2015 Professional Edition current procedural terminology Your trusted source! The only official CPT® codebook with rules and guidelines from the AMA’s CPT Editorial Panel 13-0600 CPT prof_cvr_spread.indd 1 7/15/14 2:31 PM Place-of-Service Codes for Professional Claims Listed below are place-of-service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (eg, Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes. If you would like to comment on a code(s) or description(s), please send your request to [email protected]. Place of Service Place of Service Code(s) Name Place of Service Description A facility or location where drugs and other medically related items and services are sold, dispensed, or 01 Pharmacy otherwise provided directly to patients. (Effective 10/1/05) 02 Unassigned N/A 03 School A facility whose primary purpose is education. A facility or location whose primary purpose is to provide temporary housing to homeless individuals (eg, 04 Homeless Shelter emergency shelters, individual or family shelters). A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, Indian Health Service 05 therapeutic (surgical and non‑surgical), and rehabilitation services to American Indians and Alaska Free‑Standing Facility Natives who do not require hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, Indian Health Service 06 therapeutic (surgical and non‑surgical), and rehabilitation services rendered by, or under the supervision Provider‑Based Facility of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. A facility or location owned and operated by a federally recognized American Indian or Alaska Native Tribal 638 07 tribe or tribal organization under a 638 agreement which provides diagnostic, therapeutic (surgical and Free‑Standing Facility non‑surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized American Indian or Alaska Native Tribal 638 08 tribe or tribal organization under a 638 agreement which provides diagnostic, therapeutic (surgical and Provider‑Based Facility non‑surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either 09 Prison/Correctional Facility Federal, State, or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. (Effective 7/1/06) 10 Unassigned N/A Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health 11 Office center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely 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. Congregate residential facility with self‑contained living units providing assessment of each resident’s 13 Assisted Living Facility needs and on‑site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. (Effective 10/1/03) A residence, with shared living areas, where clients receive supervision and other services such as social 14 Group Home and/or behavioral services, custodial service, and minimal services (eg, medication administration). (Effective 10/1/03) A facility/unit that moves from place‑to‑place equipped to provide preventive, screening, diagnostic, 15 Mobile Unit and/or treatment services. A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient 16 Temporary Lodging receives care, and which is not identified by any other POS code. (Effective 4/1/08) A walk‑in health clinic, other than an office, urgent care facility, pharmacy, or independent clinic, which is 17 Walk‑in Retail Health Clinic not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. (Effective 5/1/10) A location, not described by any other POS code, owned or operated by a public or private entity where Place of Employment— the patient is employed, and where a health professional provides on‑going or episodic occupational 18 Worksite medical, therapeutic or rehabilitative services to the individual. (This code is available for use effective January 1, 2013 but no later than May 1, 2013.) 