CPT Code Billing & Denial Guide
A practical reference for the CPT codes most frequently denied or downcoded by insurance payers. Each entry covers documentation requirements, common denial reasons, billing tips, and reimbursement benchmarks.
154
CPT Codes Covered
12
Categories
$25-$118
Cost to Rework a Denial
60s
RediClaim Appeal Generation
Evaluation & Management
Office Visit, Established Patient, Low Complexity
An office or other outpatient visit for the evaluation and management of an established patient with low medical decision making complexity. Typically involves straightforward problems and minimal risk assessment. Typical time: 20-29 minutes.
Office Visit, Established Patient, Moderate Complexity
An office or other outpatient visit for the evaluation and management of an established patient with moderate medical decision making complexity. Multiple or complex problems requiring significant decision making. Typical time: 30-39 minutes.
Office Visit, Established Patient, High Complexity
An office or other outpatient visit for the evaluation and management of an established patient with high medical decision making complexity. Multiple chronic conditions with significant risk management required. Typical time: 40-59 minutes.
Office Visit, New Patient, Straightforward
An office or other outpatient visit for the evaluation and management of a new patient with straightforward problems and minimal risk. Typical time: 10-19 minutes.
Office Visit, New Patient, High Complexity
An office or other outpatient visit for the evaluation and management of a new patient with high medical decision making complexity and moderate to high risk. Typical time: 40-59 minutes.
Emergency Department Visit, Self-Limited or Minor
An emergency department visit for the evaluation and management of a patient with a self-limited or minor problem. Minimal examination and decision making required.
Emergency Department Visit, High Complexity
An emergency department visit for the evaluation and management of a patient with high complexity and high risk. Multiple problems requiring significant decision making and resource utilization.
Hospital Subsequent Inpatient Visit, Low Complexity
An inpatient hospital subsequent day visit for the evaluation and management of an established inpatient with stable clinical status. Low medical decision making complexity.
After-Hours E/M Service
E/M service provided after normal office hours, in the evening, at night, or on weekends when office is normally closed.
Office Visit, New Patient, Very High Complexity
An office or other outpatient visit for the evaluation and management of a new patient with very high medical decision making complexity and high risk. Typical time: 60-74 minutes.
Office Visit, Established Patient, Very Minimal
An office or other outpatient visit for the evaluation and management of an established patient with minimal complexity or straightforward problem. Typical time: 10-19 minutes.
Office Visit, Established Patient, Minimal
An office or other outpatient visit for the evaluation and management of an established patient that requires no more than a nurse visit. Straightforward, self-limited problem or routine follow-up. Typical time: 5-10 minutes.
Office Visit, New Patient, Minimal
An office or other outpatient visit for the evaluation and management of a new patient with minimal complexity. Straightforward self-limited problem. Typical time: 10-19 minutes.
Office Visit, New Patient, Moderate Complexity
An office or other outpatient visit for the evaluation and management of a new patient with moderate medical decision making complexity. Multiple or complex problems. Typical time: 20-29 minutes.
Emergency Department Visit, Low Complexity
An emergency department visit for the evaluation and management of a patient with low complexity and minimal risk. Straightforward problems requiring limited evaluation.
Emergency Department Visit, Moderate Complexity
An emergency department visit for the evaluation and management of a patient with moderate complexity and moderate risk. Multiple problems or significant injury requiring moderate resource utilization.
Emergency Department Visit, Very High Complexity
An emergency department visit for the evaluation and management of a patient with very high complexity and very high risk. Critical or multi-system illness requiring immediate physician evaluation and significant resource utilization.
Hospital Subsequent Inpatient Visit, Moderate Complexity
An inpatient hospital subsequent day visit for the evaluation and management of an established inpatient with stable or improving status. Moderate medical decision making complexity.
Hospital Subsequent Inpatient Visit, High Complexity
An inpatient hospital subsequent day visit for the evaluation and management of an established inpatient. High medical decision making complexity with significant changes in clinical status or treatment plan.
Postoperative Follow-up Visit
Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason related to the original procedure.
Prolonged Service, First Hour
Prolonged evaluation and management service in the outpatient setting requiring direct patient contact beyond the usual service, first hour. An add-on code billed with the primary E/M service.
