Coding Notes Billing Coding Pocket Guide

Providers Coding
Notes
Billing and Coding Pocket Guide
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1
General Billing and Insurance Guidelines
Patient Registration Form
The patient registration form is one of the most important forms in a medical practice. It contains all necessary information required for billing for services and procedures. This form should be updated yearly. Patient information should be reviewed and verified at each patient encounter to ensure that the practice has the most current and accurate information on file. Each item on the form should be verified by asking the patient, Do you still live at . . . instead of using a general statement such as Has anything changed since your last visit? A copy of the patients health insurance card, both front and back, should be copied during each visit. This form should contain the following information:
Data
Date Patients name Patients address Patients phone number
Reason
Required for billing purposes Required for billing purposes Required for billing purposes Required for billing purposes and to contact patient regarding appointments and testing results Required for billing purposes Required for billing purposes Required for patient identification purposes only Required for billing purposes
Patients date of birth Patients age Patients social security number Guarantors name, address, and phone number if patient is not guarantor Employers name, address, and phone number
Required for billing or if patient needs to be contacted during working hours

(Continued text on following page)
GENERAL
GENERAL
Data
Spouses name Spouses employers name, address, and phone number Insurance company name, address, and phone number Insurance identification and group numbers Person to be notified in case of emergency Referred by Patients signature Some forms will contain the following: List of current medications Past illnesses/surgeries Allergies
Reason
May be required for billing purposes May be required for billing purposes or if spouse needs to be contacted during working hours Required for billing purposes
Required for billing purposes Required in case of emergency Required for billing purposes and quality of care purposes Required for billing purposes
For clinical reasons
Review this form for completeness as this information is critical to the billing process. Any missing information should be completed by asking the patient questions. There are some key areas to look for that may be tell-tale for nonpaying patients. These areas are: I Incomplete information on the form I Questionable employment information I No phone number I Post office box listed in lieu of a street address I Motel address I No insurance information I No referral information
3
A potential nonpaying patient may sometimes be identified by items on the previous list. If any of the listed elements exist, extra care should be taken to obtain accurate and complete information.
Patient Encounter Form

One of the most important factors in medical billing is an accurate billing form. This form has many names, patient encounter form, superbill, fee slip, charge slip, billing form, etc. This form is used to communicate the patient visit charges to the billing personnel. All information on this form must be accurate and complete and contain the following information: I Patients name I Patients address I Patients home phone number I Patients account number/medical record number I Guarantors name I Patient/guarantors insurance company and identification number I Date of service I Date of birth I Provider name I Diagnosis section I CPT code section I Space for next appointment I Space for provider to complete with any studies that may need to be ordered This form must be reviewed and updated twice a year when the codes are updated. Deleted codes, new codes, and revised codes should be updated when necessary. The patients should be questioned at each visit to identify any changes that may have occurred since their last visit.
GENERAL
GENERAL
Life Cycle Of An Insurance Form

New Patient, Office
A new patient is one who has not been seen by the physician or any physician in that specialty group within the last 3 years. These visits are reported using codes 9920199205. Detailed information regarding these codes can be found in Tab Two. The steps involved in an office visit for a new patient are:
Step 1
The patient arrives at the office. The patient is either interviewed or completes a patient registration form to obtain information listed to the right. If the patient registration form is not completed in its entirety, the office staff should question the patient in order to obtain all the necessary information. Some offices will have the patient complete a history form in addition to the registration form.
Patient information
Patients name Address Phone number Place of employment Spouse name, if applicable Emergency contact information Allergies Reason for the visit Type of insurance Address of insurance Sign a record release form, if applicable
OR Step 1
The patient calls the office to make an appointment. Information is collected during the phone call to obtain information as listed to the right. Patient
Patient information
Patients name Address Phone number Place of employment Spouse name, if applicable
*Current Procedural Terminology 2006 American Medical Association, All Rights Reserved. (Continued text on following page)
5
Step 1
is asked to bring his/her insurance card to the office visit.
Patient information
Emergency contact information Allergies Reason for the visit Type of insurance Address of insurance
Step 2
The patient arrives at the office with his/her insurance card.
Insurance
Patient registration form is completed. Both sides of the insurance card are copied. This copy is placed in the patients chart. All patients with insurance must sign an authorization of benefits form to allow the practice to release information necessary for payment of the claim and to request that payment be made directly to the physician practice. Depending on the insurance, verification of coverage may be necessary. If this is a specialty office and the patient has a managed care plan, a referral is necessary for treatment. Most managed care plans have co-pays, which must be paid at the time of the visit. If the patient has Medicare, a deductible must be met at the beginning of each calendar year. If the patient has Medicaid or other insurances, there may be deductibles and co-pays that are necessary to be paid. This information can be found on the insurance card. If the patient is a child, be aware of the birthday rule. If both parents carry insurance, the child will be covered under the parent whose birthday is first in a calendar year.
GENERAL
GENERAL
Step 3
A patient chart is created with the forms listed to the right.
Create the chart

Place patient registration form and copy of insurance card in chart. Place all other authorization forms in the chart. Any forms used by the practice to record clinical information, such as medication logs, progress note forms, office visit templates, history forms, problem lists, etc. Apply appropriate labels to the chart, such as type of insurance, year of the visit, alphabetize labels indicating the patient name for faster filing.
Step 4
Data Entry
A patient account is created in the computer using the following the information collected from the patient registration form and insurance card.
Step 5
A patient encounter form is generated and placed on the front of the patients chart. This document becomes the source of information for billing. This document has many names, some of which you can see in the column to the right.
Generate a patient encounter form

Fee slip Superbill Charge slip Billing form Charge capture form
The patient is seen by the physician and is discharged from that office visit.
7
Established Patient, Office
An established patient is one who has been seen by the physician within the last 3 years. These visits are reported using codes 9921199215. Detailed information regarding these codes can be found in Tab Two. The steps involved in an office visit for an established patient are as follows:
Step 1
Scheduling of appointment
The patient either schedules a follow-up appointment while at the office, or calls the office for an appointment.
Step 2
Preauthorization of services or procedures
If the physician is a specialist, the staff must check the preauthorization to be sure it has not expired. If the referral has expired, it will be necessary to obtain a new form from the primary care physician. Most physician offices submit referrals electronically as opposed to paper.
Step 3
Review and update patient registration form
Be sure that all information listed on the patient registration form is accurate and complete. These forms should be completely updated yearly, however, at each patient visit, the staff should inquire as to any changes that may have occurred in the patients insurance, address, employment, etc.
Step 4
Collect co-pays and deductibles
All co-pays should be collected at the time of patient check-in. On Medicare patients, deductibles are not collected at the time of the service. Medicare is billed and any deductible still due is deducted from the physician payment. This is stated on the Explanation of Medicare Benefits. The patient is then billed for the deductible amount.
*Current Procedural Terminology 2006 American Medical Association, All Rights Reserved.
GENERAL
GENERAL
Generate a patient encounter form
Fee slip Superbill Charge slip Billing form Charge capture form
Step 5
A patient encounter form is generated and placed on the front of the patients chart. This document becomes the source of information for billing. This document has many names, some of which you can see in the column to the right.
The purpose of the patient encounter form is to communicate charges (services and procedures the patient received) and diagnoses to the billing department. This form is also used to inform the staff of any diagnostic studies that are to be ordered and to indicate any follow-up appointments that may be necessary. The patient is seen by the physician and is discharged from that office visit.
Patient Discharge Step 1 Physician practices will have check-out staff procedures. Step 2 Charges
The patient charges are totaled on the patient encounter form.
Posting
The patient charges are posted to the patients account in the computer system.
Step 3
Patients financials
Payment
If no insurance, the patient is expected to pay at the time of the service. If the patient has a co-pay that has not been collected during check-in, they will be expected to pay at discharge.
9
Step 3 Payment
If the patient has insurance, but it does not cover office visits, the patient is expected to pay at the time of service. Any payment made is then posted to the patients account. The purpose of the CMS 1500 claim form is to create a standard for collecting Medicare information. The most common claim denials based on the claim form is incomplete or inaccurate diagnosis codes (Box 21) and incorrect place of service codes (Box 24b). The CMS 1500 form information has been completed, is accurate, and ready for submission when all items in the following table have been completed.
Step 4 Step 5
For filing paper claims only
Generate insurance form (CMS 1500 Form) Attachments

Copy and staple any attachments that are necessary to the CMS 1500 form. If no attachments are necessary, claim can be sent electronically. Attachments are needed if there is a concurrent care situation, if an unusual service or procedure was performed.
Step 6
Signatures are an important part of the claim form.
Signature, patient
The patient must sign the CMS claim form if a form is being sent by paper claim. On claims where the patient has signed an authorization form, the phrase SOF or signature on file can print in box 12 on the CMS 1500 paper claim. If claim is being submitted electronically, SOF or signature on file can print in box 12. When an illiterate or physically handicapped patient signs by a mark (X), a witness must enter his or her name and address next to the mark on the claim form.
GENERAL
GENERAL
Step 6 Signature, patient
A representative may sign the claim on the patients behalf if the patient is physically or mentally unable to sign. When this occurs, the signature line must indicate the patients name followed by the word by, the representatives name, address, relationship to the patient, and the reason the patient cannot sign. If there is no signature, the claim will not be transferred automatically to Medigap.
Step 6
Signatures are an important part of the claim form.
Signature, provider
The claim must be signed by the provider or an authorized representative if the claim is being generated on paper. No signature is necessary if the claim is being sent electronically. A signature stamp may be used if the providers name is typed below.
Step 7
Submitted claims should be tracked.
Insurance tracking
If the claim is manually produced (paper), an insurance log must be kept with information such as the patient name, amount of claim, insurance carrier, and date submitted. If the claim is submitted electronically, the computer will provide the practice with a report.
Step 8
Submit claim
Either mail or submit the claim electronically. Claims should be submitted daily for better cash flow.
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11
Step 8 Submit claim
When submitting a claim electronically, run a presubmission report to identify any errors, which may cause denials and correct them before submission.
Step 9
A check along with an explanation of benefits (EOB) is mailed to the provider if the provider is participating.
Check is mailed
Information is taken from EOB and posted to the patients account. Any claim denials must be thoroughly reviewed, corrected, and resubmitted if possible. Automatic rebilling of claims to the carrier without investigation and analysis of the claim can result in duplicate claims and duplicate payments. This can be construed as fraudulent billing.
Preauthorization/Precertification
Preauthorization: Some insurance carriers require permission to perform a service or procedure before it is done. This preauthorization identifies whether the insurance program will allow the service or procedure to be performed based on the medical necessity information provided by provider. Precertification: Identifies whether the service or procedure is covered under the patients insurance plan. It is not based on the medical necessity of the procedure, but on whether or not the patient has coverage. Although proper steps have been taken to obtain preauthorization/precertification, there is no guarantee that services will be covered.
GENERAL
GENERAL
Documentation
Documentation is the story of patient visit, a legal document, and serves as the groundwork for reimbursement of health-care services and procedures. It explains to the carrier what you did, why, and how. In Tab 2, the Evaluation and Management codes are discussed in detail to illustrate the various components necessary for choosing the appropriate level of service. Proper documentation will: I Allow your billing staff to identify the services and procedures that you performed. I Allow for appropriate reimbursement.
General Instructions for Good Documentation
I Make sure that you have the correct chart. I Be sure to write the patients name on each page when documenting (this can be done by office staff). I Make sure all entries in the medical record are legible and preferably written in black ink. I Be sure to date, sign (hard copy, or authenticate an electronic signature) each entry. I For inpatient records, document the time using military time and the service you are on, i.e., medicine, surgery, cardiology, etc. I Use standard abbreviations (it is a good idea to obtain a listing from the hospital; most use Stedmans). I Avoid canned verbiage. No two patients are the same. I Avoid vague language such as, routine visit, follow-up, doing well, check up, exam unchanged, etc. I Make sure there is a record of all prescriptions refilled and all telephone calls with patients. I Be sure to either dictate or hand write the documentation as soon as possible after the patient encounter (memories fade). I Document specifics of any unusual procedure or service that requires more time than usual (document such things as the time it took, what you did that took the extra time, or any difficulties that you may have had either with the procedure
12
13
I I I I itself or the patient). These procedures would be reported using the 22 modifier (see Tab 7). Document the difference between an acute and a chronic condition. Be sure to include your reasoning to support the medical necessity for the visit. Document nonresponses to treatments or medications and any newly developed symptoms. Do not dictate the phrase Dictated, not read on your dictations. You are responsible for verifying that the dictation is true and correct.
Completion of a CMS 1500 Form