19 Unassigned N/A Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose 20 Urgent Care Facility and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. (Effective 1/1/03) A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and 21 Inpatient Hospital non‑surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a hospital which provides diagnostic, therapeutic (both surgical and non‑surgical), and 22 Outpatient Hospital rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 23 Emergency Room—Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. Ambulatory Surgical A free‑standing facility, other than a physician’s office, where surgical and diagnostic services are 24 Center provided on an ambulatory basis. A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for 25 Birthing Center labor, delivery, and immediate postpartum care as well as immediate care of newborn infants. A medical facility operated by one or more of the Uniformed Services. Military treatment facility (MTF) also 26 Military Treatment Facility refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). 27‑30 Unassigned N/A 31449_CPT Prof 2015_FM i-ii_NF front-back.indd 1 8/1/14 2:16 PM i A facility that primarily provides inpatient skilled nursing care and related services to patients who 31 Skilled Nursing Facility require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. A facility that primarily provides to residents skilled nursing care and related services for the 32 Nursing Facility rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health‑related care services above the level of custodial care to other than mentally retarded individuals. A facility that provides room, board, and other personal assistance services, generally on a 33 Custodial Care Facility long‑term basis, and which does not include a medical component. A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients 34 Hospice and their families are provided. 35‑40 Unassigned N/A A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or 41 Ambulance—Land injured. An air or water vehicle specifically designed, equipped, and staffed for lifesaving and transporting the 42 Ambulance—Air or Water sick or injured. 43‑48 Unassigned N/A A location, not part of a hospital and not described by any other Place of Service code, that is organized 49 Independent Clinic and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (Effective 10/1/03) Federally Qualified A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary 50 Health Center medical care under the general direction of a physician. A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on 51 Inpatient Psychiatric Facility a 24‑hour basis, by or under the supervision of a physician. A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program Psychiatric Facility— 52 for patients who do not require full time hospitalization, but who need broader programs than are Partial Hospitalization possible from outpatient visits to a hospital‑based or hospital‑affiliated facility. A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health Community Mental services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day 53 Health Center emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental healthfacilitiestodetermine the appropriateness of such admission; and consultation and education services. A facility that primarily provides health‑related care and services above the level of custodial care to Intermediate Care 54 mentally retarded individuals but does not provide the level of care or treatment available in a hospital or Facility/Mentally Retarded SNF. A facility which provides treatment for substance (alcohol and drug) abuse to live‑in residents who do Residential Substance 55 not require acute medical care. Services include individual and group therapy and counseling, family Abuse Treatment Facility counseling, laboratory tests, drugs and supplies, psychological testing, and room and board. Psychiatric Residential A facility or distinct part of a facility for psychiatric care which provides a total 24‑hour therapeutically 56 Treatment Center planned and professionally staffed group living and learning environment. A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Non‑residential Substance 57 Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs Abuse Treatment Facility and supplies, and psychological testing. (Effective 10/1/03) 58‑59 Unassigned N/A A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This 60 Mass Immunization Center generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. A facility that provides comprehensive rehabilitation services under the supervision of a physician to Comprehensive Inpatient 61 inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech Rehabilitation Facility pathology, social or psychological services, and orthotics and prosthetics services. A facility that provides comprehensive rehabilitation services under the supervision of a physician to Comprehensive Outpatient 62 outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech Rehabilitation Facility pathology services. 