes-sionals to effectively respond to payment policy requirementsestablished by other entities. The judicious application ofmodifiers obviates the necessity for separate procedure list-ings that may describe the modifying circumstance.Modifiers may be used to indicate to the recipient of areport that:

A service or procedure had both a professional and techni-cal component.

A service or procedure was performed by more than onephysician or other health care professional and/or in morethan one location.

A service or procedure was increased or reduced.

Only part of a service was performed.

An adjunctive service was performed.

A bilateral procedure was performed.

A service or procedure was provided more than once.

Unusual events occurred.

Example

A physician providing diagnostic or therapeutic radiologyservices, ultrasound, or nuclear medicine services in ahospital would add modifier 26 to report the professionalcomponent.

73090 with modifier 26 = Professional component only foran X-ray of the forearm

Example

Two surgeons may be required to manage a specific surgicalproblem. When two surgeons work together as primary sur-

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geons performing distinct part(s) of a procedure, each sur-geon should report his/her distinct operative work by addingmodifier 62 to the procedure code and any associatedcode(s) for that procedure as long as both surgeons continueto work together as primary surgeons. Each surgeon shouldreport the co-surgery once using the same procedure code.Modifier 62 would be applicable. For instance, a neurologi-cal surgeon and an otolaryngologist are working as co-sur-geons in performing transphenoidal excision of a pituitaryneoplasm.

The first surgeon would report:

61548 62 = Hypophysectomy or excision of pituitary tumor,transnasal or transseptal approach, nonstereotactic twosurgeons modifier

and the second surgeon would report:

61548 62 = Hypophysectomy or excision of pituitary tumor,transnasal or transseptal approach, nonstereotactic twosurgeons modifier

If additional procedure(s) (including add-on procedure[s])are performed during the same surgical session, separatecode(s) may also be reported with modifier 62 added. Itshould be noted that if a co-surgeon acts as an assistant inthe performance of additional procedure(s) during the samesurgical session, those services may be reported using sepa-rate procedure code(s) with modifier 80 or modifier 82added, as appropriate. A complete listing of modifiers isfound in Appendix A.

Place of Service and FacilityReportingSome codes have specified places of service (eg, evaluationand management codes are specific to a setting). Other ser-vices and procedures may have instructions specific to theplace of service (eg, therapeutic, prophylactic, and diagnosticinjections and infusions). The CPT code set is designated forreporting physician and qualified health care professionalservices. It is also the designated code set for reporting ser-vices provided by organizations or facilities (eg, hospitals) inspecific circumstances. Throughout the CPT code set, theuse of terms such as physician, qualified health care pro-fessional, or individual is not intended to indicate thatother entities may not report the service. In selected instanc-es, specific instructions may define a service as limited toprofessionals or limited to other entities (eg, hospital orhome health agency). The CPT code set uses the term facil-ity to describe such providers and the term nonfacility todescribe services settings or circumstances in which no facili-ty reporting may occur. Services provided in the home by anagency are facility services. Services provided in the home bya physician or other qualified health care professional who isnot a representative of the agency are nonfacility services.

Unlisted Procedure or ServiceIt is recognized that there may be services or procedures per-formed by physicians or other qualified health care profes-sionals that are not found in the CPT code set. Therefore, anumber of specific code numbers have been designated forreporting unlisted procedures. When an unlisted procedurenumber is used, the service or procedure should be described(see specific section guidelines). Each of these unlisted proce-

Introduction

American Medical Association xv Contains new or revised text

dural code numbers (with the appropriate accompanyingtopical entry) relates to a specific section of the book and ispresented in the guidelines of that section.

In some cases alternative coding and procedural nomencla-ture as contained in other code sets may allow appropriatereporting of a more specific code. CPT references to use anunlisted procedure code do not preclude the reporting of anappropriate code that may be found in other code sets.

Results, Testing, Interpretation, andReportResults are the technical component of a service. Testingleads to results; results lead to interpretation. Reports are thework product of the interpretation of test results. Certainprocedures or services described in CPT involve a technicalcomponent (eg, tests) which produces results (eg, data,images, slides). For clinical use, some of these results requireinterpretation. Some CPT descriptors specifically requireinterpretation and reporting to report that code.

Special ReportA service that is rarely provided, unusual, variable, or newmay require a special report. Pertinent information shouldinclude an adequate definition or description of the nature,extent, and need for the procedure and the time, effort, andequipment necessary to provide the service.