The CMS 1500 was revised to accommodate many changes including addition of the NPI number for providers. The revisions began in June of 2004 and the new form was released in January of 2007.
CMS Areas
Box 1: Type of insurance
Completion Instructions
Indicate the type of health insurance coverage: Medicare, Medicaid, Champus/Tricare, Champva, group health plan, FECA/black lung, other Box 1a: Insureds Contains the patients health insurance number ID number Box 2: Patient Enter patients name exactly as it is on the name insurance card Address, phone number Do not leave a space between a prefix and a name For hyphenated names, capitalize both names and separate by a hyphen Leave a space between the last name and a suffix
GENERAL
GENERAL
CMS Areas
Box 3: Patients date of birth and sex
Enter the date of birth using two digits for the month, two for the day, and four for the year. Check the box that indicates the sex of the patient; the sex of the patient must be valid for the diagnosis of the patient For Medicare: Enter the name of the insured person only if that persons insurance is primary to Medicare; if Medicare is primary, leave it blank Enter the complete mailing address and telephone number If the patient lives in a nursing home, list the nursing home address as the patients Do not place punctuation in a city name that contains an abbreviation This relationship is the primary insured; choices are self, spouse, child, and other Only complete this box if Box 4 is completed; otherwise leave it blank Only complete this box if Box 4 is completed, otherwise leave it blank. Place the patients marital status and employment or student status The choices for marital status are single, married, and other The choices for employment are employed, full-time student, and part-time student Enter the name of the insured person who is enrolled in a Medigap policy if the name is different from the name shown in Box 2; enter the word same if it is the same
Box 4: Insureds name
Box 5: Patients address
Box 6: Patient relationship to the insured Box 7: Insureds address Box 8: Patients status
Box 9: Other insureds name
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15
CMS Areas
Box 9a: Other Insureds Policy or Group Number Box 9b: Other insureds date of birth, sex Box 9c: Employers Name or School Name Box 9d: Insurance plan name or program name Box 10: Is patients condition related to:
Enter the policy or group number of the other insured (Box 9)
Enter the 8-digit date of birth, two digits for the month, two digits for the day, and four digits for the year Enter the name of the other insureds employer or school. Enter the other insureds insurance plan or program name If the patients condition is related to employment, an automobile accident, or some other accident This information is used for coordination of benefits If the patients condition is not related to any of these, place an X in the no box for each item Yes or No Yes or No Yes or No Enter information when asked by local carrier Enter the insureds policy, group, or FECA number. If Box 4 is completed, then this field needs to be completed
Box 10a: Employment Box 10b: Auto accident Box 10c: Other accident Box 10d: Reserved for local use Box 11: Insureds policy, group, or FECA number
GENERAL
GENERAL
CMS Areas
Box 11a: Insureds date of birth, sex
Date of birth and sex of the individual who carries the insurance
Box 11b: Insureds Name of the employer of the individual who employers name carriers the insurance Box 11c: Insurance plan name or program name Box 11d: Is there another health benefit plan? Box 12: Patients or authorized persons signature Box 13: Insureds or authorized persons signature Box 14: Date of current illness, injury or pregnancy Name of insurance plan of the individual who carriers the insurance Answer as to whether or not there is a secondary insurance Enter the signature of the patient or the patients representative and the date This signature allows for the release of information necessary to process the claim The insureds signature must be entered in this block; if the insureds signature is on file, enter SOF Enter the date if the current illness (first symptom), injury (accident), or pregnancy (last menstrual period) If an accident date is entered, complete Box 10b or 10c For chiropractic services, enter the date of the initiation of the course of treatment and the x-ray date in Box 19 Box 15: If patient has had same or similar illness Do not complete this area for Medicare patients For all other insurers, the date should match the same date or be later than the date entered in Box 24a
16
17
CMS Areas
Box 16: Dates patient unable to work in current occupation
This block provides the dates that the patient was employed but unable to work This field MUST be completed for all Workers Compensation claims. Box 17: Name of Enter the name and credentials of the referring provider professional who requested the service or other source Box 17a: ID number The qualifying number should be listed just of referring or left of the other ID number of the referring ordering provider or ordering provider. The qualifying numbers are: OB State license number 1B BS provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS ID number E1 Employers ID number G2 Provider commercial number LU Location number N5 Provider plan network ID number SY SSI number X5 State industrial accident provider number ZZ Provider taxonomy Box 17b: NPI Enter the NPI number of the referring or number ordering provider Box 18: Enter the admission and discharge dates Hospitalization If the services were rendered in a facility other dates related to than the patients home or a physicians current services office, provide the name and address of that facility in Box 32 Box 19: Reserved Enter information when asked by local carrier. for Local Use
GENERAL
GENERAL
CMS Areas
Box 20: Outside diagnostic services/ charges
Place a Yes in the box when a provider, other than the provider billing for the service, performed the diagnostic test; when Yes is checked, Box 32 must be completed Enter the purchase price of the tests in the charges column; show the dollars and cents, omitting the dollar sign Enter the ICD-9-CM code for the diagnoses, conditions, problems, or other reasons for the visit Report at least one diagnosis per claim Only four diagnosis codes can be submitted Enter the codes and original Medicaid reference number of a Medicaid claim This area must be completed when resubmitting a claim to Medicaid Enter the number assigned by the peer review organization For laboratory services performed by a physician office lab (POL), enter the 10-digit CLIA certification number Enter the beginning and ending date of service for the entire period reflected by the procedure code. Enter the appropriate 2-digit place of service code Yes or No Enter the appropriate CPT or HCPCS code for the service, procedure, or supply
Box 21: Diagnosis or nature of illness or injury Box 22: Medicaid resubmission
Box 23: Prior authorization number
Box 24a: Date(s) of service Box 24b: Place of service Box 24c: EMG Box 24d: Procedures, service, or supplies
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19
CMS Areas
Box 24e: Diagnosis pointer Box 24f: Charges
Enter the appropriate diagnosis code reference number (pointer) that is linked to the service, procedure, or supply Enter the amount charged by the provider for each of the services or procedures listed on the claim Do not bill a flat fee for multiple dates of service Enter the number of days or units of procedures, services, or supplies listed in Box 24d Stands for early periodic screening, diagnosis, and treatment services Enter Yes or No These services apply only to children who are 12 or younger and receive medical benefits through Medicaid
Box 24g: Days or units Box 24h: EPSDT
Box 24i: ID qualifier
Enter the qualifier identifying if the number is a non-NPI. The qualifying numbers are: OB State license number 1B BS Provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS ID number E1 Employers ID number G2 Provider commercial number LU Location number N5 Provider plan network ID number SY SSI number X5 State industrial accident provider number ZZ Provider taxonomy
GENERAL
GENERAL
CMS Areas
Box 24j: Rendering provider number Box 24: Supplemental information (gray area)
Enter the number of the rendering physician Supplemental information such as anesthesia duration in hours and/or minutes with start and end times, narrative descriptions of unspecified codes, NDC for drugs, vendor product numbers, product numbers for Health Care Uniform Code Council, can be entered in the shaded areas of this box Enter the tax ID number or social security number of the physician or supplier Enter the patients account number in this area; this will then be referenced on the explanation of benefits for easier posting of monies to the patient account Check Yes when the physician accepts assignment for the claim Enter the total amount charged for all services, procedures, and supplies in Boxes 24f, lines 1 through 6 Enter the dollars and cents without the dollar sign Enter the dollar amount paid toward the total cost of the service Enter the dollar amount due after subtracting the amount paid If the claim is Medicare, leave this area blank The provider or his or her representative must sign the providers name A stamp may be used, but the providers full name must be typed below the stamp
Box 25: Federal tax ID number Box 26: Patients account number Box 27: Accept assignment? Box 28: Total charge
Box 29: Amount paid Box 30: Balance due Box 31: Signature of physician or supplier, including degrees or credentials
20
21
CMS Areas
Box 32: Service facility location information Box 32a: NPI number Box 32b: Other ID number
If services were provided in a hospital, clinic, laboratory, or any facility other than the physicians office or the patients home, this area must be completed Enter NPI number of the service facility location Enter the two digit qualifier identifying the non-NPI number followed by the ID number The qualifying numbers are: OB State license number 1B BS Provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS ID number E1 Employers ID number G2 Provider commercial number LU Location number N5 Provider plan network ID number SY SSI number X5 State industrial accident provider number ZZ Provider taxonomy Enter the billing name, address, and telephone number of the physician or supplier who furnished the service
Box 33: Physicians suppliers billing names, address, zip code, phone number
GENERAL
GENERAL
CMS Areas
Box 33a: NPI number Box 33b: Other ID number
Enter NPI number of the service facility location Enter the two-digit qualifier identifying the non-NPI number followed by the ID number. The qualifying numbers are: OB State license number 1B BS Provider number 1C Medicare provider number 1D Medicaid provider number 1G Provider UPIN number 1H CHAMPUS ID number E1 Employers ID number G2 Provider commercial number LU Location number N5 Provider plan network ID number SY SSI number X5 State industrial accident provider number ZZ Provider taxonomy
Place of Service Codes

When submitting a claim for reimbursement, a place of service code must be placed in Item 24b on a CMS 1500 form. Not all of the codes listed below are approved by all carriers. When performing the billing function, the carrier should be contacted to verify that the place of service code is valid.
22
23
Code
03 04
Type
School Homeless shelter
Description
Service is provided at a school Service is provided at a shelter that serves as temporary housing for the patient Service is provided at a facility that is operated by the Indian Health Service where patients are not admitted Service is provided at a facility that is operated by the Indian Health Service where patients are admitted as outpatients or inpatients Service is provided at a facility that is operated by the Indian Health Service under a 638 agreement, which provides diagnostic, therapeutic, and rehabilitation services to those who are not admitted Service is provided at a facility that is operated by the Indian Health Service under a 638 agreement, which provides diagnostic, therapeutic, and rehabilitation services to those who are admitted as outpatients or inpatients Service is provided in an office setting Service is provided in the patients or caregivers home
05
06
Indian Health Service/Free Standing Facility Indian Health Service/Freestanding facility
07
Tribal 638 Freestanding facility
08
Tribal 638 Freestanding facility
11 12
Office Home
GENERAL
GENERAL
Code
13
Type
Assisted-living facility
Description
Service is provided in a residential facility with selfcontained living units that provides support 24 hours a day; this facility has the capacity to arrange for other services if needed Service is provided at a shared living residence, where patients receive supervision and other services such as social, behavioral, and custodial Service is provided at a facility that moves from place to place to provide preventive services, screening, diagnostic, and treatment services Service is provided at a facility, separate from a hospital emergency room (ER), where patients can be diagnosed and treated for illness or injury; these patients require immediate medical attention Service is provided at a hospital Service is provided at a portion of the hospital that provides diagnostic, therapeutic, and rehabilitation services to patients who do not require admission to the hospital Service is provided at a hospital emergency department
14
Group home
15
Mobile unit
20
Urgent care facility
21 22
Inpatient hospital Outpatient hospital
23
Emergency Room-Hospital
24
25
Code 24 Type Ambulatory surgical center Description Service is provided at a freestanding facility where surgical and diagnostic services are provided on an ambulatory basis; cannot be provided in a physicians office
Service is provided at a facility, separate from a hospital or physicians office, where maternity facilities are available Service is provided at a facility operated by the Uniformed Services Service is provided at a facility that provides inpatient skilled nursing care Service is provided at a facility that provides patients with skilled nursing care and related services Service is provided at a facility that provides room and board and other assistance to patients on a long-term basis without a medical component Service is provided at a facility other than the patients home, where palliative and supportive care for the terminally ill is provided A land vehicle equipped to provide transportation and lifesaving care to patients
25
Birthing center
26
Military treatment facility Skilled nursing facility Nursing facility
31
32
33
Custodial care
34
Hospice
41
Ambulance: land
GENERAL
GENERAL
Code
42
Type
Ambulance: air/water Independent clinic
Description
An air or water vehicle equipped to provide transportation and life-saving care to patients Service is provided at a clinic, which is not part of a hospital that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to patients Service is provided at a facility located in a medically underserved area that provides Medicare patients with preventive care under the direction of a physician Service is provided at a facility that provides inpatient psychiatric care for the diagnosis and treatment of mental illness on a 24-hour basis Service is provided at a facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full-time hospitalization, but who need broader programs that are not offered as outpatients
49
50
Federally qualified health center
51
Inpatient psychiatric facility
52
Psychiatric facility: partial hospitalization
26
27
Code
53
Type
Community mental health center
Description
Service is provided at a facility that provides the following services: outpatient services for children, elderly, individuals who are chronically ill, and residents of the center who were discharged from inpatient treatment; day treatment, partial hospitalization, screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission and consultation and education services Service is provided at a facility that provides health-related care and services above the level of custodial care to mentally retarded patients Service is provided at a facility that provides treatment for substance abuse to live-in residents who do not require acute medical care Service is provided at a facility for psychiatric care that provides a total 24-hour therapeutically and professionally staffed group living and learning environment Service is provided at a facility that provides treatment for substance abuse on an ambulatory basis
54
Intermediate care facility/mentally retarded
55
Residential substance abuse treatment facility
56
Psychiatric residential treatment center
57
Nonresidential substance abuse treatment facility
GENERAL
GENERAL
Code
60
Type
Description
Mass immuniza- Service is provided at a facility where tion center providers administer pneumococcal pneumonia and influenza vaccines and submit these services for billing; can be a public health center, pharmacy, or mall Comprehensive inpatient rehabilitation facility Service is provided at a facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities; services include physical therapy (PT), occupational therapy (OT), speech pathology, psychological services, and orthotics and prosthetics Service is provided at a facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities; services include PT, OT, speech pathology, psychological services, and orthotics and prosthetics Service is provided at a facility other than a hospital, which provides dialysis treatment, maintenance, and/or training Service is provided at a facility maintained by the state or local health departments that provides ambulatory primary care under the direction of a physician
61
62
Comprehensive outpatient rehabilitation facility
65
End-stage renal disease treatment facility State or local public health clinic
71
28
29
Code
72
Type
Rural health clinic
Description
Service is provided at a facility, which is certified as a rural underserved area, that provides ambulatory primary care under the direction of a physician Service is provided at an independent laboratory that is certified to perform diagnostic and/or clinical tests Other place of service not identified
81
Independent laboratory
99
Other place of service
Claims Submission Issues

There are some common problems identified with claims submissions: I Incorrect insurance number I Incorrect physician NPI number I Submission to an incorrect carrier I Incorrect diagnosis code (missing, incomplete) I Patients name, address, etc. as listed does not match insurance carrier records I Gender of patient is incorrect I Incorrect date of service I Incorrect place of service code I Incorrect or missing modifier(s) I Incorrect units billed I Missing provider ID number I Illegible claim form
GENERAL
GENERAL
Explanation of Benefits (EOB)
An EOB or remittance advice identifies which services, procedures, and/or supplies were paid and which were denied. All denials will contain a reason code that fully explains the reason for denial. An EOB contains the following information:
Components of an Explanation of Benefits

Patient Name Patient ID number or HIC number Claim processing ID number Provider name Date of service Procedure code Diagnosis code Allowable charge Submitted charge What portion is deductible and/or co-pay What is paid and to whom Patient responsibility amount If no payment, the reason code for the nonpayment EOBs will not be sent to providers who do not accept assignment on claims. This is prohibited by the Federal Privacy Act of 1974. In this case, the EOB will be sent to the patient. If an appeal is required on a non-assigned claim, the patient must provide the EOB along with a letter stating the provider is permitted to assist in the appeal. The EOBs should be reviewed periodically to ensure that the provider is receiving accurate reimbursement.
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31
Denial of Claims
There are some common denials identified with claims submissions. Below you will find a listing with a recommendation to follow.
Rejected claims
Recommendation
Claims are many times Review all claim information for rejected due to incorrect or accuracy and completeness invalid information (date of before submission. Correct all birth, transposed numbers, rejected claims and resubmit. provider numbers, dates of service, incorrect gender, etc.) submitted to the carrier.
Delays in payment
Claims that are delayed can result due to claim being in process, where the carrier is awaiting additional information requested from the provider or beneficiary.
Recommendation
Correct claims quickly and resubmit so that cash flow is not interrupted. Claims that have been suspended awaiting information from the patient are more difficult to handle. Once the practice verifies that the delay lies with the patient, the practice should call the patient to suggest perhaps that they could help to provide this information.
Service was not covered by insurance

Some services are not considered to be a covered service, i.e., hearing test, eyeglasses, preventive medicine services, etc.
Recommendation
Send the patient a letter explaining that the claim was denied due to lacking coverage. This charge now becomes the patients responsibility.
GENERAL
GENERAL
Service provided was for a pre-existing condition
Some services cannot be reimbursed as the patient has a pre-existing condition (a condition for which they have already obtained care).
Recommendation
When the patient presents to the office as a new patient, ask about any pre-existing conditions. When performing a service or procedure that may fall under that condition, always check with the carrier to see if a pre-existing clause exists. If so, discuss the charge with the patient to identify whether or not the patient wants to proceed with the understanding that they will have to pay.
Deductible is not met