63‑64 Unassigned N/A End‑Stage Renal Disease A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to 65 Treatment Facility patients or caregivers on an ambulatory or home‑care basis. 66‑70 Unassigned N/A A facility maintained by either State or local health departments that provides ambulatory primary 71 Public Health Clinic medical care under the general direction of a physician. A certified facility which is located in a rural medically underserved area that provides ambulatory 72 Rural Health Clinic primary medical care under the general direction of a physician. 73‑80 Unassigned N/A A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a 81 Independent Laboratory physician’s office. 82‑98 Unassigned N/A 99 Other Place of Service Other place of service not identified above. 31449_CPT Prof 2015_FM i-ii_NF front-back.indd 2 7/23/14 9:06 AM ii cpt current procedural terminology ® 2015 Professional Edition Michelle Abraham,MHA, CCS-P DeHandro Hayden,BS Danielle Pavloski,BS, RHIT, CCS-P Jay T. Ahlman Nadia Khalid,MJ, RHIA, RMM Desiree Rozell,MPA Angela J. Boudreau Lia Levreau-Davis,MBA, CPC Nancy Spector,BSN, MSC Judy Connelly Elizabeth Lumakovska,MPA, RHIT Lianne Stancik,RHIT Rick A. Crosslin Janette Meggs,RHIA Asif A. Syed,MD, MPH Biljana Dimovski,MS, RHM, CDC Marie L. Mindeman,BA, RHIT Ada Walker,CCA Desiree D. Evans,AAS Karen E. O’Hara,BS, CCS-P Arletrice Watkins,MHA, RHIA Lauren M. Feldman Mary R. O’Heron,RHIA Rejina L. Young 31449_CPT Prof 2015_FM iii_Title Pg.indd 3 7/31/14 10:53 AM ExecutiveVice President, Chief Executive Officer: James L. Madara, MD Chief Operating Officer: Bernard L. Hengesbaugh SeniorVice President and General Manager, AMA Business Services: Mary G. Henderson, PhD SeniorVice President and Chief Development Officer: Robert A. Musacchio, PhD Vice President, Coding and Reimbursement Products Portfolio: Jay Ahlman Vice President, Sales and Marketing: Ana English Director, CPT Coding and Regulatory Services: Marie Mindeman Director, CPT Education and Information Services: Danielle Pavloski Director, CPT Medical Informatics and Healthcare Strategy: Asif A. Syed, MD Director, CPT/DBP Intellectual Property Services: Matthew Menning Manager, Book and Product Development and Production: Nancy Baker Senior Developmental Editor: Lisa Chin-Johnson Production Specialist: Mary Ann Albanese Director, Sales, Key Accounts, Sales and Marketing:Susan Wilson Director, Key Account Management: Joann Skiba Director, Marketing: Karen Christensen-Araujo Director, Channel Programs and Marketing Operations: Erin Kalitowski Marketing Manager: Rachel Dunn Professional ISBN: 978-1-62202-026-3 ISSN: 0276-8283 CurrentProcedural Terminology (CPT®) copyright 2014 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 1966 2nd Edition printed 1970 3rd Edition printed 1973 4th Edition printed 1977 Revised: 1978, 1979, 1980, 1981, 1982, 1984, 1985, 1986, 1987, 1988, 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014 To purchase additional CPT products, contact the American Medical Association Customer Service at 800 621-8335 or AMA|Store atamastore.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 Association CPT/DBP Intellectual Property Services, 330 NorthWabash Avenue, Suite 39300, Chicago, IL 60611, 312 464-5022. AC36:EP054115:9/14 AC36:EP888815:9/14 31449_CPT Prof 2015_FM iv-xvi.indd 4 7/24/14 12:05 PM iv Eye and Ocular Adnexa / Surgery Foreword Acknowledgments CurrentProcedural Terminology (CPT®), Fourth Edition, is a Publication of the annual CPT codebook represents many listing of descriptive terms and identifying codes for reporting challenges and opportunities. From reconciling the many medical services and procedures performed by physicians.The differences of opinion about the best way to describe a purpose of the terminology is to provide a uniform language procedure, to the last details on placement of a semicolon, many that will accurately describe medical, surgical, and diagnostic individuals and organizations devote their energies and expertise services, and