Telephone E/M, 5-10 Minutes
Telephone evaluation and management service by a physician or qualified healthcare professional to an established patient, 5-10 minutes of medical discussion.
Office Consultation, Straightforward
Office or other outpatient consultation for a new or established patient with straightforward medical decision making. Note: Medicare no longer recognizes consultation codes — use new or established patient E/M codes instead.
Office Consultation, Low Complexity
Office or other outpatient consultation for a new or established patient with low medical decision making complexity.
Online Digital E/M, 5-10 Minutes
Online digital evaluation and management service for an established patient, cumulative time 5-10 minutes over a 7-day period. Asynchronous patient-initiated digital communication requiring clinical decision making.
Advance Care Planning, First 30 min
Advance care planning including the explanation and discussion of advance directives such as standard forms with completion of such forms, first 30 minutes face-to-face with the patient, family member(s), and/or surrogate.
Observation/Inpatient Same-Day Admit and Discharge
Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, requiring low or moderate medical decision making complexity.
Eye Exam, Established Patient, Intermediate
Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.
Observation Same-Day Admit/Discharge, High Complexity
Hospital inpatient or observation care, admission and discharge on the same date, requiring high medical decision making complexity.
Observation Care Discharge
Observation care discharge day management. Used when the patient is discharged from observation status on a date different from the admission date.
Hospital Discharge, 30 min or Less
Hospital inpatient or observation discharge day management, 30 minutes or less on the date of discharge.
Critical Care, First 30-74 Minutes
Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes. Direct delivery of medical care for a critically ill patient requiring constant physician attention.
Eye Exam, Established Patient, Comprehensive
Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1+ visits.
Care Management
Chronic Care Management, Non-Complex
Chronic care management services for a single chronic condition requiring behavioral, social, or psychosocial interventions. Care plan development and monitoring of at least 20 minutes per calendar month.
Chronic Care Management, Complex
Chronic care management services for multiple chronic conditions requiring complex behavioral, social, or psychosocial interventions. Care plan development and monitoring of at least 30 minutes per calendar month.
Complex Chronic Care Management, 60 min
Complex chronic care management services with the following required elements: multiple chronic conditions expected to last at least 12 months with risk of significant deterioration or death, comprehensive care plan, and moderate or high complexity medical decision making. First 60 minutes per calendar month.
Remote Physiologic Monitoring Treatment, First 20 min
Remote physiologic monitoring treatment management services, clinical staff/physician time during a calendar month requiring interactive communication with the patient/caregiver, first 20 minutes.
Remote Physiologic Monitoring Setup
Remote monitoring of physiologic parameter(s), initial setup and patient education on use of equipment.
Remote Physiologic Monitoring Device Supply
Remote monitoring of physiologic parameter(s), device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
Surgical/Procedures
Incision and Drainage of Abscess
Surgical incision and drainage of superficial abscess on the skin and subcutaneous tissue. Includes local anesthesia and post-operative care instructions.
Foreign Body Removal, Superficial
Removal of a foreign body or calculus from the subcutaneous tissue not requiring a surgical operation. Includes appropriate anesthesia and wound care.
Destruction of Lesions, Benign, Single
Destruction by any method of a single benign lesion including wart, molluscum contagiosum, or verruca. Destruction includes electrosurgery, cryotherapy, or laser ablation.
Destruction of Lesions, Benign, 2-14 Lesions
Destruction by any method of 2 to 14 benign lesions. Includes cryotherapy, electrosurgery, or laser ablation of multiple benign lesions.
Joint Injection, Arthrocentesis, Single Joint
Therapeutic injection into a single joint or bursa for treatment of inflammatory arthritis, osteoarthritis, or other joint pathology. Includes aspiration and/or injection.
Splinting, Application of Prefabricated Splint
Application of a prefabricated or thermoplastic splint to immobilize and stabilize an extremity. Includes evaluation, fitting, and post-application instructions.
Venipuncture, Necessary Service
Venipuncture (blood draw) for diagnostic specimen collection. Separately billable when performed as a distinct service not included with E/M.
Upper Endoscopy with Biopsy
Esophagogastroduodenoscopy (EGD) with tissue biopsy. Includes anesthesia, visualization, biopsy collection, and post-procedure monitoring.