TimeThe CPT code set contains many codes with a time basis forcode selection. The following standards shall apply to timemeasurement, unless there are code or code-rangespecificinstructions in guidelines, parenthetical instructions, or codedescriptors to the contrary. Time is the face-to-face timewith the patient. Phrases such as interpretation and reportin the code descriptor are not intended to indicate in allcases that report writing is part of the reported time. A unitof time is attained when the mid-point is passed. For exam-ple, an hour is attained when 31 minutes have elapsed (morethan midway between zero and sixty minutes). A secondhour is attained when a total of 91 minutes have elapsed.When codes are ranked in sequential typical times and theactual time is between two typical times, the code with thetypical time closest to the actual time is used. See also theEvaluation and Management (E/M) Services Guidelines.When another service is performed concurrently with atime-based service, the time associated with the concurrentservice should not be included in the time used for reportingthe time-based service. Some services measured in unitsother than days extend across calendar dates. When thisoccurs a continuous service does not reset and create a firsthour. However, any disruption in the service does create anew initial service. For example, if intravenous hydration(96360, 96361) is given from 11 pm to 2 am, 96360 wouldbe reported once and 96361 twice. For facility reporting ona single date of service or for continuous services that lastbeyond midnight (ie, over a range of dates), report the totalunits of time provided continuously.

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xvi Introduction CPT 2015

Introduction

The symbol refers to the CPT Assistant monthly newslet-ter and CPT Changes: An Insiders View, an annual book withall of the coding changes for the current year. The symbol refers to the quarterly newsletter Clinical Examples inRadiology.

Example

36598 Contrast injection(s) for radiologic evaluation ofexisting central venous access device, includingfluoroscopy, image documentation and report

CPT Changes: An Insiders View 2006

Clinical Examples in Radiology Winter 2006:15

In this example, the green reference symbol indicates that inthe 2006 edition of CPT Changes: An Insiders View materialis available that may assist in understanding the applicationof the code. The red reference symbol indicates that the2006 Winter issue of Clinical Examples in Radiology (page15) should be consulted.

Individual back issues are available for purchase by calling800 621-8335 or at amastore.com.

CPT Assistant and Clinical Examples in Radiology are nowonline! Based on the best-selling hard copy newsletters, CPTAssistant Online and Clinical Examples in Radiology Onlineput the content medical coding professionals rely on daily ina more user-friendly format. Benefits exclusive to the onlineversions include:

Monthly (CPT Assistant) and quarterly (Clinical Examplesin Radiology) updates! The home screen notifies you whena new issue is available and you can review the latest issuein its entirety.

Unlimited access to every archived issue and article datingback to when the newsletter first published.

A historical CPT code list that references when a code wasadded, deleted, and/or revised since 1990.

Simple search capabilities, including intuitive menus and acumulative index of article titles.

Anatomical illustrations, charts, and graphs for quickreference.

For more information call 800 621-8335 or visitamacodingonline.com.

Current and past editions of CPT Changes: An Insiders Viewcan be purchased by calling the AMAs Unified ServiceCenter at 800 621-8335 or visiting amastore.com.

In addition, CPT Changes: An Insiders View is now availableonline. Instantly access current CPT code changes and his-torical changes dating back to 2000. This invaluable onlinelibrary provides you with an easy and efficient way to searchevery edition of CPT Changes: An Insiders View (from 2000to the current year) for the official interpretation and ratio-nale behind every code and guideline change. For moreinformation call 800 621-8335 or visit amacodingonline.com.

Code SymbolsA summary listing of additions, deletions, and revisionsapplicable to the CPT codebook is found in Appendix B.New procedure numbers added to the CPT codebook areidentified throughout the text with the symbol placedbefore the code number. In instances where a code revisionhas resulted in a substantially altered procedure descriptor,the symbol is placed before the code number. The sym-bols are used to indicate new and revised text other thanthe procedure descriptors. These symbols indicate CPTEditorial Panel actions. The symbol is used to indicatereinstated/recycled code. The AMA reserves the right to cor-rect typographical errors and make stylistic improvements.

CPT add-on codes are annotated by the symbol and arelisted in Appendix D. The symbol is used to identifycodes that are exempt from the use of modifier 51 but havenot been designated as CPT add-on procedures or services.A list of codes exempt from modifier 51 usage is included inAppendix E. The symbol is used to identify codes thatinclude moderate sedation (see Appendix G). The symbol is used to identify codes for vaccines that are pendingFDA approval (see Appendix K). The symbol # is used toidentify codes that are listed out of numerical sequence (seeAppendix N).

Resequenced codes that are not placed numerically are iden-tified with the # symbol, and a reference placed numerically(ie, Code is out of numerical sequence. See) as a naviga-tional alert to direct the user to the location of the out-of-sequence code (see Appendix N). Resequencing is utilized toallow placement of related concepts in appropriate locationswithin the families of codes regardless of the availability ofnumbers for sequential numerical placement.

Alphabetical Reference IndexThis codebook features an expanded alphabetical index thatincludes listings by procedure and anatomic site. Proceduresand services commonly known by their eponyms or otherdesignations are also included.