will thereby provide an effective means for reliable to the preparation of this revision. nationwide communication among physicians, patients, and The editorial staff wishes to express sincere thanks to the many third parties.CPT 2015 is the most recent revision of a work national medical specialty societies, health insurance that first appeared in 1966. organizations and agencies, and individual physicians and other CPT descriptive terms and identifying codes currently serve a health professionals who have made contributions. wide variety of important functions in the field of medical Thanks are due to Robert A. Musacchio, PhD, SrVP, American nomenclature.The CPT code set is useful for administrative Medical Association; Claudia Bonnell, Blue Cross and Blue management purposes such as claims processing and for the Shield Association; Nelly Leon-Chisen, American Hospital development of guidelines for medical care review.The uniform Association; Sue Bowman, RHIA, American Health language is also applicable to medical education and outcomes, Information Management Association; and Raemarie Jiminez, health services, and quality research by providing a useful basis CPC, American Academy of Professional Coders, for their for local, regional, and national utilization comparisons.The invaluable assistance in enhancing the CPT code set. CPT code set is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs. In 2000, the CPT code set was designated by the Department of Health and Human Services as the national coding standard for physician and other health care professional services and procedures under the Health Insurance Portability and Accountability Act (HIPAA).This means that for all financial and 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 by the CPT Editorial Panel with the assistance of physicians representing all specialties of medicine, and with important contributions from many third-party payers and governmental agencies. The American Medical Association trusts that this revision will continue the usefulness of its predecessors in identifying, describing, and coding medical, surgical, and diagnostic services. AmericanMedicalAssociation v 31449_CPT Prof 2015_FM iv-xvi.indd 5 7/24/14 12:05 PM AMA CPT Editorial Panel American Academy of Pain Medicine Eduardo M. Fraifeld, MD Chair Peter A. Hollmann, MD* American Academy of Pediatrics Vice-Chair Joel F. Bradley, Jr, MD, FAAP Kenneth P. Brin, MD, PhD, FACC* SanjeevY.Tuli, MD, MEd, FAAP American Academy of Physical Medicine and Rehabilitation Albert E. Bothe, Jr, MD, FACS Jeffrey S. Brault, DO Boyd R. Buser, DO, FACOFP Annie D. Purcell, DO‡ Leslie F. Davidson, PhD, OTR/L Frank J. Dubeck, Jr, MD, FACP* American Academy of Sleep Medicine Richard Duszak, Jr, MD, FACR* Amy J. Aronsky, DO, FAASM, FCCP, CBSM David A. Ellington, MD William C. Sherrill, Jr, MD Ronald A. Gabel, MD American Association for Clinical Chemistry Edith Hambrick, MD, JD William A. Clark, PhD, DABCC, FACB‡ Christopher L. Jagmin, MD Katharine Krol, MD American Association forThoracic Surgery Victor L. Lewis, Jr, MD, FACS Kirk R. Kanter, MD Bernard A. Pfeifer, MD† Stephen J. Lahey, MD Julia M. Pillsbury, DO, FAAP, FACOP Antonio E. Puente, PhD American Association of Clinical Endocrinologists Mark S. Synovec, MD* Eric A. Orzeck, MD, FACP, FACE Secretary American Association of Neurological Surgeons Marie L. Mindeman, BA, RHIT R. Patrick Jacob, MD Henry H.Woo, MD, FAANS *Member of the CPT Executive Committee †New Panel Member American Association of Neuromuscular and Electrodiagnostic ‡New Advisors Medicine Andrea J. Boon, MD AMA CPT Advisory Committee American Clinical Neurophysiology Society American Academy of Allergy, Asthma and Immunology Marc R. Nuwer, MD, PhD, FAAN, FACP DonaldW. Aaronson, MD, JD, MPH Ronald G. Emerson, MD American Academy of Child & Adolescent Psychiatry American College of Allergy, Asthma and Immunology Benjamin N. Shain, MD, PhD Gary N. Gross, MD David I. Berland, MD American College of Cardiology American Academy of Dermatology Robert N. Piana, MD, FACC Alexander Miller, MD Randall C.Thompson, MD‡ Ann F. Haas, MD American College of Chest Physicians American Academy of Disability Evaluating Physicians Steve G. Peters, MD DouglasW. Martin, MD, FAADEP, FACOEM Michael E. Nelson, MD, FCCP