The patient is responsible for a certain dollar amount of deductible each year. Payment cannot be made until that deductible is met.
Recommendation
Ask the patient when they arrive for their appointment whether or not they have seen any other physicians since January 1 of that calendar year. This may provide some insight into what may have already been applied to the deductible. The best practice is to submit the bill to the insurance carrier and to review the EOB/ remittance advice to identify what dollar amount has been applied to the deductible. Once that figure is obtained, bill the patient for the deductible amount.
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33
Check Verification
A personal check is the most common form of payment in a medical office. Important facts regarding checks: I Always check the name and address on a personal check against the patients drivers license. I On any suspicious or out-of-town check, call the bank to verify that the funds are available. It is a good practice not to accept out-of-town checks; however, some practices are located in resort areas where out-of-town checks are common. In this case, attempt to have the patient pay by credit/debit card. I Do not accept third-party checks. I Do not cash checks over the amount due to give the patient cash back. I Do not accept a check in which the patient has inscribed PAYMENT IN FULL on the check. Once this check is cashed, it could be argued that no additional payment is needed. I Be sure the check is signed. If the unsigned check is from an established patient and merely an oversight, the practice should try to reach the patient and request that they stop by to sign the check. If it is difficult for the patient to return to sign the check, it can be handled in the following manner: I Write the word over on the signature line of the check. I On the back of the check in the endorsement area, write Lack of signature guaranteed, the practices name, and ones own name and title. This tells the bank that the practice will accept the loss in such a case where the patient would not honor the check.
Returned Checks
The most common reason for a check to be returned, is for nonsufficient funds (NSF). When this occurs, the following steps should be followed: I Redeposit the check or call the patient to see if the check can be redeposited. Most banks will allow a redeposit one time.
GENERAL
GENERAL
I If the check cannot be redeposited, ask the patient how they would like to cover this outstanding balance. Credit card, debit, cash, etc. I If the check is returned after the second deposit, call the patient and ask how they intend to resolve this matter. If this phone call becomes difficult send a letter demanding payment. This letter should include the following information: I Check date I Check number I The bank on which it was drawn I The name of the person who wrote the check I The name of the person who the check was payable to I The amount of the check I The number of days the patient has to correct the matter Some offices charge an additional administrative fee for returned checks. This amount would also have to be included in the letter.
Financial Hardship
When patients have true financial problems and inability to pay, a reasonable attempt must be made to collect the fee. A reasonable attempt to collect would be demonstrated by the following: I Any collection process used to collect an amount from a nonMedicare patient I Patient statements are sent to either the patient or guarantor I Collection letters or telephone calls in an effort to collect payment; all telephone calls should be documented to create a paper trail Once it has been determined that the patient is a true hardship case, the provider must determine the patients ability to pay through a review of additional information requested from the patient. I Request a copy of the patients tax form from the previous year or a copy of their W-2 or statement of earnings from the Social Security Administration I Some practices have developed financial determination forms for the patient to complete
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35
Unpaid Claims
An Aged Trial Balance report should be obtained from the practice computer. This report should be used to follow up on all unpaid claims. This report can be run by the insurance carrier or as one general report. Step 1 Run computer-generated Aged Trial Balance report. Report can be generated with the following parameters: I By insurance carrier I By provider I By codes I By dollar amount I By practice (includes all providers, all codes, all carriers) Begin follow-up by starting with the largest dollar amount listed and continue through the smallest amount. If no EOB was received, call carrier to obtain status of claim. If EOB was received, review the EOB to ascertain the reason for the denial. If claim requires additional information from the provider, this should be completed and then resubmitted. Follow up on denial reason code. Correct error and resubmit. Never resubmit a claim without proper investigation into why it has not been paid.
Step 2
Step 3a Step 3b Step 4a
Step 4b Step 5
GENERAL
GENERAL
Insurance Commissioner
There is an insurance commissioner in each state where insurance problems can be reported for further action. Examples of some of these problems are: I Delays in payment by third-party carriers I Incorrect denial of claims I Incorrect termination of a policy Have information available when contacting the commissioner. Such information would be: I Patient name, address, phone number I Insureds name address, phone number I Name of insurance company I Policy number I Problem
Collections
Statute of Limitations
Each state has a statute of limitations, which sets a time limit* on the maximum time one has to collect a debt. Consult the table below to check this law.
State
AK AL AR AZ CA CO CT DC DE
Oral Agreements
6 6 3 3 2 6 3 3 3
Written Contracts
6 6 5 6 4 6 6 3 3
Promissory Notes
6 6 6 5 4 6 6 3 6
Open Accounts
6 3 3 3 4 6 6 3 3
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37
State
FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH NJ NM NV NC ND NY OH
Oral Agreements
4 4 6 5 4 5 6 3 5 10 6 3 6 6 6 5 3 5 4 3 6 4 4 3 6 6 6
Written Contracts
5 6 6 10 5 10 10 5 15 10 6 3 6 6 6 10 3 8 5 3 6 6 6 3 6 6 15
Promissory Notes
5 6 6 5 10 6 10 5 15 10 6 6 6 6 6 10 3 8 6 6 6 6 3 5 6 6 15
Open Accounts
4 4 6 5 4 5 6 3 5 3 6 3 6 6 6 5 3 5 4 3 6 4 4 3 6 6
GENERAL
GENERAL
Oral Agreements
3 6 4 15 10 6 6 4 4 3 6 3 6 5 8
State
OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
*
Written Contracts
5 6 6 15 10 6 6 4 6 5 6 6 6 10 10
Promissory Notes
5 6 4 10 3 6 6 4 6 6 5 6 10 6 10
Open Accounts
3 6 6 10 3 6 6 4 4 3 6 3 6 5 8
Reported in years.
Collection Abbreviations Abbreviation

Atty B Bal BTTR C CB CLM DFB
Description
Place with Attorney Bankrupt Balance Best time to reach Collections Call back Claim Demand for balance
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39
Abbreviation
DC EOM EOW FN HSB HHC HU INS IP L1, L2, L3 LB LM LMVM MR NA NFA NP NSF PA PH PF PM PMT PN POE POW PP PT S SEP SK
Description
Disconnected End of month End of week Final Notice Husband Have husband call Hung up Insurance Insurance pending Letter 1, letter 2, letter 3 Line busy Left message Left message, voice mail Mail return No answer No forwarding address No phone Nonsufficient funds Payment arrangement Phones Payment in full Payment in mail Payment Private number Place of employment Payment on the way Partial payment Patient Spouse Separated Skipped town
GENERAL
GENERAL
Abbreviation
TW UE UTC VE VI
Description
Talked with Unemployed Unable to contact Verified employment Verified insurance
Bankruptcy
Some patients file for bankruptcy in order to obtain relief of their debts. The types of bankruptcy are:
Type
Chapter 7
Description
All nonexempt assets of the patient are sold with the proceeds distributed to the creditors. Secured creditors are first to be paid. Unsecured (like medical bills) are last to be paid. This is considered an absolute bankruptcy in which many or all debts are wiped out. Not relevant for medical bills. Used for reorganization of a town. Not relevant for medical bills. Used for reorganization of a business, when they want to continue doing business. Used for reorganization for a farmer who cannot meet financial obligations. Referred to as a wage earners bankruptcy. Protects the wage earner from creditors while the wage earner makes arrangements to repay all or some of the debts over 35 year. At the end of 35 years, the balance of what is owed on most debts is erased. Portion the bills (about 75%) over a fixed period.
Chapter 9 Chapter 11
Chapter 12 Chapter 13
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Overpayments
An overpayment can result when: I Payment results from two different sources for the same service or procedure I Payment should have been sent to the patient I Payment resulted in more dollars than the allowed amount I Payment is the result of a computer or data entry error All overpayments must be returned to the carrier within a reasonable amount of time (24 weeks). If check is for multiple patients, make a copy of the check and then deposit it. If check is for that one patient only, copy check and return it to the carrier. Attach a copy of the EOB/remittance advice so that the carrier can identify the patient. Keep a copy of all correspondence regarding this overpayment in a file.
Billing for Relatives

Medicare does not permit providers to bill for relatives or members of their households. Household members would include anyone living in the house as part of the family, such as nanny, maid, butler, chauffeur, medical caregiver, or assistant. Individuals considered to be boarders (college students renting a room) would not be included. Relatives that would be considered immediate are: I Spouse I Parent, child, brother, sister I Grandparents/grandchild and spouse I Stepparent, stepchild, stepbrother, stepsister
CPT (HCPCS Level I)

The CPT book is released in the later part of August or early September of each year. The codes found in this book become effective on January 1 the following year. It is imperative that a new book be purchased each year due to revisions, new codes, and deleted codes.
GENERAL
GENERAL
Sections of the CPT Book Code Range
9920199499 0010001999 9910099140 1002169990 7001079999 8004889356 9028199199 9950099602
Section Heading
Evaluation and Management Anesthesiology Surgery Radiology Laboratory/Pathology Medicine
Each section contains guidelines for the codes in that specific section. These guidelines should be reviewed before using the codes listed in that section. In the event that a specific CPT code does not exist for the procedure performed, each section contains unlisted codes for this purpose. For example, unlisted procedure, pharynx, adenoids, or tonsils, 42999.
CPT Symbols Symbol

L M M
G
Description
New code Revised code New or revised description Codes include conscious sedation Codes exempt from use of modifier 51 Codes that can be added onto a procedure or service
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Clean Claim
A clean claim is one that has been submitted within the proper time period and contains all the necessary information. This allows for the claim to be paid promptly, as additional information does not have to be requested. A clean claim means: I It has no deficiencies and passes all the edits. I The third-party carrier does not have to obtain additional information before processing the claim. I The claim may be investigated in a postpayment state, rather than holding payment until any investigation that may take place is completed. Other claim-related terms: I Incomplete: A claim that is missing required information. The provider is notified so that information can be sent. I Rejected: A claim that requires investigation and needs further clarification. This claim would need to be resubmitted with the necessary information. I Invalid: A claim that contains complete, necessary information, but is incorrect. This claim would need to be resubmitted with the proper corrections. I Dirty: A claim submitted with errors, a claim that requires manual processing, or a claim that has been rejected for payment. I Dingy: A claim that cannot be processed for the service or procedure, or bill type. I Paper: A claim that is submitted on paper, whether typed or computer generated. I Electronic: A claim that is submitted to the carrier through a central processing unit or by telephone line or direct wire.
Locum Tenens Providers

Locum tenens providers cover a physician during periods of illness, pregnancy, or vacation. The locum tenens will cover the physicians practice and treat patients as if the practice was their own. Established patients are still billed as established patients, as all billing is reported under the regular physician. See the following listing of conditions that must be met to bill for locum tenens:
GENERAL
GENERAL
I The patients regular physician is not available. I The regular physician pays the locum tenens a per diem fee. I The locum tenens cannot provide services to Medicare patients for more than 60 days. I These services by the locum tenens are billed using modifier Q6 in Box 24d of the CMS 1500 form.
Managed Care
Summary of Managed Care Plans
Summary of most common types of managed care plans. I HMOhealth maintenance organization I PPOpreferred provider organization I IPAindependent practice association I EPOexclusive provider organization I POSpoint of service
Managed Care Plan

HMO
Co-pay Deductible
Co-pay is fixed
Payment
Capitated Fee for service carve-outs Fee for service Capitated Fee for service carve-outs Capitated Fee for service carve-outs Capitated Fee for service carve-outs
Authorization Required
Yes
PPO IPA
Co-pay is fixed Deductible Co-pay is fixed
Yes Yes
EPO
Co-pay is fixed
Yes
POS
Co-pay is fixed Deductible
Yes
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Dos and Donts of Working with Managed Care
Do I Label each patients chart with the name of the patients managed care organization. Bill each organization the same day of the service. I Monitor the number of days it takes to be paid under a feefor-service method. Document any late capitation checks. Promptly call your provider representative with the results. I Appeal inconsistent fee-for-service payments for the same CPT code or unreasonable payments inconsistent with the contracted fee schedule. I Appeal problem payment decisions directly to the medical director of each organization. I Request financial reports each year and have the doctors review them before contacting time. Network with other practices involved with the managed care organization if dissatisfied. I Read the regulations and requirements of the managed care carrier and incorporate them into the policy and procedure manual of the practice. Dont I Bill a patient who is a member of a managed care organization unless it is for a deductible, co-payment, or excluded benefit. I Let your doctors accept the decision of a nurse reviewer if you feel the patients care would be compromised. Have your doctor always speak to a medical director when services have been denied. I Let the doctors discharge a patient or cancel a test they feel is medically necessary when benefits have been denied. Discuss the managed care carrier negatively with your patients. I Discriminate against managed care organization patients by not giving them timely appointments.
GENERAL
GENERAL
Quick Guide To Managed Care Entity
Patient
Advantages
Cost reduction Better benefits
Disadvantages
Less attention Restricted use of providers General confusion Contract demands Adverse member reactions Multiple contract rates Reduced fees Contract demands Complex billing Reduced fees Contract demands Complex billing Upsets patient relations Upsets referral patterns
Managed Care Plan Hospital
Fixed rates Cost reduction Easy claim payment Small number of providers Possible volume increase Prompt payment Possible volume increase Prompt payment Maintaining current patients
Physician
Medicare
Nonparticipating Providers
Providers that do not participate in Medicare are subject to a certain dollar amount that they can charge. This charge is referred to as a limiting charge. The Medicare Fee Schedule contains a column listing the limiting charge. A federal law prohibits a nonparticipating provider from charging more than this limiting charge.
Deductibles and Co-pays

Medicare deductibles and co-pays cannot be waived on a routine basis. If this should occur routinely, the practice could be in violation of the Anti-Kickback Statute or False Claims Act.
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The following listing contains examples of inappropriate waiving of Medicare deductibles and co-pays. I Routine reason of financial hardship given to patient without proper investigation of finances. I Routine waiving of a specific group of individuals in order to obtain additional patients (for example, all Medicare patients living in the XYZ senior home).
Medicare Secondary Payor (MSP)
There are cases where another health insurance pays before the patients Medicare benefits. In these cases, the other health insurance is primary with Medicare being the secondary insurance. This situation will arise under the following conditions:
MSP Billing Guide Primary Insurer: Medicare

The patient is 65 or older and is retired or disabled.
Primary Insurance: Other Insurance

The patient is 65 or older and is still employed and covered under an employers insurance contract. The patient has Veterans Administration benefits that cover all services and procedures.
The patient works for the military and carries Tricare insurance coverage. Medicare is primary and Tricare is secondary. The patient has Railroad The patient has Medicaid. Retirement benefits. Medicaid becomes the secondary payor and covers the patients deductible. The patient is 65 or older and The patient is 65 or older retired. The patients spouse and retired. The patients works and both the spouse and spouse works, but has no patient have coverage through health insurance coverage the spouses employer. through the employer.
GENERAL
GENERAL
MSP Billing Guide Primary Insurer: Medicare
The patient has coverage under a self-employed plan, such as real estate agents.
Primary Insurance: Other Insurance

I The patient is a member of the United Mine Workers of America. I The patients injury or condition is a result of a motor vehicle accident. I The patients injury or condition is a result of employment.
Physician Assistant Billing

Medicare pays the PAs employers in all settings at 85 percent of the physicians fee schedule. This includes: I Hospitals (inpatient, outpatient, and emergency departments) I Nursing facilities I Home I Offices and clinics I First assisting at surgery Important billing facts: I Assignment is mandatory, state law determines supervision and scope of practice. I Medicare pays the PAs employers for medical services provided
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Setting
Office/clinic when physician is not on site
Supervision Requirement
State law
Reimbursement Rate
85% of physicians fee schedule
Services
Office/clinic when physician is on site
Home visit House call Skilled nursing facility State law & nursing facility State law Hospital First assisting at surgery in all settings Federally certified rural health clinics HMO State law State law State law
Physician must be in the suite of the office State law
All services PA is legally authorized to provide that would have been covered if provided personally by a physician 100% of physicians fee Same as above schedule 85% of physicians fee schedule 85% of physicians fee schedule 85% of physicians fee schedule 85% of physicians first assist fee schedule Cost-based reimbursement Reimbursement is on capitation basis Same as above Same as above Same as above Same as above Same as above All services contracted for as part of an HMO contract
49
GENERAL
GENERAL
Nurse Practitioner (NP) Billing
Important facts: I NPs must submit their own billing number for all professional services furnished in facility or other provider settings. I A UPIN billing number must be obtained and submitted on all claims. In situations when NPs are members of a group practice, the group practice PIN number will be entered on one line of the claim form and the NP UPIN in another. I Modifiers are now only applicable when submitting assistant at surgery claims. I Payments to NPs now equal 80 percent of the lesser of either the actual charge or 85 percent of the physician fee schedule amount. I For assistant at surgery services, payments equal 80 percent of the lesser of either the actual charge or 85 percent of the physician fee schedule amount paid to a physician serving as an assistant at surgery. I Nurse practitioners will be unable, however, to receive separate Medicare payments in rural health clinic (RHC) and federally qualified health center (FQHC) settings.
Medicare Fee Schedule

There are three reimbursement columns in a Medicare fee schedule: PAR Non-PAR LC Participating provider fee Nonparticipating provider fee Limiting charge fee
50
51
Medical Supplies and Equipment
Medicare can be billed for any supply and equipment that will be used in a patients home. Medicares definition of a home includes the following locations: I The patients home I A relatives home where the patient is living I A home for senior citizens I A homeless shelter Nursing homes cannot be considered a patients home and therefore medical supplies and equipment cannot be billed.
Medicare Covered/Noncovered Services

Some of the most common covered and noncovered services are listed in the following table. The Medicare manual for each state will provide a comprehensive listing of these services.
Medicare Part B Covered Services

Provider services (office visits, hospital visits, consultations, nursing home visits, etc.) X-rays, laboratory testing, PT, OT, and other outpatient diagnostic testing Ambulatory surgical center (ASC) services Surgical dressings, casts, splints, etc. Certain braces Durable medical equipment
Medicare Part B Noncovered Services

Cosmetic surgery
Dental services
Custodial care Services resulting from workers compensation or motor vehicle accident Services deemed not medically necessary Routine physical examinations
GENERAL
GENERAL
Medicare Billing Summary
Deductibles: Allowable fees $100 for will vary acphysician cording to the services plan; most and outuse Usual, patient Customary, and Reasonable basis Deadline for A minimum Coal miner of 45 days processing claims sent must pass claims is to: Federal before a Dec. 31 of Black Lung claim can the year Program be subfollowing Box 828 mitted the DOS LanhamSeabrook, MD 207030828 CMS-1500 form is used to submit claims A Surgical Financial Disclosure Form is required for all nonassigned claims of $500 or more Durable medical equipment (DME) claims must be sent to the appropriate DME regional carrier
Medicare Review Process