CPT 2015 in Electronic FormatsCPT 2015 procedure codes and descriptions are also avail-able as data file on CD-ROM or as downloadable data file.The CPT data file is available in ASCII and EBCDIC for-mats and provides a convenient way to import the 2015CPT codes and descriptions into existing documentation orinto any billing and claims reporting software that accepts atext (.TXT) file format. The data file contains the completeofficial AMA CPT guidelines, descriptor package, and newdescriptors for consumers and clinicians. For more informa-tion call 800 621-8335 or visit amastore.com.

References to AMA ResourcesThe symbols and appear after many codes throughoutthis codebook and indicate that the AMA has published ref-erence material regarding that particular code.

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American Medical Association xvii

It is essential that coders have a thorough understanding ofmedical terminology and anatomy to code accurately. Thefollowing section reviewing the basics of vocabulary andanatomy can be used as a quick reference to help you with yourcoding. It is not intended as a replacement for up-to-datemedical dictionaries and anatomy texts, which are essential toolsfor accurate coding.

Prefixes, Suffixes, and RootsAlthough medical terminology may seem complex, manymedical terms can be broken into component parts, whichmakes them easier to understand. Many of these terms arederived from Latin or Greek words, but some include the namesof physicians.

Prefixes are word parts that appear at the beginning of a wordand modify its meaning; suffixes are found at the end of words.By learning what various prefixes and suffixes mean, it ispossible to decipher the meaning of a word quickly. Thefollowing lists are a quick reference for some common prefixesand suffixes.

NumbersPrefix Meaning Example

mono-, uni- one monocyte, unilateral

bi- two bilateral

tri- three triad

quadr- four quadriplegia

hex-, sex- six hexose

diplo- double diplopia

ConditionsPrefix Meaning Example

ambi- both ambidextrous

aniso- unequal anisocoria

dys- bad, painful, difficult dysphoria

eu- good, normal euthanasia

hetero- different heterogeneous

homo- same homogeneous

hyper- excessive, above hypergastric

hypo- deficient, below hypogastric

iso- equal, same isotonic

mal- bad, poor malaise

megalo- large megalocardia

Suffix Meaning Example

-algia pain neuralgia

-asthenia weakness myasthenia

-emia blood anemia

-iasis condition of amebiasis

-itis inflammation appendicitis

-lysis destruction, break down hemolysis

-lytic destroy, break down hemolytic

-oid like lipoid

-oma tumor carcinoma

-opathy disease of arthropathy

-orrhagia hemorrhage menorrhagia

-orrhea flow or discharge amenorrhea

-osis abnormal condition of tuberculosis

-paresis weakness hemiparesis

-plasia growth hyperplasia

-plegia paralysis paraplegia

-pnea breathing apnea

Surgical ProceduresSuffix Meaning Example

-centesis puncture a cavity to remove fluid amniocentesis

-ectomy surgical removal (excision) appendectomy

-ostomy a new permanent opening colostomy

-otomy cutting into (incision) tracheotomy

-orrhaphy surgical repair/suture herniorrhaphy

-opexy surgical fixation nephropexy

-oplasty surgical repair rhinoplasty

-otripsy crushing, destroying lithotripsy

Illustrated Anatomical andProcedural Review

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xviii Illustrated Anatomical and Procedural Review CPT 2015

Directions and PositionsPrefix Meaning Example

ab- away from abduction

ad- toward adduction

ecto, exo- outside ectopic, exocrine

endo- within endoscope

epi- upon epigastric

infra- below, under infrastructure

ipsi- same ipsilateral

meso- middle mesopexy

meta- after, beyond, transformation metastasis

peri- surrounding pericardium

retro- behind, back retroversion

trans- across, through transvaginal

Word Meaning

anterior or ventral at or near the front surface of the body

posterior or dorsal at or near the back surface of the body

superior above

inferior below

lateral side

distal farthest from center

proximal nearest to center

medial middle

supine face up or palm up

prone face down or palm down

sagittal vertical body plane, divides the body intoequal right and left sides

transverse horizontal body plane, divides the bodyinto top and bottom sections

coronal vertical body plane, divides the body intofront and back sections

Additional ReferencesFor best coding results, you will need to use other referencematerials in addition to your CPT coding books. Thesereferences include medical dictionaries and anatomy books.

Medical DictionariesDorlands Illustrated Medical Dictionary, 32nd ed.Philadelphia, PA: Elsevier; 2011

Stedmans CPT Dictionary, 2nd ed.Chicago, IL: American Medical Association; 2009.OP:300609

Stedmans Medical Dictionary. 28th ed.Philadelphia, PA: Lippencott; 2005.

Anatomy ReferencesBernard, SP. Netters Atlas of Human Anatomy for CPT SurgeryChicago, IL: American Medical Association; Spring, 2015.

Kirschner, CG. Netters Atlas of Human Anatomy for CPT

Coding, 2nd ed.Chicago, IL: American Medical Association; 2009.OP:490609

Netter, FH. Atlas of Human Anatomy, 6th ed.Philadelphia, PA; Elsevier; 2014O