James B.Talmage, MD American College of Emergency Physicians American Academy of Family Physicians Kenneth L. DeHart, MD, FACEP Robert J. Carr, Jr, MD Jacob Mark J. Meredith, III, MD, MMM, FACEP Gretchen M. Dickson, MD, MBA American College of Gastroenterology American Academy of Neurology ChristopherY. Kim, MD, MBA, FACG, FASGE, AGAF, FACP Marc R. Nuwer, MD, PhD, FAAN, FACP Daniel C. DeMarco, MD, FACG Bruce H. Cohen, MD, FAAN American College of Medical Genetics and Genomics American Academy of Ophthalmology David B. Flannery, MD Michael X. Repka, MD, MBA John M. Haley, MD‡ American College of Medical Quality Joel Grossman, MD American Academy of Orthopaedic Surgeons American College of Mohs Surgery Richard J. Friedman, MD, FACSC David B. Pharis, MD, PC M. Bradford Henley, MD, MBA American College of Nuclear Medicine American Academy of Otolaryngic Allergy Scott C. Bartley, MD PaulT. Fass, MD, FACS American College of Occupational and Environmental Medicine American Academy of Otolaryngology Head and Neck Surgery Lee S. Glass, MD, JD Bradley F. Marple, MD, FAAOA Lawrence M. Simon, MD, FAAP vi CPTEditorial Panel/Advisory Committee CPT 2015 31449_CPT Prof 2015_FM iv-xvi.indd 6 7/24/14 12:05 PM Eye and Ocular Adnexa / Surgery American College of Physicians American Society for Reproductive Medicine Jeannine Z. Engel, MD, FACP DrewV. Moffitt, MD R. Scott Hanson, MD, MPH, FACP American Society for Surgery of the Hand American College of Radiation Oncology Daniel J. Nagle, MD AndyW. Su, MD Leo S. Benson, MD Paul E.Wallner, DO, FACR, FAOCR, FASTRO, FACRO American Society of Anesthesiologists American College of Radiology Peter A. Goldzweig, DO Daniel Picus, MD, FACR, RCC Kevin E.Vorenkamp, MD Timothy A. Crummy, MD, RCC American Society of Cataract and Refractive Surgery American College of Rheumatology Stephen S. Lane, MD Gerald M. Eisenberg, MD, FACP, FACR American Society of Clinical Oncology Robert J. Lloyd, MD, FACP, FACR Christian A.Thomas, MD American College of Surgeons American Society of Colon and Rectal Surgeons Linda M. Barney, MD, FACS Stephen M. Sentovich, MD, MBA, FCS, FASCRS MarkT. Savarise, MD, FACS William J. Harb, MD, FACS American Congress of Obstetricians and Gynecologists American Society of Cytopathology Jordan G. Pritzker, MD, MBA, FACOG Carol A. Filomena, MD Judith K.Volkar, MD‡ American Society of General Surgeons American Dental Association George K. Gillian, MD, FACS‡ Anthony M. Spina, DDS, MD Christopher C. Smith, MD‡ Joshua E. Everts, DDS, MD American Society of Hematology American Gastroenterological Association Samuel M. Silver, MD, PhD, FACP, FAHA JoelV. Brill, MD, AGAF, FASGE, FACG, CHCQM Robert Weinstein,MD American Geriatric Society American Society of Interventional Pain Physicians Robert A. Zorowitz, MD, MBA, FACP, AGSF, CMD Frank J.E. Falco, MD‡ American Institute of Ultrasound in Medicine Sachin Jha, MD, MS‡ Harvey L. Nisenbaum, MD American Society of Neuroradiology American Medical Directors Association Raymond K.Tu, MD Dennis L. Stone, MD, MBA Jacqueline A. Bello, MD, FACR American Orthopaedic Association American Society of Ophthalmic Plastic and Reconstructive Surgery Blair C. Filler, MD L. Neal Freeman, MD, MBA, CCS-P, FACS American Orthopaedic Foot and Ankle Society American Society of Plastic Surgeons Walter J. Pedowitz, MD‡ RaymondV. Janevicius, MD David I. Pedowitz, MD‡ Deborah S. Bash, MD American Osteopathic Association American ThoracicSociety Judith A. O’Connell, DO, FAAO Stephen P. Hoffmann, MD Brian E. Kaufman, DO‡ American Urological Association American Psychiatric Association Jeffrey A. Dann, MD, MBA David K. Nace, MD Ronald P. Kaufman, Jr, MD, FACS Jeremy S. Musher, MD Association of University Radiologists American Roentgen Ray Society Robert K. Zeman, MD, FACR Mark D. Alson, MD, FACR, RCC College of American Pathologists American Society for Aesthetic Plastic Surgery, Inc. Michael D. McEachin, MD Paul R.Weiss, MD Congress of Neurological Surgeons American Society for Clinical Pathology Joseph S. Cheng, MD Lee H. Hilborne, MD, MPH, FASCP Heart Rhythm Society American Society for Dermatologic Surgery Oussama M.Wazni, MD Murad Alam, MD Joseph E. Marine, MD‡ Jeremy S. Bordeaux, MD, MPH Infectious Disease Society of America American Society for Gastrointestinal Endoscopy Steven K. Schmitt, MD