The following steps illustrate the Medicare review process. The Medicare manual in each state will provide the details necessary to begin this process.
Steps
1
Action
Review
Key Points
I Claim must be requested within 6 months of the date on the Explanation of Benefits. I Claim must be requested in writing within 6 months of the result of the review. I Claim must exceed $100 in amount.
Fair hearing
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53
Steps Action Key Points
I Hearings take place over the phone, face-to-face, or on-therecord (where the decision is automatically based on the facts submitted). Administrative I Claim must be requested in writing law judge within 60 days of the result of the hearing fair hearing. I Claim must exceed $500 in amount. Appeals council I Claim must be requested in writing review through the Social Security Administration (SSA) Office of Hearings and Appeals within 60 days of the result of the administrative law judge hearing. I Claim must exceed $500 in amount. Federal district I Civil action must be filed in federal court hearing district court within 60 days of the result of the Appeals Council decision. I The claimant must be represented by an attorney.
Advance Beneficiary Notice (ABN)

When a service is provided to a Medicare patient that Medicare considers not medically necessary, the physician should notify the patient by using an Advance Beneficiary Notice (ABN). This notice must be completed, signed, and dated. The modifier GA must be used when submitting the claim for a service or procedure where an ABN is on file in the physicians office. The following table contains a list of reasons that the physician practice
GENERAL
GENERAL
believes the service or procedure may not be covered. This reason must be stated clearly on the ABN that the patient signs. 1 2 3 4 5 6 Medicare does not usually pay for this many services Medicare does not usually pay for this service Medicare does not pay for this because it is a treatment that has not been proven effective Medicare does not pay for such extensive treatment(s) Medicare does not pay for this equipment for the diagnosis stated Medicare does not pay for this many services within the time frame reported
These ABN notices should be completed by all Medicare patients, only when there is a possibility of noncoverage of the service or procedure. Having patients sign ABNs blanketly is not a good practice.
Medicaid
Medicaid Services Available
I I I I I I I I I I I I Inpatient and outpatient services Physician visits Dental visits (surgical) Nursing facility services for those over age 21 Home health for those eligible for a skilled nursing facility Family planning and supplies Rural health clinics Laboratory tests and x-rays NP services Federally qualified health center Nurse midwife services Early and periodic screen, diagnosis, and treatment services (EPSDT) for individuals under age 21
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55
Confirming Medicaid Eligibility Steps
Step 1 Step 2
Procedure
The patient must present a valid ID card. Eligibility can change monthly since it is based on monthly income, so always verify using the dedicated phone line. Confirmation of eligibility should be obtained and maintained in the patients chart in case of future denial of claim. Confirmation can also be obtained through a swipe box. A print-out will indicate coverage. Retroactive eligibility is sometimes granted to patients whose income has fallen below the state-set eligibility level and who had high medical expenses prior to filing for Medicaid. The office must verify any patient notification of retroactive eligibility. If the patient made payments for services during that time frame, the payments must be returned to the patient, and Medicaid should be billed.
Step 3
Step 4 Step 5
Step 6
Preauthorization
Some states have placed their Medicaid plans into an HMO. These HMOs require preauthorization services which include: I Elective admissions I Reason for inpatient treatment I Admission diagnosis and outline of treatment plan I Emergency admissions I Medical justification for inpatient treatment I Date of admission I Admission diagnosis and outline of treatment plan
GENERAL
GENERAL
I Preoperation days greater than 1 I Reason why surgery cannot be performed within 24 hours of time need was established I Number of additional days requested I Outpatient procedure performed as an inpatient I Code and description of surgical procedure I Medical justification for performing the surgery as an inpatient I Exceeding hospital stay limit (set by state) due to complications I Beginning and ending dates originally authorized I Statement describing the complications I Date complications presented I Diagnosis for first illness I Diagnosis stated on original preauthorization request I Diagnosis for secondary disorder
Extension of Inpatient Days

I I I I
Medical necessity for the extension Number of additional days requested Basis for approval of more than one preoperation day Performance of multiple procedures that, when combined, necessitate a length of stay in excess of that required for any one individual procedure I Development of postoperative complications or a medical history that dictates longer than usual postoperative observation by medical staff
Physician Assistant (PA) Billing

Important facts: I 50 states cover medical services provided by PAs under their Medicaid programs. I The rate of reimbursement, which is paid to the employing practice and not directly to the PA, is either the same as or slightly lower than that paid to physicians.
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57
Nurse Practitioner (NP) Billing
Important facts: I Federal law mandates direct reimbursement to pediatric (PNP) and family (FNP) nurse practitioners providing services to children. I Physician collaboration is not required within the federal mandate. I Each state will determine the reimbursement rate for nurse practitioners.
Medicaid Billing Summary

CMS-1500 form is used to submit claims Deadlines for processing claims is determined by each individual state A minimum Deductibles: of 45 days There is a must pass deductible before a for patients claim can be who are resubmitted. medically indigent All nonemergency Allowable hospitalizations fees will must be preauvary thorized according to each state Co-payments are required by most states, generally ranging from $2$10 per encounter There is no Medicaid premium
GENERAL
GENERAL
Tricare
TRICARE is a health-care program for: I Active duty members of the military and their qualified family members I CHAMPUS-eligible retirees and their qualified family members I Eligible survivors of members of the uniformed services It consists of three plans with varying benefits: 1. TRICARE Prime 2. TRICARE Extra 3. TRICARE Standard TRICARE differs from other insurance carriers as the fiscal year for collecting deductibles runs from October 1 through September 30.
Physician Assistant (PA) Billing

Important facts: I TRICARE covers all medically necessary services provided by a physician assistant. I The PA must be supervised in accordance with state law. I The supervising physician must be an authorized TRICARE provider. I The employer bills for the services provided by the PA. I The allowable charge for all medical services provided by PAs under TRICARE Standard, the fee-for-service program, except assisting at surgery, is 85% of the allowable fee for comparable services rendered by a physician in a similar location. I Reimbursement for assisting at surgery is 65% of the physicians allowable fee for comparable services.
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I PAs are eligible providers of care under TRICAREs two managed care programs, TRICARE Prime and Extra. I TRICARE Prime is similar to an HMO. I TRICARE Extra is run like a preferred provider organization in which practitioners agree to accept a predetermined discounted fee for their services.
Workers Compensation
Eligibility consists of an on-the-job injury or a condition that is the direct result of their job. The law states that a waiting period must elapse before income benefits are payable. This period is determined by each individual state. Classifications of workers compensation consist of: I Medical claims with no disability I Temporary disability I Permanent disability I Vocational rehabilitation I Death of a worker The provider must accept workers compensation as payment in full and cannot bill any additional fees. Fees are reimbursed either by the Medicare fee schedule or a private fee schedule and are determined by each individual state.
Miscellaneous Terms/Facts
I Guarantor: the individual who is responsible for payment of the medical bill. For children to be guarantors, they must be either 18 or 21 years of age (depending on the state regulations) I Major Medical: an insurance policy that covers medical expenses resulting from catastrophic or prolonged illness/injuries, or coverage for such things as office visits that are not included in the plans coverage
GENERAL
GENERAL
Miscellaneous Facts
I Claims denied as not medically necessary cannot be billed to the patient, unless an ABN has been completed acknowledging a patients understanding of the service and why it may or may not be covered. The burden of medical necessity is placed on the provider and is the primary reason for Medicare denials across the country. I Use an Evaluation and Management (E&M) code when pronouncing death of a patient.
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Evaluation and Management Services
Evaluation and Management (E&M) codes are CPT codes used for the reporting of certain services such as office visits, consultations, inpatient services, emergency room services, nursing facility services, domiciliary care services, and home services. Each category of E&M service contains two to seven levels for billing. Each level requires a specific amount of documentation to be billable. These services are listed in the following Table of Evaluation and Management Services.
CPT Codes 9920199205

9921199215 9922199223 9923199233 9924199245 9925199255 9923499236 9921799220 9928199285 9930499306 99318 9930799310 9929399294 9929599296 9929899300 9934199345
Description New patient office visit codes

Established patient office visit codes Initial hospital service Subsequent hospital service Consultation, outpatient Consultation, inpatient Hospital Observation or inpatient care services Hospital Observation services Emergency room services Initial nursing facility service Annual nursing facility assessment Subsequent nursing facility service Initial inpatient pediatric critical care Inpatient neonatal critical care Continuing intensive care services Home services, new patient
EVAL MGMT
EVAL MGMT
CPT Codes
9934799350 9932499328 9933499337 9938199387 9939199397 9935499355 9935699357 9935899359
Description
Home services, established patient Domiciliary care, new patient Domiciliary care, established patient Preventive med codes, new patient Preventive med codes, established patient Prolonged care, outpatient Prolonged care, inpatient Prolonged care, without direct patient contact
The Principles of Documentation were released in 1995 as collaboration between the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS, known then as Health Care Finance Administration). These guidelines were revised in 1997 and 2000 and are still undergoing revisions. Until the final guidelines are released, CMS instructs providers to use either the 1995 or 1997 guidelines; the decision becomes the providers.
Principles of Documentation
The medical record: 1. is a tool of clinical care and communication. 2. should be complete and legible. 3. should include as documentation: a. the reason for the visit; appropriate history, physical examination, review of diagnostic test results and any other ancillary services. b. the providers assessment of the patients condition, clinical impressions, or diagnoses. c. a plan of care/treatment plan. d. the date and legible identity of the person who provided the service.
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4. 5. 6. 7. should contain the rationale for ordering diagnostic services. should contain accessibility to past and present diagnoses. should contain appropriate health risk factors. should contain the patients progress, responses to treatment, complications, and changes in treatment or diagnoses. 8. should support the CPT and ICD-9 codes billed. 9. should be confidential. Seven components are involved in E&M services.
Components of E&M Services 1. History 2. Examination 3. Medical Decision-Making 4. Counseling 5. Coordination of Care 6. Nature of Presenting Problem 7. Time The first three items above (history, examination, and medical decision-making) are the key components in choosing a level of service. Time
Time, which is No. 7 on the list, is only a consideration if counseling is 50% or more of the visit. Some CPT codes are time-based codes. Time-based codes are chosen by the time associated with the service provided. These codes are used to report episodes of Critical Care and Psychology service areas. The only time-based codes listed in the Table of Evaluation and Management Services are the prolonged care codes. When choosing an E&M code based on time, the documentation requirements are very specific. The documentation in the medical record must illustrate that counseling is 50% or more of the visit. For example, a note should look like this:
EVAL MGMT
EVAL MGMT
I spent 45 minutes with Barbara Smith and her husband today. Of that 45 minutes, 30 minutes was spent discussing the results of her abnormal echocardiogram. The note should then provide a summary of the key components of the discussion. This documentation illustrates that counseling was more than 50% of the visit. The following note does not meet this criterion: I spent 30 minutes with Barbara discussing the results of her abnormal echocardiogram. This note does not illustrate that the time spent counseling Barbara Smith was 50% or greater than the total time of the office visit.
History
There are four levels of history:
Level
1 2 3 4
Description
Problem focused Expanded problem focused Detailed Comprehensive
Within these four levels, there are four types of history:
Types
1 2 3 4
Description
Chief compliant History of present illness Review of systems Past, family, and social history
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Chief complaint (written as cc)
The chief complaint is the reason for the visit, or why the patient sought care. This is generally in the patients own words and is a short phrase or two. It is important to be specific when documenting this element and to not use vague language as this may disqualify the patient encounter for reimbursement. For example, the following table illustrates language that is vague; it does not state why the patient sought care. Incorrect cc - check-up Follow-up visit up Routine visit Correct cc - check-up on high blood pressure Follow-up visit for back pain up on diabetes Routine visit for reflux
To elicit the chief complaint, ask broad questions such as: I What brings you in today? I Tell me whats been going on?
History of Present Illness (written as HPI)

The history of present illness is a description of the present illness from the beginning of symptoms to the time of the patient encounter. This is an expansion of the chief complaint and should contain all the information necessary for a differential diagnosis. Begin with open-ended questions such as: I Tell me more about the pain. I What else is going on? I What was that like for you?
EVAL MGMT
EVAL MGMT
Use facilitating expressions to encourage the patient to continue, such as: I I I I Mmm Hmm Yes? Uh Huh? And what else?
Now use more directed questions to complete this history, such as: I I I I What is wrong? When did it start going wrong? How did it go wrong? Why do you think it is wrong?
Use multiple-choice questions such as: I Do you have nausea, vomiting, constipation, or diarrhea? I Is the headache sharp, dull, shooting? Use Yes or No questions, such as: I Do you have a headache every day? I Do you have any allergies? Use quantitative questions, such as: I How many loose stools do you have a day? I How many dizzy spells do you have in a day? Avoid leading questions, such as: I You dont smoke do you? I You havent had any dizziness, have you? Avoid compound questions, such as: I Do you have trouble urinating? When does it bother you? There are eight elements of the history of present illness. They are:
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1 2 3 4 5 6 7 8
HPI Elements Location: Where is the injury or condition?

Quality: Is the pain sharp, dull, crushing, gnawing? Severity: On a scale of 1 to 10, how bad is it, or use descriptive words such as mild, severe, etc. Duration: How long have you had the injury or illness? Timing: When did you first experience the symptom or problem? Context: What were you doing when this occurred? Modifying factors: What have you done to improve your symptoms? Laid down, took analgesics? Associated signs & symptoms: What else bothers you when this occurs?
There are two levels of HPI: 1. Brief: documentation of one to three elements from the previous list. 2. Extended: documentation of four or more elements from the previous list OR the status of three chronic conditions. A brief history focuses on the patients problem, while an extended history will go beyond that to obtain information that may support multiple diagnoses. An example of a brief HPI is as follows: cc - complaining of knee pain HPI - pain has been present in left knee (location) for 2 weeks (timing) In the previous example, left knee is the location and 2 weeks is the timing. Two elements of HPI are met, location and timing. Continuing to build on this note will provide more information about the patients complaint and justify an extended HPI. See the following example: cc - complaining of knee pain
EVAL MGMT
EVAL MGMT
HPI - pain has been present in left knee for 2 weeks. Patient states that pain has gotten so severe (severity), that Advil used to help but now it doesnt (modifying factors). Patient reports pain started when she played softball (context) with her son and fell running to a base. In the last note, left knee is the location and 2 weeks is the timing, pain is so severe, analgesics do not relieve it anymore, pain started when playing softball. In this note, five elements of HPI are met, location, timing, severity, modifying factors, and context.
Review of Systems (written as ROS)

An ROS is an accounting of signs and symptoms of various organ systems obtained through a series of questions. There are 14 systems contained in an ROS. These systems are:
Organ Systems
1 2 3 4 5 6 7 8 9 10 11 12 13 14 Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematological/lymphatic Allergic/immunological
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There are three levels of ROS:
Level
1 2 3 Problem pertinent Extended Complete
Description
Review and documentation of one system Review and documentation of two to nine systems Review and documentation of at least 10 systems
A problem pertinent ROS involves a review of system(s) that can be affected by, play a role in, or are likely to be involved in the patients problem. An extended review includes a more in-depth review of system(s). A complete review includes 10 of the 14 systems listed above. This type of review is considered comprehensive in nature.
Past, Family, Social History (written as PFSH)

A past history contains information about the patients past experiences with illnesses, injuries, and treatments. This may include information about the following: I I I I I I I Hospitalizations Illnesses and/or injuries Surgeries Current medications Allergies to drugs or the environment Age-appropriate immunization status Age-appropriate dietary or feeding status
A family history contains information about the patients family. This may include information as: I Diseases of either the mother, father, siblings, children I Health status or cause of death of any of the above I Diseases of family members that may be hereditary or cause the patient to be at risk
EVAL MGMT
EVAL MGMT
A social history contains information about past or current activities and/or conditions. This may include such information as: I Marital status I Employment I Use of controlled substances I Use of alcohol I Living arrangements I Current employment I Occupational history I Level of education I Sexual history
The two levels of PFSH