Colonoscopy with Biopsy
Colonoscopy with tissue biopsy collection. Includes visualization of entire colon, biopsy collection, and post-procedure monitoring.
Debridement, Skin Lesions, Single
Surgical removal and debridement of devitalized or damaged tissue from a single skin lesion including the lesion itself.
Debridement, Skin Lesions, 2 or More
Surgical removal and debridement of devitalized or damaged tissue from two or more skin lesions.
Repair of Superficial Wound, 2.5 cm or Less
Surgical repair (suture or staple closure) of a simple, superficial skin wound of 2.5 cm or less in length.
Repair of Complex Wound, Face
Surgical repair of a complex wound of the face including the eyelids, lips, and ears. May require layered closure or tissue approximation.
Arthrodesis, Talonavicular Joint
Surgical arthrodesis (joint fusion) of the talonavicular joint of the foot. Includes articular surface preparation and fixation.
Removal of Implanted Material
Surgical removal of implanted material (pins, screws, plates, wires) from bone and soft tissue.
Total Knee Replacement
Surgical replacement of the knee joint with prosthetic components including resurfacing of femur and tibia.
Cardiac Catheterization, Right Heart, With Imaging
Cardiac catheterization of the right heart chambers including hemodynamic measurements and angiographic imaging.
Total Abdominal Hysterectomy
Surgical removal of the uterus and cervix via abdominal incision, including exploration of abdominal cavity.
Cataract Removal, Intracapsular Extraction
Surgical removal of the cataract with removal of the intact lens capsule through incision.
Kidney Transplantation, Donor Nephrectomy
Surgical removal of kidney from living donor for transplantation. Includes dissection, isolation, and removal of renal vessels and ureter.
Tangential Biopsy of Skin, First Lesion
Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette), single lesion. Used for superficial skin biopsies where the specimen is obtained by horizontal slicing.
Removal of Skin Tags, Up to 15
Removal of skin tags, multiple fibrocutaneous tags, any area, up to and including 15 lesions.
Destruction of Benign Lesions, Up to 14
Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions, up to 14 lesions.
Removal of Impacted Cerumen (Ear Wax)
Removal impacted cerumen requiring instrumentation, unilateral. Manual removal of impacted ear wax using instruments, irrigation, or suction that requires physician skill.
Debridement, Subcutaneous Tissue, First 20 sq cm
Debridement, subcutaneous tissue (includes epidermis, dermis, and subcutaneous tissue); first 20 sq cm or less. Removal of devitalized tissue to promote wound healing.
Debridement of Nails, 6 or More
Debridement of nail(s) by any method; 6 or more. Trimming and debridement of dystrophic or fungal nails.
Avulsion of Nail Plate, Single
Avulsion of nail plate, partial or complete, simple; single. Removal of part or all of a nail plate, typically for ingrown nails or nail pathology.
Arthroscopic Shoulder Acromioplasty
Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament release when performed.
Knee Arthroplasty, Unicompartmental
Arthroplasty, knee, condyle and plateau; medial OR lateral compartment. Partial knee replacement surgery replacing only the damaged compartment.
Simple Repair, 2.6-7.5 cm
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.6 cm to 7.5 cm.
Puncture Aspiration of Abscess/Cyst
Puncture aspiration of abscess, hematoma, bulla, or cyst. Drainage of a fluid collection using needle aspiration technique.
Radiology
Chest X-ray, 2 Views
Frontal and lateral chest radiographs for evaluation of thoracic structures including heart, lungs, mediastinum, and pleura.
Lumbar MRI, Complete
Complete magnetic resonance imaging of the lumbar spine including all imaging planes and views for evaluation of spinal cord, nerve roots, and vertebral bodies.
Brain MRI, Complete
Complete magnetic resonance imaging of the brain including all imaging sequences and planes for evaluation of brain parenchyma, vasculature, and other intracranial structures.
Shoulder X-ray, 3 Views
Three-view shoulder radiographs including frontal, scapular Y, and axillary views for evaluation of shoulder joint, humerus, and scapula.
Chest X-ray, Single View
Radiologic examination of the chest, single view. A basic chest X-ray providing one projection, typically PA (posteroanterior) or AP (anteroposterior).