Glenn D. Littenberg, MD, FACP Lyssette L. Cardona, MD, MPH, MSHA‡ American Society for Radiation Oncology International Spinal Intervention Society David C. Beyer, MD, FACR, FACRO, FASTRO Scott I. Horn, DO William F. Hartsell, MD‡ Claire Tibiletti,MD AmericanMedicalAssociation vii 31449_CPT Prof 2015_FM iv-xvi.indd 7 7/24/14 3:59 PM National Association of Medical Examiners American Academy of Physician Assistants John S. Denton, MD‡ Patrick J. Cafferty, MPAS, PA-C North American Spine Society American Association of Naturopathic Physicians William Mitchell, MD Wendell B. Milliman, ND David R. O’Brien, Jr, MD Eva Miller, ND Radiological Society of North America American Association for Respiratory Care Timothy A. Crummy, MD Susan Rinaldo-Gallo, MEd, RRT, FAARC Renal Physicians Association American Chiropractic Association Chester A. Amedia, Jr, MD, FACP Craig S. Little, DC, FACO Timothy A. Pflederer, MD‡ Leo Bronston DC, MappSC Society for Cardiovascular Angiography and Interventions American MassageTherapy Association Arthur C. Lee, MD, FSCAI Susan B. Rosen, LPM Society for Investigative Dermatology Nancy M. Porambo, BA, MS, LMT, NCTMB‡ Stephen P. Stone, MD American Nurses Association Society forVascular Surgery Jamesetta A. Newland, PhD, RN, FNP-BC, FAANP, DPMAP‡ Sean P. Roddy, MD, FACS Leslie C.Verucci, RN, MSN, CNS, CRNP, APRN-BC‡ Society of American Gastrointestinal Endoscopic Surgeons American OccupationalTherapy Association John S. Roth, MD, FACS Mary Jo McGuire, MS, OTR/L, FAOTA Kevin E.Wasco, MD, FACS Doris J. Shriver, OTR, FAOTA, QRC, CLCP‡ Society of Critical Care Medicine American Optometric Association George A. Sample, MD, FCCP Douglas C. Morrow, OD Society of Interventional Radiology Rebecca H.Wartman, OD Donald F. Denny, Jr, MD Timothy L. Swan, MD American PhysicalTherapy Association Helene M. Fearon, PT Society of Nuclear Medicine and Molecular Imaging Kathleen M. Picard, PT Gary L. Dillehay, MD, FACNP, FACR American Podiatric Medical Association Society ofThoracic Surgeons Phillip E.Ward, DPM Francis C. Nichols, III, MD Ira H. Kraus, DPM Jeffrey P. Jacobs, MD, FACS, FACC, FCCP American Psychological Association The Endocrine Society Neil H. Pliskin, PhD, ABPP-CN Allan R. Glass, MD Randy E. Phelps, PhD‡ The TriologicalSociety Richard W. Waguespack,MD,FACS American Speech Hearing Association Stuart G.Trembath, MA, CCC-A United States and Canadian Academy of Pathology R.Wayne Holland, EdD, CCC-SLP David S.Wilkinson, MD, PhD National AthleticTrainers’ Association AMA Health Care Professionals Karen D. Fennell, MS, ATC, LAT WilliamT. Griffin, MA, LAT, ATC‡ Advisory Committee (HCPAC) National Association of SocialWorkers Peter A. Hollmann, MD*, Co-Chair Mirean F. Coleman, LICSW AMA CPT Editorial Panel National Society of Genetic Counselors Antonio E. Puente, PhD, Co-Chair Leslie H. Cohen, MS, CGC AMA CPT Editorial Panel Pharmacy Health InformationTechnology Collaborative Academy of Nutrition and Dietetics Daniel E. Buffington, PharmD, MBA Keith-Thomas Ayoob, EdD, RN, FADA, CSP Jessie M. Pavlianc, MS, RD, CSR, LD‡ American Academy of Audiology Brad A. Stach, PhD Paul M. Pessis, AuD viii CPTEditorial Panel/Advisory Committee CPT 2015 31449_CPT Prof 2015_FM iv-xvi.indd 8 7/24/14 12:05 PM Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . .11 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Office or Other Outpatient Services . . . . . . . . . . . . . . . . . .11 Hospital Observation Services . . . . . . . . . . . . . . . . . . . . . .13 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii Hospital Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . .15 Section Numbers and Their Sequences . . . . . . . . . . . . . . .xii Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Instructions for Use of the CPT Codebook . . . . . . . . . . . . .xii Emergency Department Services . . . . . . . . . . . . . . . . . . . .22 Format of the Terminology . . . . . . . . . . . . . . . . . . . . xiii Critical Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Requests to Update the CPT Nomenclature . . . . . . xiii Nursing Facility Services . . . . . . . . . . . . . . . . . . . . . . . . . .25 Application Submission Requirements . . . . . . . . . xiii Domiciliary, Rest Home (eg, Boarding Home), General Criteria for Category I and