Level
1 2 Pertinent Complete
Description
Documentation of one history area Documentation of two to three history areas, depending on the category of E&M service
A complete history must contain the documentation of either two or three history areas, depending on the category of E&M service. The following tables identify which types of service require the documentation of two history areas (2 out of 3 rule) and which type of service requires the documentation of three history areas (3 out of 3 rule).
3 Out of 3 Rule
When the service type is one of an initial contact, all three history areas must be documented.
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Visit Types
1. 2. 3. 4. 5. 6. 7. 8. New office service Consultation, outpatient Consultation, inpatient Initial hospital service Initial nursing facility service Home services, new patient Observation services Observation services or inpatient hospital
2 Out of 3 Rule
When the service type is one of an established service, only two of the three history areas must be documented.
Visit Types
1. 2. 3. 4. 5. 6. Established office service Consultation, follow-up inpatient Subsequent hospital service Subsequent nursing facility service Home services, established patient Emergency services
History Summary Type of History

CC
Present Present Present Present
HPI
Brief Brief Extended Extended
ROS
N/A Problem Pertinent Extended Complete
PFSH
N/A N/A Pertinent Comprehensive
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Examination
The examination portion of the visit contains documentation of the objective findings of the provider of the service. There are currently two sets of examination guidelines; 1995 and 1997. The 1995 guidelines are somewhat subjective, whereas the 1997 guidelines are very specific. The provider of the service may choose which guideline set he/she wants to use.
1995 Examination Guidelines Level

Problem focused Expanded problem focused Detailed
Description
A limited examination of the affected body area or organ system A limited examination of the affected body area or organ system and other symptomatic or related organ systems An extended examination of the affected body area(s) and other symptomatic or related organ system(s) A general multisystem examination or a complete examination of a single organ system
Comprehensive
Body Areas
Chest (including breasts and axillae) Abdomen Back (including spine) Neck Genitalia, groin, buttocks Head (including the face) Extremities, each one would be an area
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Organ Systems
Constitutional Eyes Ears/Nose/Mouth/Throat Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurological Integumentary Psychiatric Hematological/lymphatic/immunological
1997 Examination Guidelines

The 1997 examination guidelines contain a multisystem examination, plus 10 single specialty examinations. These examinations are as follows:
General Multisystem
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Cardiovascular Ears, Nose, Mouth, Throat Eye Genitourinary Hematological/Lymphatic/Immunological Musculoskeletal Neurological Psychiatric Respiratory Integumentary
EVAL MGMT
EVAL MGMT
Under the general multisystem examination, the following requirements must be met:
Level
Description
Perform and document 1 to 5 elements identified by a bullet. Perform and document at least 6 elements identified by a bullet. Perform and document at least 2 elements identified by a bullet from each of 6 areas/ systems or at least 12 elements identified by a bullet in 2 or more areas/systems. Perform all elements identified by a bullet in at least 9-organ system or body areas and document at least 2 elements identified by a bullet from each of 9 areas/systems.
Comprehensive
A detailed listing of these requirements by body areas and organ systems can be found in the Federal Register. Under the specialty guidelines, the following requirements must be met:
Level
Description
Perform and document 1 to 5 elements identified by a bullet. Perform and document at least 6 elements identified by a bullet. Perform and document at least 12 elements identified by a bullet. Perform all elements identified by a bullet and document every italicized element in a shaded area and at least 1 nonitalicized element in each of the nonshaded areas.
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Medical Decision-Making
The medical decision-making portion of the visit entails the complexity of establishing the diagnosis and/or management option(s). Medical decision-making is measured by the following three components:
Components of Medical Decision-Making

The number of diagnoses and/or management options The amount and/or complexity of medical records, diagnostic tests, and other information to be reviewed and analyzed The risk of significant complications, morbidity and/or mortality
The Four Levels of Medical Decision-Making Number of Diagnoses/ Amount and/or Management Complexity of Options Data Reviewed
Minimal Limited Multiple Extensive Minimal/None Limited/Low Moderate Extensive
Level
Straightforward Low complexity Moderate complexity High complexity
Risk of Complication and/ or Morbidity orMortality

Minimal Low Moderate High
Two of the three above indicators will establish the level of medical decision-making. If a patient presents with multiple diagnoses and multiple management options must be considered, the complexity of the medical decision-making is increased. The amount and/or com-
EVAL MGMT
EVAL MGMT
plexity of data that must be obtained, reviewed, and analyzed during the patient encounter must be clear and concise. For test results, document thought processes, analysis, and evaluation of both positive and negative findings. Their impact on treatment should be documented. Review of the patient medical record, past and present, should be documented with comments. Note the extent of records and data that is reviewed with an analysis. The potential risk to the patient is an important element in assessing the complexity of this key component of medical decision making. The following table can be used to identify risk:
Table of Risk Type of Problem

Minimal
Description
May not require presence of physician, but service provided under the physicians supervision Runs definite and prescribed course; transient in nature and not likely to permanently alter health status; or has a good prognosis with management/compliance Risk of morbidity without treatment low; little to no risk of mortality without treatment; full recovery without functional impairment expected Risk of morbidity without treatment moderate; moderate risk of mortality without treatment; uncertain prognosis or increased probability of prolonged functional impairment Risk of morbidity high to extreme; moderate to high risk of mortality without treatment or high probability of severe, prolonged functional impairment
Self-limited/ minor
Low severity
Moderate severity
High severity
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Examples of various types of risk are illustrated in the following table:
Level of Risk
Minimal
Presenting Problems
Insect bite, cold, Tinea corporis Cystitis, sprains, controlled DM, controlled BP Lump in breast, colitis, pneumonia
Diagnostic Procedures Ordered

ECG, chest x-ray, KOH, UA Pulmonary functions, BE, skin biopsies Arteriogram, lumbar puncture, endoscopies/ no risk CV imaging studies w/contrast, endoscopies w/risk
Management
Options Selected Rest, gargle, bandages OTC drugs, PT, OT, IV fluids, minor surgery/ no risk Rx mgmt, IV fluids w/meds, closed treatment of fracture, elective major surgery Emergency major surgeries, DNRs, monitoring toxic drugs
Low
Moderate
High
Acute MI, psych illness w/threat, TIA, trauma
Medical Necessity
Although the service may `contain a properly documented history, examination, and medical decision-making, if there is no medical necessity for the level of service chosen for billing, the service may be downcoded by the carrier. The government definition of medical necessity is that it is a service that is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.
EVAL MGMT
The Decision Matrix for New Office Patients Medical DecisionMaking

Straightforward Straightforward Low Moderate High
Code
99201 99202
History
Problem focused Expanded problem focused Detailed Comprehensive Comprehensive
Examination
Nature of Presenting Problem

Self-limited/ minor Low to moderate Moderate Moderate to high High
Counseling/ Coordination of Care

Yes Yes
Time
10 20
99204 99205
Yes Yes
45 60
Requires all three key components to be documented. *Current Procedural Terminology 2006 American Medical Association, All Rights Reserved.
EVAL MGMT
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99203
Yes
30
The Decision Matrix for Established Office Patients Medical DecisionMaking Nature of Presenting Problem
Minimal
Code
99211
History
Generally does not require a physician Problem focused Expanded problem focused Detailed Comprehensive
Examination

No
Time
5
99212
Straightforward Low
Self-limited/ minor Low to moderate Moderate to high Moderate to high
Yes Yes
10 15
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99213
99214 99215
Moderate High
Yes Yes
25 40
Requires all two of the three key components to be documented. *Current Procedural Terminology 2006 American Medical Association, All Rights Reserved.
EVAL MGMT
The Decision Matrix for Initial Hospital Patients Medical DecisionMaking

Straightforward or low Moderate
Code
99221
History
Detailed/ Comprehensive Comprehensive Comprehensive
Examination
Detailed/ Comprehensive Comprehensive Comprehensive

Low

Yes
Time
30
99222
Moderate
Yes
50
99223
High
High
Yes
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EVAL MGMT
80
The Decision Matrix for Subsequent Hospital Patients Medical DecisionMaking Nature of Presenting Problem Counseling/ Coordination of Care Time
Yes 15
Code
99231
History
Problem focused
Examination
Problem focused
Straightfor- Patient is ward/Low stable, recovering, or improving Moderate Responding inadequately or minor complication Unstable or developed significant complication of problem
99232
Expanded problem focused Detailed
Expanded problem focused Detailed
Yes
25
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99233
High
Yes
35
EVAL MGMT
Discharge Services Code

99238 99239
Hospital Discharge Day

Includes final exam, discussion of hospital stay, instructions for care Preparation of discharge records Includes final exam, discussion of hospital stay, instructions for care Preparation of discharge records 30 minutes or less Over 30 minutes
The Decision Matrix for Consultation, Outpatient Medical DecisionMaking

Straightforward Straightforward Low Moderate High
Code
99241 99242 99243 99244 99245
History
Examination

Self-limited/ minor Low Moderate Moderate to high Moderate to High
Counseling/ Coordination of Care Time

Yes Yes Yes Yes Yes 15 30 40 60 80
EVAL MGMT
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The Decision Matrix for Consultation, Inpatient Medical DecisionMaking

Straightforward Straightforward
Code
99251
History
Examination

Self-limited/ minor Low

Yes
Time
20
99252
Yes
40
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99253 99254
Low
Moderate Moderate to high Moderate to High
Yes Yes
55 80
Comprehensive Moderate
99255
Comprehensive
Comprehensive High
Yes
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EVAL MGMT
The Decision Matrix for Hospital Observation or Inpatient Care Medical DecisionMaking
Straightforward or low
Code
99234
History
Detailed/Comprehensive
Examination

Low

Consistent with nature of problems Consistent with nature of problems Consistent with nature of problems
Time
N/A
99235
Comprehensive
Moderate
N/A
99236
Comprehensive
Comprehensive High
High
N/A
EVAL MGMT
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The Decision Matrix for Hospital Observation Services Medical DecisionMaking

Straightforward or low
Code
99218
History
Examination

Low

Consistent with nature of problems Consistent with nature of problems Consistent with nature of problems
Time
N/A
99219
Comprehensive
Moderate
N/A
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99220
Comprehensive
Comprehensive High
High
N/A
99217
EVAL MGMT
Discharge DayCan only be used if discharge is on other than the initial date of N/A observation status.
The Decision Matrix for Emergency Room Services Medical DecisionMaking

Straightforward Low
Code
99281
History
Problem focused Expanded problem focused Expanded problem focused Detailed
Examination
Problem focused Expanded problem focused Expanded problem focused Detailed

Selflimited/ minor Low to moderate Moderate

Consistent with nature of problems Consistent with nature of problems Consistent with nature of problems Consistent with nature of problems Consistent with nature of problems
Time
N/A
99282
N/A
99284
Moderate
High
N/A
99285
Comprehensive
Comprehensive High
High
N/A
EVAL MGMT
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99283
Moderate
N/A
After Hours Codes For Emergencies

99052 99054 Services requested between 10 pm and 8 am, report in addition to the basic service code Services requested on Sundays and holidays in addition to the basic service code
The Decision Matrix for Initial Nursing Facility Comperhensive New or established History Detailed 99304
Comprehensive Comprehensive
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Examination Comprehensive
99305 99306
Medical DecisionMaking Straightforward or low Moderate

Moderate to High
Nature of Counseling/ Presenting Coordination Problem of Care Time Low Yes 30
Moderate High
Yes Yes
40 50
EVAL MGMT
The Decision Matrix for Subsequent Nursing Facility Subsequent New or Established
99307 99308
History
Examination
Medical DecisionMaking
Counseling/ Coordination of Care Time

Yes Yes 15 25
99310
Comprehensive
Comprehensive
EVAL MGMT
Requires two of the three key components to be documented. *Current Procedural Terminology 2006 American Medical Association, All Rights Reserved.
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99309
Straight- Patient is stable, recovforward ering, or improving Low Responding inadequately or developed minor complication Moderate Patient has developed a significant complication or a significant new problem High Unstable or developed significant complication or new significant problem
Yes
35
The Decision Matrix For Annual Nursing Facility Assessment Code

99318
History
Detailed
Examination
Comprehensive
Medical Decision-Making Nature of Presenting Problem

Low to moderate Patient is stable, recovering, or improving
Requires all three key components to be documented.
The Decision Matrix for Discharge Services
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Code
99238
Nursing Facility Discharge Day Management

Includes final exam, discussion of hospital stay, instructions for care, prescriptions, preparation of discharge records Includes final exam, discussion of hospital stay, instructions for care, prescriptions, preparation of discharge records 30 minutes or less
99239
Over 30 minutes
EVAL MGMT
The Decision Matrix for Home Services, New Patient Medical DecisionMaking
Straightforward Straightforward Moderate Moderate High
Code
99341 99342
History
Examination

Low Low

Yes Yes
Time
20 30
99343 99344 99345
High High Unstable problem, requires immediate attention
Yes Yes Yes
45 60 75
EVAL MGMT
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The Decision Matrix for Home Services, Established Patient Medical DecisionMaking
Straightforward Low
Code
99347
History
Problem focused, interval Expanded problem focused, interval Detailed, interval Comprehensive, interval
Examination

Self-limited or minor Low to moderate

Yes
Time
15
99348
Yes
25
91
99349 99350
Moderate Moderate
Moderate to high Moderate to high
Yes Yes
40 60
EVAL MGMT
The Decision Matrix for Domiciliary Care, New Patient Medical DecisionMaking
Straightforward Low
Code
99324
History
Examination

Low severity

Consistent with problem Consistent with problem Consistent with problem Consistent with problem Consistent with problem
Time
20
99325
Moderate severity
30
99327
Moderate
High severity
60
99328
High
Patient may be unstable or may have developed a significant new problem requiring immediate physician attention
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EVAL MGMT
92
99326
Moderate
Moderate to high severity
45
The Decision Matrix for Domiciliary Care, Established Patient Medical DecisionMaking
Straightforward Low
Code
99334
History
Examination

Self-limited or minor Low to moderate severity Moderate to high

Consistent with problem Consistent with problem Consistent with problem
Time
15
99335
25
93
99336
Moderate
40
99337
Comprehensive
Comprehensive
Moderate to high
Patient may be Consistent unstable or may with have developed a problem significant new problem requir-ing immediate physician attention
60
EVAL MGMT
EVAL MGMT
The Decision Matrix for Inpatient Pediatric Critical Care Code
99293
Description
Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
99294
The Decision Matrix for Inpatient Neonatal Critical Care Code

99295
Description
Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less
99296
The Decision Matrix for Continuing Intensive Care Code

99298
Description
Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams) Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight less than 15002500 grams) Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight less than 25015000 grams)
99299
99300
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The Decision Matrix for Preventive Medicine Services, New Patient
Initial preventive medicine service including a comprehensive history and examination, counseling; anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures.
Code
99381 99382 99383 99384 99385 99386 99387
Description
Infant, under 1 year of age Early childhood, age 14 years Late childhood, age 511 years Adolescent, age 1217 years Age 1839 years Age 4064 years Age 65 years and over
The Decision Matrix for Preventive Medicine Services, Established Patient

Periodic preventive medicine re-evaluation including a comprehensive history and examination, counseling; anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures.
Code
99391 99392 99393 99394 99395 99396 99397
Description
Infant, under 1 year of age Early childhood, age 14 years Late childhood, age 511 years Adolescent, age 1217 years Age 1839 years Age 4064 years Age 65 years and over
EVAL MGMT
EVAL MGMT
The Decision Matrix for Prolonged Care Services, Outpatient Code
99354
Description
Prolonged physician service in the office or outpatient setting requiring direct (face-to-face) patient contact beyond the usual service Each additional 30 minutes
Time
First hour
99355
30
The Decision Matrix for Prolonged Care Services, Inpatient Code

99356
Description
Time
First hour
99357
30
The Decision Matrix for Prolonged Care Services, Without Direct Patient Contact Code
99358
Description
Time
First hour
99359
30
Critical Care
Critical care services are not site specific. They can be performed in any location of the hospital. They are provided for episodes of conditions that are generally life-threatening. They are not used for
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inpatient days when a patient is in the Intensive Care Unit or Cardio Care Unit of a hospital. In these cases, the appropriate inpatient codes should be utilized. There is no limit to the number of critical care services that can be provided and billed each day. These services may be provided to patients under the following conditions: I Central nervous system or circulatory system failure I Hepatic, renal, or respiratory failure I Severe infection I Postoperative complications The time spent providing critical care services may be time spent providing the following services: I Direct care to the patient I Review of studies and test results I Discussion of patient with other team members I Documentation of critical care in the medical record I Time spent with family members or patient decision makers Critical care codes are time-based and are billed as follows: I 99291 Critical care, first 30-74 minutes I 99292 Critical care, each additional 30 minutes (list separately in addition to code 99291)
Examples of Billing for Critical Care Codes Total Time Documented for Critical Care Services Provided
Less than 30 minutes 3074 minutes 75104 minutes 105134 minutes 135164 minutes 165194 minutes 194 minutes or more
Billing for Critical Care

Use appropriate inpatient code 99291 99291 and 99292 99291 and 99292 2 99291 and 99292 3 99291 and 99292 4 99291 and 99292 for the length of time spent
EVAL MGMT
EVAL MGMT
Note: Only one physician can bill for a given hour of critical care, even though more than one physician may be involved. Codes that are bundled into Critical Care are as follows: 36000 36410 36415 36540 36600 43752 71010 71015 71020 91105 92953 93561 93562 94656 94657 94660 93662 94760 94762 99090 G0001 Introduction of needle or intracatheter, vein Venipuncture, child over age 3 or adult, requiring physician Collection of venous blood by venipuncture Collection of blood specimen from a completely implantable venous access device Arterial puncture, blood for diagnosis Naso- or orogastric tube placement with fluoroscopic guidance Chest x-ray, single view, frontal Chest x-ray, stereo, frontal Chest x-ray, two views, frontal and lateral Gastric intubation, aspiration/lavage for treatment Temporary transcutaneous pacing Indicator dilution studies, arterial/venous catheter with cardiac output measure Subsequent measurement of cardiac output Ventilation management, first day Subsequent days Continuous positive airway pressure (CPAP), initiation/management Continuous negative pressure ventilation (CNP), initiation/management Noninvasive oximetry for oxygen saturation, single determination By continuous overnight monitoring Analysis of information/data in computers Routine venipuncture for collection of specimen
These cannot be billed separately when billing for critical care.

