page Sample Contents About CPT...................................... v Evaluation and Management........................ .11 Maintenance and Authorship of the CPT Code Set ...... v Office or Other Outpatient Services................. .11 AMA CPT Staff .................................. v Hospital Observation Services ..................... .13 Hospital Inpatient Services ....................... .15 Introduction...................................... .xiii Consultations .................................. .19 Section Numbers and Their Sequences.............. xiii Emergency Department Services ................... .22 Instructions for Use of the CPT Codebook ............ xiii Critical Care Services ............................ .23 Format of the Terminology ................... xiv Nursing Facility Services ......................... .25 Requests to Update the CPT Nomenclature ...... xiv Domiciliary, Rest Home (eg, Boarding Home), Application Submission Requirements ......... xiv or Custodial Care Services ........................ .28 General Criteria for Category I, II, and III Codes ... xiv Domiciliary, Rest Home (eg, Assisted Living Facility), Category-Specific Requirements............... xv or Home Care Plan Oversight Services .............. .30 Guidelines ................................ xv Home Services ................................. .30 Add-on Codes ............................. xvi Prolonged Services.............................. .32 Modifiers ................................. xvi Case Management Services....................... .35 Place of Service and Facility Reporting.......... xvi Care Plan Oversight Services ...................... .36 Unlisted Procedure or Service................ xvii Preventive Medicine Services ..................... .37 Results, Testing, Interpretation, and Report..... xvii Non-Face-to-Face Services........................ .39 Special Report ............................ xvii Special Evaluation and Management Services . .43 Time.................................... xvii Newborn Care Services .......................... .44 Delivery/Birthing Room Attendance and Code Symbols ............................ .xvii Resuscitation Services ........................... .44 Alphabetical Reference Index ................ xviii Inpatient Neonatal Intensive Care Services and Use of Anti-Piracy Technology Pediatric and Neonatal Critical Care Services......... .45 in CPT Professional 2020 Codebook ........... xviii Cognitive Assessment and Care Plan Services ........ .49 CPT 2020 in Electronic Formats............... xviii Care Management Services....................... .50 References to AMA Resources ............... xviii page Psychiatric Collaborative Care Management Services ...53 Illustrated Anatomical and Procedural Review ...... xix Transitional Care Management Services............. .55 Prefixes, Suffixes, and Roots . xix Advance Care Planning........................... .56 Numbers ................................. xix General Behavioral Health Integration Care Surgical Procedures......................... xix Management .................................. .57 Other Evaluation and Management Services ..........57 Conditions ................................ xix Directions and Positions ..................... xx Anesthesia Guidelines ............................. .60 Additional References ........................... .xx Time Reporting ................................. .60 Medical Dictionaries ........................ xx Anesthesia Services............................. .60 Anatomy References ........................ xx Supplied Materials.............................. .60 SampleLists of Illustrations ............................. .xx Separate or Multiple Procedures ................... .60 Anatomical Illustrations ..................... .xx Unlisted Service or Procedure ..................... .60 Procedural Illustrations . xxi Special Report ................................. .61 Evaluation and Management Tables . .xxix Anesthesia Modifiers............................ .61 Qualifying Circumstances......................... .61 Evaluation and Management (E/M) Services Guidelines 4 Classification of Evaluation and Management Anesthesia........................................ .62 (E/M) Services .................................. .4 Head . .62 Definitions of Commonly Used Terms ................ .4 Neck ......................................... .62 Unlisted Service . .8 Thorax (Chest Wall and Shoulder Girdle)............. .63 Special Report .................................. .8 Intrathoracic . .63 Clinical Examples . .8 Spine and Spinal Cord ........................... .63 Instructions for Selecting a Level of E/M Service ....... .9 Upper Abdomen ................................ .64 x Contents CPT 2020 42531_CPT Prof 2020_00_FM iv-xviii.indd 10 8/6/19 5:14 PM Contents Lower Abdomen . .64 Separate Procedures ........................... .474 Perineum...................................... .65 Unlisted Service or Procedure .................... .474 Pelvis (Except Hip) .............................. .65 Special Report ................................ .475 Upper Leg (Except Knee).......................... .66 Supervision and Interpretation, Knee and Popliteal Area.......................... .66 Imaging Guidance.............................. .475 Lower Leg (Below Knee, Includes Ankle and Foot) ..... .66 Administration of Contrast Material(s) ............. .475 Shoulder and Axilla ............................. .67 Written Report(s) .............................. .475 Upper Arm and Elbow............................ .67 Radiology........................................ .476 Forearm, Wrist, and Hand ........................ .67 Diagnostic Radiology (Diagnostic Imaging) . .476 Radiological Procedures.......................... .68 Diagnostic Ultrasound .......................... .495 Burn Excisions or Debridement .................... .68 Radiologic Guidance............................ .501 Obstetric ...................................... .68 Breast, Mammography.......................... .503 Other Procedures ............................... .69 Bone/Joint Studies............................. .504 Surgery Guidelines ................................ .72 Radiation Oncology............................. .504 Services ...................................... .72 Nuclear Medicine.............................. .512 CPT Surgical Package Definition ................... .72 Pathology and Laboratory Guidelines ............... .540 Follow-Up Care for Diagnostic Procedures ........... .72 Services in Pathology and Laboratory .............. .540 Follow-Up Care for Therapeutic Surgical Procedures ... .72 Separate or Multiple Procedures .................. .540 Supplied Materials.............................. .72 Unlisted Service or Procedure .................... .540 Reporting More Than One Procedure/Service ......... .72 Special Report ................................ .540 Separate Procedure ............................. .72 Pathology and Laboratory.......................... .541 Unlisted Service or Procedure ..................... .73 Organ or Disease-Oriented Panels................. .541 Special Report ................................. .74 Drug Assay . .543 Imaging Guidance............................... .74 Therapeutic Drug Assays . .550 Surgical Destruction............................. .74 Evocative/Suppressionpage Testing ................... .553 Surgery........................................... .77 Consultations (Clinical Pathology) ................. .554 General ....................................... .77 Urinalysis .................................... .554 Integumentary System . .78 Molecular Pathology............................ .555 Musculoskeletal System ........................ .118 Genomic Sequencing Procedures and Other Molecular Respiratory System............................. .191 Multianalyte Assays............................ .583 Cardiovascular System.......................... .216 Multianalyte Assays with Algorithmic Analyses...... .586 Hemic and Lymphatic Systems ....................293 Chemistry .................................... .588 Mediastinum and Diaphragm..................... .298 Hematology and Coagulation..................... .599 Digestive System .............................. .304 Immunology .................................. .601 Urinary System ................................ .361 Transfusion Medicine........................... .607 SampleMale Genital System ........................... .385 Microbiology.................................. .608 Reproductive System Procedures.................. .391 Anatomic Pathology . .616 Intersex Surgery . .391 Cytopathology................................. .616 Female Genital System.......................... .395 Cytogenetic Studies . .618 Maternity Care and Delivery ..................... .405 Surgical Pathology ............................. .619 Endocrine System.............................. .408 In Vivo (eg, Transcutaneous) Laboratory Procedures... .625 Nervous System . .414 Other Procedures .............................. .625 Eye and Ocular Adnexa.......................... .449 Reproductive Medicine Procedures . .625 Auditory System ............................... .466 Proprietary Laboratory Analyses .................. .627 Operating Microscope .......................... .470 Medicine Guidelines.............................. .639 Radiology Guidelines (Including Nuclear Medicine Add-on Codes ................................. .639 and Diagnostic Ultrasound) ....................... .474 Separate