Knee X-ray, 1 or 2 Views
Radiologic examination of the knee, 1 or 2 views. Standard X-ray examination of the knee joint for evaluation of injury, arthritis, or other conditions.
CT Abdomen and Pelvis with Contrast
Computed tomography of the abdomen and pelvis with contrast material. A comprehensive cross-sectional imaging study of the abdomen and pelvis commonly used for abdominal pain, masses, and staging.
Ultrasound, Pelvic, Complete
Ultrasound, pelvic (non-obstetric), real-time with image documentation, complete. Used for evaluating pelvic organs including uterus, ovaries, and adnexa.
Ultrasound, Abdomen, Complete
Ultrasound, abdominal, real-time with image documentation, complete. Comprehensive abdominal ultrasound including liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and aorta.
Screening Mammography, Bilateral
Screening mammography, bilateral (2-view study of each breast), including computer-aided detection when performed.
Chest X-ray, 4+ Views
Radiologic examination of the chest, 4 or more views. Comprehensive chest X-ray study with multiple projections.
Ankle X-ray, Complete, 3+ Views
Radiologic examination of the ankle, complete, minimum of 3 views.
Lumbar Spine X-ray, 2-3 Views
Radiologic examination of the lumbosacral spine, 2 or 3 views.
Pathology/Lab
Comprehensive Metabolic Panel (CMP)
Clinical laboratory test measuring 14 analytes including glucose, electrolytes, kidney function, liver function, albumin, and total protein for comprehensive metabolic assessment.
Complete Blood Count (CBC), With Differential
Complete blood count with differential including white blood cell count with differential, red blood cell count, hemoglobin, hematocrit, and platelet count.
Influenza Virus Antigen, Single
Laboratory immunoassay testing for detection of influenza virus antigen (Type A or B) in respiratory specimen including nasopharyngeal swab, nasal aspirate, or throat swab.
Urinalysis, Non-Automated
Laboratory analysis of urine specimen including physical, chemical, and microscopic examination for evaluation of urinary tract pathology.
Urinalysis, Automated with Microscopy
Urinalysis by dipstick or tablet reagent with automated microscopy. A common point-of-care test performed during office visits for UTI symptoms, routine screening, and chronic disease monitoring.
Hemoglobin A1c (HbA1c)
Glycosylated hemoglobin (HbA1c) test. A critical laboratory test for diagnosing and monitoring diabetes mellitus, measuring average blood glucose over the preceding 2-3 months.
Glucose, Quantitative (Blood Sugar)
Glucose, quantitative blood test. A basic laboratory test for measuring blood sugar levels, used for diabetes screening, diagnosis, and monitoring.
Basic Metabolic Panel (BMP)
Basic metabolic panel. Includes glucose, BUN, creatinine, sodium, potassium, chloride, CO2, and calcium. A standard panel for evaluating kidney function, electrolytes, and blood sugar.
Complete Blood Count (CBC), Automated
Complete blood count (CBC), automated (hemoglobin, hematocrit, RBC, WBC, platelet count). Does not include differential. A basic hematology panel for screening and monitoring blood disorders.
Lipid Panel
Lipid panel consisting of total cholesterol, HDL cholesterol, and triglycerides. LDL is calculated. A standard screening and monitoring panel for cardiovascular risk assessment.
Strep A Test, Rapid
Infectious agent antigen detection by immunoassay, Streptococcus Group A. A rapid point-of-care test for diagnosing strep throat.
Chlamydia Detection, Amplified Probe
Infectious agent detection by nucleic acid (DNA or RNA), Chlamydia trachomatis, amplified probe technique. The standard screening test for chlamydia infection.
Collection of Capillary Blood Specimen
Collection of capillary blood specimen (e.g., finger, heel, ear stick). Used when a capillary specimen is collected for point-of-care or send-out laboratory testing.
Bacterial Culture, Any Source
Culture, bacterial; any other source except urine, blood, or stool, aerobic, with isolation and presumptive identification of isolates.
Urine Culture, Quantitative Colony Count
Culture, bacterial; quantitative colony count, urine. The standard culture for diagnosing urinary tract infections with colony count to determine clinical significance.
Thyroid Stimulating Hormone (TSH)
Thyroid stimulating hormone (TSH). The primary screening and monitoring test for thyroid function disorders.