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99
Inpatient Neonatal and Pediatric Critical Care Services
99293 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days or less Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present weight less than 1500 grams) Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 15002500 grams) Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 25015000 grams)
99294
99295
99296
99298
99299
99300
Care rendered to patients with CPT codes 9929399292 include: I Management I Monitoring and treatment I Respiratory I Pharmacologic control of the circulatory system I Enteral and parenteral nutrition I Metabolic and hematologic maintenance I Parent/family counseling I Case management services I Personal direct supervision of the health-care team
EVAL MGMT
EVAL MGMT
Documentation Formats
The most commonly used format, of the three currently used documentation formats, is SOAP .
Description
S ubjective Includes patient complaints, history of illness or injury, answers to questions about organ systems, and past, family and/or social history Includes findings on examination of the patient Includes the prognosis and/or differential diagnosis of the patient and diagnostic studies Includes patient instructions, testing to be performed, next appointment, prescriptions, referrals
O bjective A ssessment
lan
The next most commonly used is SNOCAMP:
Description
S ubjective Includes patient complaints, history of illness/injury, answers to questions about organ systems, and PFSH. Includes a disease, illness, injury, symptom, or finding that relates to the chief complaint Findings on patient exam Patient visits where counseling constitutes more than 50% of the visit Includes prognosis and/or differential diagnosis of the patient and diagnostic studies
N ature of presenting problem O bjective C ounseling/coordination of care A ssessment
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Description
M Complexity of the visit and physicians thought edical process; this component is subjective and is decisionbased on three components: making 1) number of diagnoses/management options 2) amount and/or complexity of data 3) risk of mortality/morbidity Includes patient instructions, tests to be lan performed, next appointment, Rx, referrals
Concurrent Care
Concurrent care is the provision of similar services to the same patient by more than one provider on the same day. When both providers bill the same diagnosis code, a claim denial may occur. If there is no documentation to support the medical necessity for the second provider, the provider who sends the claim in first gets paid, the second claim gets denied. To eliminate this claim denial, document the need for the second provider to be involved in the patients care. Generate a paper claim (CMS 1500 form) and attach the documentation to the form. The claim form should be completed with the appropriate CPT and ICD-9-CM codes.
Consultations
Consultations are requested when an opinion is asked of a colleague regarding a patient. There are two types of consultations: I Inpatient (9924199245) I Outpatient (9925199255)
EVAL MGMT
EVAL MGMT
When documenting a consultation, the following information must be present: I The reason for the consult I Who requested the consult I The appropriate level of history, examination, and medical decision-making I A diagnosis or impression and treatment plan I Disposition of patient, Will follow or Patient will return to your office in follow-up
The Three Rs of a Consultation
1. Request 2. Render an opinion 3. Report If all of the above are not met, consultation codes cannot be billed. Consultation codes can be used by primary care physicians when they examine their patients and submit a report for medical clearance prior to surgery.
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Surgery Coding/Anesthesia Coding/Anesthesia
Facts: I Anesthesia is billed using time units that equal 10 to 15 minutes per unit (based on state regs). I Time begins when the physician or certified registered nurse anesthetist (CRNA) prepares the patient for induction and ends when the patient is released from anesthesia care in the recovery room. I Time is rounded to one decimal place, when necessary. I Time is not used when administering local medications intravenously. Physical Status Modifiers are used to report that the anesthesia administered was complicated by the physical status of the patient. Important facts: I Some payers will reimburse a higher amount when these modifiers are used. I In other cases, such as Medicare, payers do not recognize these modifiers. I Each case is carrier-specific and the reporting rules for the carrier must be obtained prior to submission of the claim.
Physical Status Modifiers Modifier

P1 P2
Description
A normal healthy patient A patient with a mild systemic disease This modifier indicates that the patient was healthy. This modifier indicates that the patient had some type of mild disease process, such as hypertension.
SURG ANES
SURG ANES
Physical Status Modifiers Modifier
P3
Description
This modifier indicates that the patient had a severe systemic disease that could affect the care of the patient. This modifier may be used with a patient who is a brittle diabetic with complications of congestive heart failure and uncontrolled hypertension. This modifier indicates that the A patient with a patient has a severe disease severe systemic that is a threat to life, such as disease that is a a patient who has had a heart threat to life attack and now requires an angioplasty. This modifier is used for A moribund patient critically injured patients who who is not expected require emergency surgery. to survive without the procedure A declared brain-dead This modifier is used for a patient who is brain-dead patient whose being maintained on life organs are being support waiting for organ removed for harvesting. transplant A patient with a severed systemic disease
P4
P5
P6
Monitored Anesthesia Care

Monitored anesthesia consists of the following: I Preanesthesia evaluation I Perianesthesia evaluation I Postanesthesia evaluation I Patient evaluation on admission and discharge from anesthesia care I Time-based records of vital signs and level of consciousness
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Medically Directed Anesthesia Services
Medically directed services occur when a physician is responsible for the direction of 2, 3, or 4 concurrent cases involving CRNAs. These medically directed services are reported using the modifier QX.
Moderate (Conscious) Sedation

Moderate (conscious) sedation occurs when sedation is achieved with or without the administration of an analgesic. This sedation places the patient into a lower level of consciousness, allowing for certain procedures to be carried out. Medicare does not permit these codes (99143 and 99145) to be billed separately and considers them bundled into the procedure.
HCPCS Modifiers for Anesthesia Services Modifier

AA AD G8 G9 QK QS QX QY QZ
Description
Anesthesia services performed personally by an anesthesiologist Medical supervision by a physician; more than four concurrent anesthesia procedures at one time Monitored anesthesia care (MAC) for deep, complex, complicated, or markedly invasive surgical procedure Monitored anesthesia care for patient who has history of severe cardiopulmonary condition Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals Monitored anesthesia care service CRNA service with medical direction by a physician Anesthesiologist medically directs one CRNA CRNA service without medical direction by a physician
SURG ANES
SURG ANES
Surgery
The operative record is a major part of the medical record, as it is the direct source for reporting procedures performed. Accurate operative records will translate into accurate billing and proper reimbursement.
Important Definitions
I Assistant surgeon: Assists the primary surgeon in charge of the case with a specific surgical procedure. I Cosurgeon: Two surgeons of different specialties are required for a specific surgical procedure. I Team surgery: A single procedure requires more than two different surgeons of two different specialties.
Global Surgeries
Components of a global surgery package are: I Preoperative visits I Intraoperative services I Complications following surgery I Postoperative visits and pain management I Supplies I Miscellaneous services such as staple and suture removal, casts, splints, removal of catheters, etc. I These items cannot be billed separately since they are considered part of the surgical package. Services that can be billed separately are as follows: I Separately identifiable service from the surgery (use separate diagnosis code when reporting) I Diagnostic testing and procedures I Second procedures that are distinct from the original procedure
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I Initial consultation that prompted the decision for surgery I History and physical that is performed more than 1 day before the surgery I Reoperations due to complications I Dialysis I Immunosuppressive drug therapy for organ transplants I Critical care
Modifiers Used with Global Surgery Billing

I Modifier 24 I Modifier 25 I Modifier 57 I Modifier 58 I Modifier 76 I Modifier 77 I Modifier 78 I Modifier 79 See Tab 7 for details of these modifiers.
Bilateral Surgeries
Important facts: I If code indicates the procedure is performed on both sides of the body, then the second side cannot be billed separately I If additional procedures are billed by the same physician on the same day, use modifier 51 (See Tab 7)
Minor Surgeries
Important facts: I They are not usually global I If there is a 10-day postoperative period, all surgery and postsurgery visits would be included in the global fee I Underlying conditions can be billed separately I The day of the procedure is not counted in the global fee period
SURG ANES
SURG ANES
Multiple Surgeries
Important facts: I When two physicians of different specialties perform separate procedures during the same session, each surgeon will bill for the specific procedure performed; there is no modifier required. I When billing a procedure code that takes one or more sessions, third-party carriers will pay one time during the global fee period. I When more than one procedure is performed at the same operative session, list the major procedure first, followed by the lesser procedures.
Critical Care
Critical care can be billed separately for preoperative and postoperative care when the following conditions exist: I Constant attention is required by the physician I Care is unrelated to the surgical procedure performed
Postoperative Pain
I Bill code 62319 for the first day of pain management by continuous epidural I Bill code 01996 for daily management of the epidural drug after the catheter was inserted. I Physician services related to PCA (patient-controlled analgesia) is included in the global fee.
Surgical Tray
Medicare can be billed for a surgical tray when performing certain surgical procedures. Billing surgical trays with other third-party carriers is carrier specific and requires the provider to check with each carrier individually. The code for billing surgical tray is A4550.
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Documenting the Operative Report
The documentation of a procedure requires documentation of the complete story. It explains what procedure was performed, how they were performed, what tissues, organs, or bones were involved, and why it was necessary to perform the procedure. All information must be complete, consistent, and in a form that is ready to be coded.
Components Involved in Coding from Operative Reports

An operative report is comprised of four main elements:
Four Elements of an Operative Report

1. 2. 3. 4. Heading History or indication for surgery Body (operation(s)/procedure(s) in detail) Findings
The heading consists of five major components:
Components of the Heading

1. 2. 3. 4. 5. Hospital-specific information Patient-specific information Date of operation or surgery Specific information regarding operation Operation(s) or procedure(s) performed Depending on the type of operation and the course of surgery, other information may be found in the heading.
SURG ANES
SURG ANES
Components Involved in Coding from Operative Reports (Continued)

Components of the Heading
1. 2. 3. 4. 5. 6. 7. Hardware Components Grafts Complications Drains Tourniquet time Other material left in place
Heading
1. 2. 3. 4.
Hospital-Specific Information Name of hospital

Address of hospital Patients medical record or other number used to track the patient Admission date
Heading Patient-Specific Information

1. 2. 3. Name Date of birth and/or age Sex
Heading Date of Operation or Surgery

Example: 11/10/05
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Components Involved in Coding from Operative Reports (Continued)
Heading
1.
2. 3. 4. 5. 6. 7. 1. 2.
Specific Information Regarding Operation Attending surgeon: all surgeons involved should be listed, i.e., primary surgeon, cosurgeons, and assistant surgeons Cosurgeon Surgery resident, if applicable Surgery assistants, if applicable Anesthetic (general, local) Complications Estimated blood loss Diagnoses Preoperative diagnoses Postoperative diagnoses Heading Operation or Procedure Performed
Specific case information is inserted in this section
History or Indication for Surgery

Contains a brief history of why the surgery is indicated.
Body (operation(s)/procedure(s) in detail)

Contains a detailed accounting of the operation(s) from start to finish.
Findings
Contains a synopsis of the findings during the operation.
SURG ANES
SURG ANES
There are other sources of documentation that could influence the coding of the operation or procedure. These documents are as follows: I Progress notes I Physician orders I Pathology reports I Discharge summary I History and physicals I Emergency department reports I Ventilator management forms I Anesthesiology forms I Recovery room course and information I Complications I Ambulance services I Consultants reports
Surgical and Postoperative Codes
ICD-9-CM Codes
ICD-9-CM categories 996999 contain the majority of the codes used when reporting surgical and postoperative complications. When coding an inpatient service, the condition leading to the admission to the hospital is the primary code used for billing. For outpatient services, the diagnosis code that reflects the most current reason for this episode of care would be primary. The principal diagnosis is defined as the reason the patient was admitted to the hospital.
Surgical Modifiers
Surgical modifiers used other than those listed in the Global Surgery section of this tab are: I Modifier 22 I Modifier 51 I Modifier 52 I Modifier 54 I Modifier 56 I Modifier 99
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Elective Surgery Notice
When nonparticipating providers submit a Medicare claim for an elective surgery, the patient must be presented with an elective surgery notice, which identifies the charges and their liability. This notice must be presented to the patient whenever the procedure charge is $500 or more. Requirements for procedure to be considered elective: I If the surgery is postponed, there will be no damage to the patients health. I There is no urgency for this surgery. I This surgery can be scheduled in advance. Physicians who do not participate in Medicare must provide their elective surgery patients with a fee disclosure form. This form must contain the following: I The estimated charge (cant be higher than the limiting charge) I The estimated Medicare allowable charge I The difference between the two charges I The patients coinsurance amount
The Patients Out-of-Pocket Expenses
The charge to the patient must not exceed 115% of the Medicare allowable amount. An example of this estimation calculation can be seen in the following table:
Description
Charge for the procedure Medicare allowable amount Medicare approved charge (Whichever of the above fees is the lowest, 1,000 or 550) Difference between Medicare approved charge and actual charge (1,000 550 450) Coinsurance (20%) (20% of the Medicare approved charge, 550 .20 110)
Fee
$1,000.00 $550.00 $550.00 $450.00 $110.00
SURG ANES
SURG ANES
Description
Patients portion of the bill if Medicare deductible was met (450 110 560) If the patients Medicare deductible has not been met (560 100 660)
Fee
$560.00 $660.00
Integumentary System Coding

Considerations when billing for procedures involving the skin: I Location I Where is it? I Method I Was it incised, excised, shaved? I Structures I Did it involve only skin or did it also involve muscle? I Depth I Was it deeper than the subcutaneous tissue? I Type I Was it complete, partial? I Size I Report using centimeters I Number I How many lesions?
Incision and Drainage