Category III Codes . xiii or Custodial Care Services . . . . . . . . . . . . . . . . . . . . . . . . .28 Category-Specific Requirements . . . . . . . . . . . . . . . xiv Domiciliary, Rest Home (eg, Assisted Living Facility), Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv or Home Care Plan Oversight Services . . . . . . . . . . . . . . .29 Add-on Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Home Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Prolonged Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Place of Service and Facility Reporting . . . . . . . . . . .xv Case Management Services . . . . . . . . . . . . . . . . . . . . . . . .33 Unlisted Procedure or Service . . . . . . . . . . . . . . . . . .xv Care Plan Oversight Services . . . . . . . . . . . . . . . . . . . . . . .34 Results, Testing, Interpretation, and Report . . . . . . .xv Preventive Medicine Services . . . . . . . . . . . . . . . . . . . . . .35 Non-Face-to-Face Services . . . . . . . . . . . . . . . . . . . . . . . . .37 Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv Special Evaluation and Management Services . . . . . . . . .39 Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv Newborn Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Code Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi Delivery/Birthing Room Attendance and Alphabetical Reference Index . . . . . . . . . . . . . . . . . xvi Resuscitation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 CPT 2015 in Electronic Formats . . . . . . . . . . . . . . . . xvi Inpatient Neonatal Intensive Care Services and References to AMA Resources . . . . . . . . . . . . . . . . xvi Pediatric and Neonatal Critical Care Services . . . . . . . . . .41 Illustrated Anatomical and Procedural Review . . . . . . xvii Care Management Services . . . . . . . . . . . . . . . . . . . .45 Prefixes, Suffixes, and Roots . . . . . . . . . . . . . . . . . . . . . .xvii Transitional Care Management Services . . . . . . . . . . . . . .48 Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii Advance Care Planning . . . . . . . . . . . . . . . . . . . . . . . .49 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . .xvii Other Evaluation and Management Services . . . . . . . . . .50 Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii Anesthesia Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Directions and Positions . . . . . . . . . . . . . . . . . . . . xviii Time Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Additional References . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Anesthesia Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Medical Dictionaries . . . . . . . . . . . . . . . . . . . . . . . xviii Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Anatomy References . . . . . . . . . . . . . . . . . . . . . . . xviii Separate or Multiple Procedures . . . . . . . . . . . . . . . . . . . .52 Lists of Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Anatomical Illustrations . . . . . . . . . . . . . . . . . . . . xviii Anesthesia Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Procedural Illustrations . . . . . . . . . . . . . . . . . . . . . . xix Qualifying Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . .53 Evaluation and Management Tables . . . . . . . . . . . . . . . .xxii Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Evaluation and Management (E/M) Services Guidelines .4 Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Classification of Evaluation and Management Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 (E/M) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Thorax (Chest Wall and Shoulder Girdle) . . . . . . . . . . . . . .54 Definitions of Commonly Used Terms . . . . . . . . . . . . . . . . .4 Intrathoracic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Unlisted Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Spine and Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Clinical Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Lower Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Instructions for Selecting a Level of E/M Service . . . . . . . .9 Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 AmericanMedicalAssociation ix  Contains new or revised text 31449_CPT Prof 2015_FM iv-xvi.indd 9 7/31/14 11:18 AM