Vitamin D, 25-Hydroxy
Vitamin D; 25 hydroxy, includes fraction(s), if performed. The standard test for assessing vitamin D status.
Culture, Screening Only
Culture, presumptive, pathogenic organisms, screening only. A screening culture test to identify the presence of pathogenic organisms.
TB Skin Test (PPD/Mantoux)
Skin test; tuberculosis, intradermal (Mantoux test). Placement and reading of a tuberculin skin test for tuberculosis screening.
Medicine
Immunization Administration, 1 Vaccine
Immunization administration including single antigen vaccine injection with patient counseling and documentation.
Immunization Administration, Each Additional Vaccine
Each additional vaccine antigen administered in addition to the first vaccine on the same service date.
Therapeutic Injection, Single Substance
Therapeutic injection of a single pharmaceutical substance administered intramuscularly, intravenously, or subcutaneously for treatment purposes.
Electrocardiogram (ECG), Complete
Complete 12-lead electrocardiogram including acquisition, recording, and tracing interpretation for assessment of cardiac electrical activity.
Psychotherapy, 60 Minutes
Psychotherapy provided to an individual patient for 60 minutes of face-to-face time for treatment of mental health conditions.
Esophageal Motility Study
Esophageal manometry study for evaluation of esophageal muscle function and pressure dynamics. Includes catheter placement and pressure recording.
IV Push, Single/Initial Substance
Therapeutic, prophylactic, or diagnostic injection, intravenous push, single or initial substance/drug. Administration of medication by IV push technique.
IV Infusion, Initial, Up to 1 Hour
Intravenous infusion for therapy, prophylaxis, or diagnosis, initial, up to 1 hour. Used for the first hour of IV infusion of a drug or substance.
Visual Acuity Screening
Screening test of visual acuity, quantitative, bilateral. A simple vision screening test performed using a standardized eye chart.
Immunization Administration, Child (First Component)
Immunization administration through 18 years of age via any route, first or only component of each vaccine or toxoid administered. Includes counseling by physician or qualified healthcare provider.
Immunization Administration, Intranasal/Oral
Immunization administration by intranasal or oral route, one vaccine (single or combination). Used for vaccines administered via nasal spray (FluMist) or oral route (rotavirus).
Specimen Handling/Transfer to Lab
Handling and/or conveyance of specimen for transfer from the office to a laboratory. Used when the practice collects a specimen and sends it to an outside laboratory for processing.
Speech/Language Treatment, Individual
Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual. Individual speech therapy session.
Speech-Language Evaluation, Complete
Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression.
Smoking Cessation Counseling, 3-10 min
Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes. Face-to-face counseling for tobacco cessation.
IV Hydration, Initial 31-60 Minutes
Intravenous infusion, hydration; initial, 31 minutes to 1 hour. Administration of prepackaged sterile fluids and electrolytes for hydration.
Influenza Vaccine, Age 3+, IM
Influenza virus vaccine, trivalent or quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use.
Unlisted Special Service/Procedure
Unlisted special service, procedure, or report. Used when no specific CPT code describes the service performed.
Supplies
Supplies and Materials Beyond Those Usually Included
Reporting code for supplies and materials (e.g., sterile trays, high-cost dressings, injectable medications for joint injection) that are not included in the basic E/M or procedural service.
Supplies and Materials
Supply and material reporting for items exceeding those usually included in the reported service.
Preventive Care
Preventive Visit, New Patient, Infant (Under 1)
Initial comprehensive preventive medicine evaluation and management of a new patient, infant under age 1. Includes age-appropriate history, examination, counseling/anticipatory guidance, and risk factor reduction interventions.
Preventive Visit, New Patient, Age 1-4
Initial comprehensive preventive medicine evaluation and management of a new patient, age 1 through 4 years. Includes comprehensive history, examination, counseling, and risk factor reduction.
Preventive Visit, New Patient, Age 5-11
Initial comprehensive preventive medicine evaluation and management of a new patient, age 5 through 11 years.
Preventive Visit, New Patient, Age 12-17
Initial comprehensive preventive medicine evaluation and management of a new patient, age 12 through 17 years. Adolescent preventive visit with age-appropriate assessments.