Considerations when billing for incision and drainage of an abscess or cyst: I Site I Arm, face, etc. I Depth I Skin, soft tissue I Method I Incision, puncture
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Removal of Foreign Bodies
Considerations when billing for removal of foreign bodies: I Site I Face, leg, hand, eye I Depth I Muscle, subcutaneous tissue I Complexity I Superficial, complicated
Repairs
Repair codes are used to suture lacerations from injury or procedures. If suturing is required as a result of a procedure, the reimbursement is included in that procedure code and CANNOT be billed for separately.
Types of Repairs
Simple Closure of a partial or full thickness wound to the skin and subcutaneous tissues. No involvement of deep structures. Closure of wounds/lacerations involving repair of one or more deeper layers of subcutaneous tissue and nonmuscle fascia along with the skin. Closure of layered wound that requires additional work, such as scar revision, dbridement, retention sutures, etc.
Intermediate Complex
Considerations for repairs: I Location I Foot, hand, face I Size I Reported in centimeters I Structure I Skin, subcutaneous tissue, muscle
SURG ANES
SURG ANES
Steps for Coding Wound Repairs
1. The repaired wound should be measured and recorded in centimeters, whether curved, angular, or stellate. 2. When multiple wounds are repaired, add together the lengths of those in the same classification and report as a single item. When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 51. 3. Decontamination and/or dbridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of tissue are removed, or when dbridement is carried out separately without immediate primary closure. 4. If the wound repair involves nerves, blood vessels and/or tendons, choose codes from appropriate subsection of the Surgery section (nervous, cardiovascular, etc.) for repair of these structures.
Burns
Considerations for local treatment of burns: I Anesthesia I With or without I Depth I Depth of burn I Location I Hand, face I Percent I Percent of body surface I Size I Small, medium
Rule of Nines
An approximation of the area of skin burnt. It divides the body into units of surface area that are divisible by ninewith the exception of the perineum. In an adult, the following are the respective percentages of the total body surface area:
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Adults: I Head and neck total for front and back: 9% I Each upper limb total for front and back: 9% I Thorax and abdomen front: 18% I Thorax and abdomen back: 18% I Perineum: 1% I Each lower limb total for front and back: 18% The Rule of Nines is relatively accurate for adults but not for children due to the relative disproportion of body part surface area. Children: I Head and neck total for front and back: 18% I Each upper limb total for front and back: 9% I Thorax and abdomen front: 18% I Thorax and abdomen back: 18% I Perineum: 1% I Each lower limb total for front and back: 13.5%
Fracture Coding
Fracture codes include evaluation and management (E&M) services: I E&M service the day of the fracture treatment I Treatment of the fracture, i.e., pinning, open, closed I Placement and removal of initial cast or splint I Follow-up care provided Subsequent casts can be billed for separately. Dislocations are reported by two factors: 1. The method in which they were stabilized 2. The type of manipulation used
SURG ANES
SURG ANES
Endoscopy Coding
There are two types of endoscopy: 1. Diagnostic 2. Therapeutic
Diagnostic Procedures
Diagnostic endoscopy
Minor Therapeutic Procedures

Biopsy of different lesion in a different area Removal of foreign body
Major Therapeutic Procedures

Removal of tumor, polyp, or lesion using hot biopsy, or snare Ablation of tumor, polyp, or lesion by other technique
Biopsy of the same lesion in the same area Brushing or washing to collect a specimen
Dilation Removal of stent
Miscellaneous Facts
I Use two codes when reporting the replacement of a pacemaker battery: I Code for the removal of the pulse generator I Code the insertion of the new pulse generator I Replacement of the pacemaker within the first 2 weeks is included in the original code and cannot be billed for separately I Surgical endoscopy includes diagnostic endoscopy I When a C-section has been performed, the physician who performed the procedure is responsible for the postpartum care
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I All sleep studies include tracing, interpretation, and report I Surgical arthroscopy includes diagnostic arthroscopy; therefore, this can never be billed for separately I An E&M service can be billed the same day as PT if the service is separately identifiable. The modifier 25 must be attached to the E&M service I There are three approaches to hysterectomies: I Abdominal I Vaginal I Laparoscopic, vaginal
SURG ANES
RAD PATH
Radiology
Radiology billing and coding is divided into four sections: 1. Diagnostic radiology, to include computerized tomography (CT scans), magnetic resonance imaging (MRI), and interventional radiology 2. Diagnostic ultrasound 3. Radiation oncology 4. Diagnostic and therapeutic nuclear medicine All procedures in the CPT book are listed by anatomical site and body system. These procedures are presented by type of service and body site. Radiation oncology is presented according to the following outline: I Treatment planning I Medical radiation physics I Treatment delivery I Treatment management Radiology procedures are many times denied due to lacking medical necessity. Accurate diagnosis coding is instrumental in the reimbursement process for radiology codes. It is the ordering physician or physician extenders responsibility to provide the diagnosis when ordering a radiology procedure. A physician extender is an individual whose professional level is between a nurse and a physician. Examples of physician extenders are nurse practitioners and physician assistants. Unless the radiology service is being performed in a freestanding facility where the equipment is also owned, most radiology coding includes only the professional component. In a hospital setting, the equipment is owned by the hospital, but the interpretation is performed by the radiologist and is billed using a modifier 26, or PC for professional component.
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Component
Technical
Description
Includes equipment, supplies, personnel (technician), costs to perform the procedure Physicians interpretation, report; also includes costs of physician education and malpractice insurance One physician provides both technical and professional components of the procedure
Modifier
TC
Professional
26
Global
None
A written report is considered part of the interpretation; therefore, it cannot be billed separately.
With Contrast
This phrase is used when a study is requested with the use of a contrast material for enhancement of the image. This phrase can be found with the following codes: I Computerized tomography (CT scan) I Computerized tomography angiography (CTA) I Magnetic resonance imaging (MRI) I Magnetic resonance angiography (MRA) Contrast material is administered via an intravenous line (within a vein), intra-articular (within a joint), or intrathecally (within a sheath: through the theca of the spinal cord.) CT and MRI scans are listed in the CPT book either with or without contrast. The following table shows some of these codes.
CPT Code
70450 70460 74150 74160
Description
Computed tomography (CT scan) head, or brain; without contrast material With contrast material Computed tomography (CT scan) abdomen; without contrast material With contrast material
The placement of the IV line for the administration of contrast is considered part of the procedure and cannot be billed for separately. *Current Procedural Terminology 2006 American Medical Association, All Rights Reserved.
RAD PATH
RAD PATH
Positron Emission Tomography (PET scan)
A PET scan is a diagnostic tool that is most often used to detect cancer and to examine the effects of cancer therapy by biochemical changes. PET scans can be used in the following areas: I Brain I Heart I Cancerous tumors
Emergency Department X-rays
I Medicare will only pay for one interpretation of an x-ray procedure. This interpretation fee is generally reimbursed to the radiologist for a formal written report and not the emergency department physician for their review of the film. Most other carriers follow the Medicare guidelines and will not reimburse for an emergency department review.
Consultations
X-ray consultations performed on x-rays made elsewhere must contain a written report. To bill for this consultation, CPT code 76140 should be used.
Key Elements to Help in Radiology Coding and Billing

The following lists include components that are found within the specific procedures that need consideration when considering a code. For example, a chest x-ray is a diagnostic procedure. A chest x-ray may be a single view, frontal, code 71010, a two view, frontal and lateral, code 71020, or a complete, four or more views, code 71030. It is important to read the codes carefully before assigning a code to a service or procedure. Does this diagnostic procedure have more than one view? Is it a complete or limited study? Is it with contrast, or without? All of these questions must be answered to properly code a diagnostic procedure. Diagnostic Procedures 1. Number of views 2. Complete or limited study 3. With or without contrast
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Ultrasound Procedures 1. Complete or limited 2. Unilateral or bilateral 3. With or without duplex scan Nuclear Medicine Procedures 1. Type of radionuclide 2. Amount of radionuclide 3. Limited, multiple, or whole body area 4. Single or multiple determinations 5. With or without flow 6. Qualitative or quantitative Computerized Tomography (CT) 1. With or without contrast media (type and amount) 2. Multiplanar scanning and/or reconstruction Magnetic Resonance Imaging (MRI) 1. With or without contrast media (type and amount) 2. Number of sequences
Modifiers
Modifiers used in radiology coding are 22, 26, 32, 51, 52, 53, 58, 59, 62, 66, 76, 77, 78, 79, 80, 90, 99.
Modifier
22
Description
Unusual procedural service
Billing Notes
I Used rarely in radiology, and when used, requires additional documentation to support use I Not recognized by most carriers I Used with CT scans when additional views or slices are needed I DO NOT OVER USE
RAD PATH
RAD PATH
Modifier
26
Description
Professional component
Billing Notes
I Used when the physician provides an interpretation of the study; this interpretation requires a separate written and signed report; simple verbiage, such as WNL within normal limits (WNL) or fx radius-normal, does not meet the requirements I Used when the service is mandated I Used rarely in radiology; sometimes used by Workers Compensation I Use this modifier when more than one procedure is performed by the same physician on the same date, on the same patient I Use this modifier when a procedure is partially reduced or eliminated at the physicians direction I Used when a postreduction film of fracture care is taken; use the comprehensive x-ray code to identify the fracture; once the fracture has been reduced, use the comprehensive x-ray code again with modifier 52 to indicate that a reduced level of service was provided
32
Mandated service
51
Multiple procedures
52
Reduced service
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Modifier
53
Description
Discontinued service
Billing Notes
58
59
62
I Used when the physician chooses to terminate the procedure I Would be used when the x-ray procedure is discontinued because the patient is at risk I Use a diagnosis code that is appropriate, such as, procedure not carried out because of contraindication (V64.1), procedure not carried out because of patients election (V64.2), procedure not carried out for another reason (V64.3) Staged or related I Applying this code to the second related procedure durprocedure or ing a postoperative period will service by the result in a denial of the claim same physician I Cannot be used in conjunction during the with codes whose descriptions postoperative state that the code represents period one or more services I This modifier indicates that the Distinct proceprocedure was distinct or dural service separate from the other procedure performed on the same day I Used when the skills of two Two surgeons different physicians from two different specialties are needed to perform a procedure on a patient during the same operation
RAD PATH
RAD PATH
Modifier Description Billing Notes
66
76
77
I Cannot be used by two physicians of the same specialty I Used when a complex procedure Surgical team requires the services of physicians from different specialties and other highly skilled individuals I May be used in instances of multiple traumas, heart transplants, separation of conjoined twins I Some carriers will not allow Repeat proceradiology to use this modidure by same fier; each modifier is carrierphysician specific, so it is best to always check with the individual carriers before using modifiers I It is used to identify that the procedure had to be performed again and that this was not a duplicate billing; without this modifier in this circumstance, the claim will be denied as duplicate I Use of this modifier is rare as a Repeat procesecond interpretation and report dure by are unusual in radiology another phyI Add this modifier to the second sician service I Sometimes used when a physician wants a better look using a darker density, so patient must return for second procedure with darker density
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Modifier
78
Description
Billing Notes
79
99
Return to operating for I Used when a subsequent related procedure procedure is related to the during the postfirst and requires the use operative period of an operating room Unrelated procedure I Used when an unrelated or service by the procedure is performed by same physician the same physician during during the postopthe postoperative period erative period of the original procedure Multiple modifiers I Used to report that multiple modifiers are being reported in this claim
Diagnostic Radiology
Minimum
In the radiology section of the CPT book, the word minimum becomes a key factor in billing. This word indicates that there is no ceiling beyond what is mentioned for that particular code. See the following table for an example of this wording.
CPT Code
73630
Description
Radiologic examination, foot, complete, minimum three views
If an x-ray of a left foot contained 4 views, the same code 73630 would be used. If an x-ray of a left foot contained 2 views, the code 73620, two views, would be used. Details make the difference: An x-ray of a hip, unilateral, one view is code 73500. An x-ray of a hip, complete, minimum of two views is code 73510.
RAD PATH
RAD PATH
An x-ray of a hip, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis is code 73520. An x-ray of a hip during an operative procedure is code 73530. An x-ray of pelvis and hips, infant or child, minimum of two views is code 73540.
Transcatheter Services
Transcatheter supervision and interpretation codes include the following services: I Contrast, angiography/venography, roadmapping, fluoroscopic guidance for the intervention I Measurement of the vessel I Angiography/venography completion, except for procedures through existing catheters for follow-up studies I Diagnostic angiography/venography performed during a transcatheter therapeutic radiological and interpretive service is separately reportable, unless otherwise specified
Diagnostic Ultrasound
Terminology
Term
A-mode M-mode
Definition
Signifies a one-dimensional ultrasonic measurement procedure Signifies a one-dimensional ultrasonic record amplitude and velocity of moving echo-producing structures Signifies a two-dimensional ultrasonic scanning procedure with a two-dimensional display Signifies a two-dimensional ultrasonic scanning procedure with display of both twodimensional structure and motion with time
B scan Real-time scan
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Doppler evaluation of vascular structures is separately reportable, unless color flow is used only for anatomic structure identification. A complete ultrasound examination of the abdomen consists of B-mode scans of: I Liver I Gallbladder I Common bile duct I Pancreas I Spleen I Kidneys I Upper abdominal aorta I Inferior vena cava I Any abnormality found in the abdomen A complete ultrasound examination of the retroperitoneum consists of B-mode scans of the: I Kidneys I Abdominal aorta I Common iliac artery origins I Inferior vena cava I Any abnormality found in the retroperitoneum
Radiation Oncology
Items Included in Radiation Oncology
1. 2. 3. 4. 5. 6. 7. 8. 9. Initial consultation Clinical treatment planning Simulation Medical radiation physics Dosimetry Treatment devices Special services Clinical treatment management procedures Normal follow-up care for 3 months following completion of radiation
RAD PATH
RAD PATH
Clinical Treatment Planning
Treatment planning for radiation oncology is a highly specialized service, which includes the following: 1. Interpretation of special testing 2. Tumor localization 3. Treatment volume determination 4. Treatment time/dosage determination 5. Choice of treatment modality 6. Determination of number and size of treatment ports 7. Selection of appropriate treatment devices
Treatment Planning Definitions

1. Simple Planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking Planning requires three or more converging ports, two separate treatment areas, multiple blocks, or special time dose constraints Planning requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotating or special beam considerations, combination of therapeutic modalities
2.
Intermediate
3.
Complex
1.
Therapeutic Radiology Simulation Definitions Simple Simulation of a single treatment area with either a single port or parallel opposed ports; blocking is simple or may not exist
Intermediate Simulation of three or more converging ports, two separate treatment areas, multiple blocks
2.
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131
3.
Therapeutic Radiology Simulation Definitions Complex Simulation of tangential portals, three or more treatment areas, rotation or arc therapy, complex blocking, custom shielding blocks, brachytherapy source verification, hyperthermia probe verification, or any use of contrast materials
ThreeThree-dimensional reconstruction of dimensional tumor volume and surrounding reconstruction of tumor volume and surrounding critical normal tissue structures from direct CT and or MRI scans in preparation for noncoplanar or coplanar therapy; the simulation uses documented three-dimensional beams eye view volume dose displays of multiple or moving beams
4.
Proton Beam Definitions

1. Simple Proton treatment delivery to a single treatment area using a single nontangential or oblique port, custom block with compensation and without compensation Proton treatment delivery to one or more treatment areas using two or more ports or one or more tangential or oblique ports, with custom blocks and compensators. Proton treatment delivery to one or more treatment areas using two or more ports per treatment area with matching or patching fields and/or multiple isocenters, with custom blocks and compensators.
2.
Intermediate
3.
Complex
RAD PATH
RAD PATH
Hyperthermia
Types of Hyperthermia
1. 2. 3. External (superficial, deep) Interstitial Intracavity
CPT Codes
77600, 77605 77610, 77615 77620
Physics planning and interstitial insertion of temperature sensors, and the use of external or interstitial heat-generating sources are included in the above codes. Consultations may be billed separately with the above procedures.
Clinical Brachytherapy
Brachytherapy Applications
1. 2. 3. Simple Intermediate Complex Application of 14 sources Application of 510 sources Application of more than 10 sources
Interventional Radiology Procedures