Preventive Visit, New Patient, Age 18-39
Initial comprehensive preventive medicine evaluation and management of a new patient, age 18 through 39 years.
Preventive Visit, New Patient, Age 40-64
Initial comprehensive preventive medicine evaluation and management of a new patient, age 40 through 64 years.
Preventive Visit, New Patient, Age 65+
Initial comprehensive preventive medicine evaluation and management of a new patient, age 65 years and older.
Preventive Visit, Established Patient, Infant
Periodic comprehensive preventive medicine reevaluation and management of an established patient, infant under age 1.
Preventive Visit, Established Patient, Age 1-4
Periodic comprehensive preventive medicine reevaluation and management of an established patient, age 1 through 4 years.
Preventive Visit, Established Patient, Age 5-11
Periodic comprehensive preventive medicine reevaluation and management of an established patient, age 5 through 11 years.
Preventive Visit, Established Patient, Age 12-17
Periodic comprehensive preventive medicine reevaluation and management of an established patient, age 12 through 17 years.
Preventive Visit, Established Patient, Age 18-39
Periodic comprehensive preventive medicine reevaluation and management of an established patient, age 18 through 39 years.
Preventive Visit, Established Patient, Age 40-64
Periodic comprehensive preventive medicine reevaluation and management of an established patient, age 40 through 64 years.
Preventive Visit, Established Patient, Age 65+
Periodic comprehensive preventive medicine reevaluation and management of an established patient, age 65 years and older.
Mental Health
Psychiatric Diagnostic Evaluation
Psychiatric diagnostic evaluation without medical services. An initial comprehensive assessment of a patient's mental health status, including history, mental status examination, and diagnostic formulation.
Psychiatric Diagnostic Evaluation with Medical Services
Psychiatric diagnostic evaluation with medical services. Initial comprehensive psychiatric assessment that includes medical evaluation components such as physical examination, medication review, and prescription of psychotropic medications.
Psychotherapy, 30 Minutes
Psychotherapy, 30 minutes with patient. Individual psychotherapy session of approximately 30 minutes (16-37 minutes face-to-face with the patient).
Psychotherapy, 45 Minutes
Psychotherapy, 45 minutes with patient. Individual psychotherapy session of approximately 45 minutes (38-52 minutes face-to-face with the patient).
Family Psychotherapy with Patient Present
Family psychotherapy (conjoint psychotherapy) with the patient present, approximately 50 minutes. Therapy involving the patient and one or more family members.
Brief Emotional/Behavioral Assessment
Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument.
Developmental Screening
Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.
Psychotherapy Add-on, 30 min with E/M
Psychotherapy, 30 minutes with patient when performed with an evaluation and management service. Add-on code billed with a primary E/M service.
Physical Therapy
Therapeutic Exercises
Therapeutic procedure, one or more areas, each 15 minutes: therapeutic exercises to develop strength, endurance, flexibility, and range of motion.
Manual Therapy Techniques
Manual therapy techniques (e.g., mobilization, manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.
Therapeutic Activities
Therapeutic activities, direct one-on-one patient contact, each 15 minutes. Use of dynamic activities to improve functional performance, incorporating use of multiple parameters (e.g., balance, coordination, posture).
PT Evaluation, Low Complexity
Physical therapy evaluation: low complexity. Requires a history with no personal factors and/or comorbidities that impact the plan of care, examination of body system using standardized tests, and clinical presentation with stable and/or uncomplicated characteristics.
PT Evaluation, Moderate Complexity
Physical therapy evaluation: moderate complexity. Requires a history with 1-2 personal factors and/or comorbidities, examination of body systems with standardized tests, and evolving or presents with changing characteristics.
PT Evaluation, High Complexity
Physical therapy evaluation: high complexity. Requires a history with 3+ personal factors and/or comorbidities, examination of body systems with standardized tests, and unstable or unpredictable clinical presentation.
Anesthesia
Anesthesia for Salivary Gland Procedures
Anesthesia for procedures on salivary glands, including biopsy. Includes general or regional anesthesia services for surgical procedures involving the salivary glands.
Anesthesia for Head/Neck Procedures
Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified.
Anesthesia for Chest Wall Procedures
Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum, not otherwise specified.
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