Interventional procedures are most often performed by the same physician, but may be performed by two physicians. For example, a liver biopsy may be performed by a surgeon and a radiologist. The surgeons responsibility would be the placement of the needle and the tissue sampling. The radiologist would be responsible for performing the x-rays, dye injections, and film interpretations.
Nuclear Medicine
Diagnostic Nuclear medicine codes do not include radium or other radioelements and should be reported separately. Nuclear medicine procedures may be performed independently or during the course of care.
132
133
Therapeutic The administration codes for oral and intravenous administration are inclusive of the mode of administration. When reporting intra-arterial, intracavitary, and intra-articular administration, also use the following codes when appropriate: I Appropriate injection and or procedure codes I Imaging guidance I Radiological supervision and interpretation codes Basic Radiology Definitions Term
Anteroposterior (AP) Anteroposterior and lateral Contrast material Front to back Two projections are included in this examination: front to back and side Usually a radiopaque material that is placed into the body to enable a system or body structure to be visualized; common terms include nonionic and low osmolar contrast medial (LOCM), ionic and high osmolar contrast media (HOCM), barium, and gadolinium Patient lying on their side Face forward Side view A form of imaging, including x-ray, fluoroscopy, ultrasound, nuclear medicine, duplex Doppler, CT, and MRI Oblique view of the object is being xrayed Back to front Immediate imaging, usually in movement
Definition
Decubitus (DEC) Frontal Lateral (LAT) Modality
Oblique (OBL) Posteroanterior (PA) Real-time
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Basic Radiology Definitions (continued) Term
Stent Subtraction
Definition
Tube to provide support in a body cavity or lumen The removal of an overlying structure to better visualize the structure in question; this is done in a series by imposing one x-ray on top of another A specialized type of x-ray imaging that provides slices through a body structure to obliterate overlying structures; commonly performed for studies on the kidneys or the temporomandibular joint (TMJ)
Tomogram
Laboratory
Laboratory and pathology studies cover the following areas: I Organ panels I Urinalysis I Chemistry I Hematology I Blood banking I Drug testing I Cytopathology I Surgical pathology Organ panels consist of various components that are generally ordered together. An example can be seen in the following basic metabolic panel:
134
135
Test
Calcium Carbon dioxide Chloride Creatinine Glucose Potassium Sodium Urea nitrogen
CPT Code
82310 82374 82435 82565 82947 84132 84295 84520
The above tests, as with other panels, are components of the basic metabolic panel and would be billed using CPT code 80048. Billing all of the above codes individually would be unbundling (complete description of this term can be found in Tab 5) and, therefore, would be considered a matter of fraud and abuse. If only two of the above tests are ordered, only the two individual codes would be billed. Other organ panels are:
Panel
General health panel Electrolyte panel Comprehensive metabolic panel Obstetric panel Lipid panel Renal function panel Acute hepatitis panel Hepatic function panel
CPT Code
80050 80051 80053 80055 80061 80069 80074 80076
In addition to the widely ordered panels above, other common tests are:
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Test
Urinalysis, by dip stick, non-automated, with microscopy Urinalysis, by dip stick, automated, with microscopy Urinalysis, by dip stick, non-automated, without microscopy Urinalysis, by dip stick, automated, without microscopy Cholesterol, total Triglycerides Glucose, quantitative, except reagent strip Glucose, blood, reagent strip Glucose tolerance test, 3 specimens Beyond 3 specimens Glucose, monitoring device for home use Prostate specific antigen (PSA) Thyroid stimulating hormone (TSH) Gonadotropin, chorionic, quantitative (HCG) Blood count, automated diff with WBC Complete blood count (CBC), automated, with automated diff. Includes Hgb, Hct, RBC, WBC, and platelet count Complete blood count (CBC) without diff. Prothrombin time Partial thromboplastin (PTT) Urine culture, bacterial, quantitative colony count Sensitivity studies, antibiotic disk method, per plate (12 fewer discs)
CPT Code
81000 81001 81002 81003 82465 84478 82947 82948 82951 82952 82962 84152 84443 84702 85004 85025
85027 85610 85730 87086 87184
136
137
Surgical Pathology
Surgical pathology codes include accession, examination, and report. There are six levels of surgical pathology codes.
Level
I II
Definition and Examples of Level

Surgical pathology, gross exam Surgical pathology, gross and microscopic exam I Appendix I Skin, plastic repair I Vas deferens, sterilization Surgical pathology, gross and microscopic exam I Carpal tunnel tissue I Gallbladder I Tonsils Surgical pathology, gross and microscopic exam I Colon biopsy I Joint resection I Stomach biopsy Surgical pathology, gross and microscopic exam I Breast, mastectomy partial/simple I Cervix, conization I Liver biopsy needle/wedge Surgical pathology, gross and microscopic exam I Colon, total resection I Prostate, radical resection I Soft tissue tumor, extensive resection
CPT Code
88300 88302
III
88304
IV
88305
88307
VI
88309
RAD PATH
RAD PATH
Collection of Specimen
Description
1. Venipuncture, routine collection of venous blood 2. Venipuncture, routine collection of venous blood, Medicare patient 3. Collection of capillary blood specimen (heel, finger, ear)
CPT Code
36415 G0001 36416
Modifiers
Modifiers used in pathology coding are 22, 26, 32, 52, 53, 59, 90, 91.
Modifier
22
Description
Billing Notes
26
Unusual proce- I Used rarely in radiology, and dural service when used, requires additional documentation to support their use I Not recognized by most carriers I Used with CT scans when additional views or slices are needed I DO NOT OVER USE Professional I Used when the physician component provides an interpretation of the study; this interpretation requires a separate written and signed report; simple verbiage, such as within normal limits (WNL) or fx radius-normal, does not meet the requirements
138
139
Modifier
32
Description
Mandated service
Billing Notes
I Used when the service is mandated I Used rarely in radiology; sometimes used by Workers Compensation I Use this modifier when a procedure is partially reduced or eliminated at the physicians direction I Used when a postreduction film of fracture care is taken; use the comprehensive x-ray code to identify the fracture; once the fracture has been reduced, use the comprehensive x-ray code again with modifier 52 to indicate that a reduced level of service was provided I Used when the physician chooses to terminate the procedure I Would be used when an x-ray procedure is discontinued because the patient is at risk I Use a diagnosis code that is appropriate, such as, procedure not carried out because of contraindication (V64.1), procedure not carried out because of patients election (V64.2), procedure not carried out for another reason (V64.3)
52
Reduced service
53
Discontinued service
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Modifier
59
Description
Distinct procedural service
Billing Notes
I This modifier indicates that the procedure was distinct or separate from the other procedure performed on the same day I Used when laboratory procedures are performed by someone other than the reporting physician I Used when it is necessary to report the same test on the same day to obtain multiple test results I Cannot be used for confirmation of results I Cannot be used when there is a problem with the specimen or equipment
90
Reference (outside) laboratory Repeat clinical diagnostic laboratory test
91
140
141
Unbundling
The process of coding integral services separately from a procedure is called unbundling. If the component is considered part of the bundled service, it cannot be coded separately. For example, CPT code 93000 is a code for Electrocardiogram, routine ECG, with at least 12 leads, with interpretation and report. If codes 93005 (ECG tracing only, without interpretation and report) and 93010 (ECG with interpretation and report only) were billed together, it would be considered unbundling, as both elements are found in the allinclusive CPT code of 93000.
Add-On Codes
There are codes that are performed in addition to the main CPT code. Add-On Code Facts: I These codes are called Add-on codes. I They are not reported with the modifier 51 for multiple procedures as other CPT codes would be. I They cannot be billed by themselves. I Add-on codes are identified by wording that designates it is an Add-on code.
Examples: Primary Code

96409
Description
Add-On Code
Description
Chemotherapy administration, intravenous; push technique
96415 Infusion technique, 1 to 8 hours, each additional hour (list separately in addition to code for primary procedure) 92608 Each additional 30 minutes (list separately in addition to code for primary procedure)
92607
Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
MED
There are instances where more than one add-on code is used. See the following table.
Primary Code
Any outpatient evaluation and management code (e.g., 9920199205, 9921199215, 9924199245)
Add-On Code
99354
Description
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient Evaluation and Management code)
Second AddOn Code

99355
Description
Each additional 30 minutes (list separately in addition to code for primary procedure)
MED
142
143
Multiple Procedure/Services
Certain procedures can be reported separately without the risk of unbundling. For example, a patient hospitalized for a mental condition can receive interactive psychotherapy in conjunction with an Evaluation and Management code. Both the psychotherapy code and the Evaluation and Management codes would be billed for that date of service.
Separate Procedures
Any code that is designated as a separate procedure cannot be billed in addition to the code for the comprehensive procedure as it is considered to be a part of the comprehensive procedure. If a code listed as separate procedure is coded independent of any other procedure, it can then be billed.
Injections
Injections of immune globulins require the CPT code for the actual immune globulin serum and a CPT code for the administration of the injection. Immune globulin codes range from 9028190399 for the serum. They should be reported with the appropriate delivery code. These codes range from 90780 to 90784. A description of codes 90780 and 90781 can be found in the following section. Vaccines and toxoids are reported using codes 9047690748. Descriptions of codes 9078290784 follow.
CPT Code
90772
Description
Therapeutic, prophylactic, or diagnostic injection (specify material injected); subcutaneous or intramuscular I Intra-arterial I Intravenous
90773 90774
MED
MED
Immunization administration codes for vaccines are reported using the following administration codes.
CPT Code
90465
Description
Immunization administration under 8 years old (includes percutaneous, intradermal, subcutaneous, or intramuscular), when the physician counsels the patients; first injection (single or combination vaccine/toxoid), per day I Each additional injection (single or combination vaccine/toxoid) per day; list separately in addition to code for primary procedure Immunization administration under 8 years old (includes intranasal or oral routes of administration) when the physician counsels the patient; first administration (single or combination vaccine/toxoid), per day I Each additional administration (single or combination vaccine/toxoid) per day; list separately in addition to code for primary procedure Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular), one vaccine (single or combination vaccine/toxoid) I Each additional vaccine (single or combination vaccine/toxoid); list separately in addition to code for primary procedure. Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) I Each additional vaccine (single or combination vaccine/toxoid); list separately in addition to code for primary procedure
90466
90467
90468
90471
90472
90473
90474
144
145
Common Vaccines and Toxoids
CPT Code
90632 90645
Description
Hepatitis A vaccine, adult dosage, for intramuscular use Hemophilus influenza b vaccine (Hib), HbOC conjugate (4-dose schedule), for intramuscular use Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use Influenza virus vaccine, split virus, preservative free, for children 635 months of age, for intramuscular use Influenza virus vaccine, live, for intranasal use Lyme disease vaccine, adult dosage, for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DtaP), for use in individuals younger than 7 years, for intramuscular use Diphtheria, tetanus toxoids (DT) absorbed for use in individuals younger than 7 years, for intramuscular use Tetanus toxoids adsorbed, for intramuscular use Mumps virus vaccine, live for subcutaneous use Measles virus vaccine, live for subcutaneous use Measles, mumps, and rubella virus vaccine, live for subcutaneous use Poliovirus vaccine, (any type) (OPV), live, for oral use Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
90648
90656
90660 90665 90700
90702
90703 90704 90705 90707 90712 90713
MED
MED
Therapeutic, Diagnostic Infusions (Excludes Chemotherapy)
CPT codes 90780 and 90781 are used to report prolonged intravenous injections. They are not used for billing of the following services: I Intradermal I Subcutaneous I Intramuscular I Routine intravenous (IV) Choose the appropriate code based on time.
CPT Code
90760 90761
Description
Intravenous infusion, hydration; initial Each additional hour up to 8 hours (list separately in addition to the code for the primary procedure).
Time
Up to 1 hour 28 hours
Psychiatry
Billing codes for psychiatry services include: 9080190802 Psychiatric diagnostic interview examinations Office or Outpatient 9080490809 Insight oriented, behavior modifying and/or supportive psychotherapy 9081090815 Interactive psychotherapy Inpatient Hospital, Partial Hospital, or Residential Care Facility 9081690822 Insight oriented, behavior modifying and/or supportive psychotherapy 9082390829 Interactive psychotherapy 9084590857 Other psychotherapy 9086290899 Other psychiatric services or procedures
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147
Guide to coding psychiatric services: I Psychiatric diagnostic interviews must include history, mental status, and a disposition I Interactive psychiatric diagnostic interviews are generally provided to children; they use physical aids and nonverbal communication to overcome barriers between the patient and the clinician due to language skills that have either been lost, or have not yet developed I Psychiatric therapeutic services are found in two categories: I Interactive psychotherapy I Insight oriented, behavior modifying and/or supportive psychotherapy I Some patients receive psychotherapy only, while others receive Evaluation and Management services (see Tab 2) in addition I Psychotherapy codes are chosen based on the type of psychotherapy, the place of service, face-to-face time spent with the patient, and whether or not an Evaluation and Management code is performed on the same day. I Medicare will not accept psychiatric therapy codes 9080490829 billed on the same day as an Evaluation and Management code.
Physical Medicine and Rehabilitation

Important facts: I Medicare patients and many other carriers require a written plan of care before the patient begins physical therapy. I Some codes are time-based codes and therefore require the documentation of time to be billable.
MED
MED
Some examples of commonly used physical therapy codes are:
CPT Code
97001 97002 97003 97004 97010 97012 97014 97022 97026 97028 97032 97033 97035 97110
Description
Physical therapy evaluation Physical therapy re-evaluation Occupational therapy evaluation Occupational therapy re-evaluation Application of a modality to one or more areas; hot or cold packs I Traction, mechanical I Electrical stimulation (unattended) I Whirlpool I Infrared I Ultraviolet Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes I Iontophoresis, each 15 minutes I Ultrasound, each 15 minutes Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility I Gait training (includes stair climbing) I Massage, including effleurage, ptrissage, and/ tapotement (stroking, compression, percussion Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic procedure(s), group (2 or more individuals)
97116 97124 97140
97150
148
149
Gastroenterology
Gastroenterology is the study of the stomach and intestine and diseases associated with them. Following is a select list of the most commonly used codes for these services. A complete listing can be found in the Medicine section of the CPT book under subsection Gastroenterology.
CPT Code
91000
Description
Esophageal intubation and collection of washings for cytology, including preparation of specimens (separate procedure) Esophageal motility Gastric intubation, and aspiration or lavage for treatment (for ingested poisons)
91010 91105
Gastroenterology Surgical Codes

There are many other gastroenterology codes listed in the surgery section of the CPT book. Some of the most commonly used codes are: Important definitions: I Sigmoidoscopy: the examination of the entire rectum, sigmoid colon, and may include examination of a portion of the descending colon. I Colonoscopy: the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. Note: There is sometimes confusion between the two procedures and codes explained above. It is important to read the procedural report carefully to establish the completeness of the examination.
MED
MED
CPT Code
43235
Description
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimens by brushing or washing (separate procedure) I With biopsy, single or multiple I With injection sclerosis of esophageal and/or gastric varices I With directed placement of percutaneous gastrostomy tube Endoscopic retrograde cholangiopancreatography (ERCP) I With biopsy, single or multiple I With sphincterotomy/papillotomy I With endoscopic retrograde removal of calculus from biliary and/or pancreatic ducts Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) I With biopsy, single or multiple I With removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery I With removal of tumor(s) polyp(s), or other lesion(s) by snare technique Colonoscopy I With biopsy, single or multiple I With control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) I With ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery, or snare technique
43239 43243 43246 43260 43261 43262 43264 45330 45331 45333 45338 45378 45380 45382 45383
150
151
CPT Code
45384 45385
Description
I With removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery I With removal of tumor(s), polyp(s), or other lesion(s) by snare technique
Ophthalmology
Ophthalmology is the study of the eye, its anatomy, physiology, and pathology. Following is a select list of the most commonly used codes for these services. A complete listing can be found in the Medicine section of the CPT book under subsection Ophthalmology. Three types of ophthalmology services:
Type Intermediate
Description Evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy Compre- Evaluation of the complete visual system; consists of hensive a single service entity but need not be performed at one session; includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields, and basic sensorimotor examination; it often includes, as indicated, biomicroscopy, examination with cycloplegia or mydriasis and tonometry; includes initiation of diagnostic and treatment programs Special Services in which a special evaluation of part of the visual system is made, which goes beyond the services included under the general ophthalmological services
MED
MED
Special services that are separately billable are: I Fluorescein angioscopy I Quantitative visual field examination I Refraction or extended color vision examination (Nagels anomaloscope)
CPT Code
92002
Description
Ophthalmological service: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient I Comprehensive, new patient, one or more visits Ophthalmological service: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; intermediate, established patient I Comprehensive, established patient, one or more visits
92004 92012
92014
Codes used for office visits can be either the Ophthalmology codes or the Evaluation and Management codes. It is the physicians choice.
Biofeedback
There are two codes used to report biofeedback services. These codes may require pre-authorization by the carrier.
CPT Code
90901 90911
Description
Biofeedback training by any modality Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
152
153
Dialysis
End-Stage Renal Disease (ESRD)
ESRD services are outpatient codes and are reported with the following codes:
CPT Code
9091890921 9092290925
Description
ESRD-related services per full month ESRD-related services (less than a full month), per day
Guide to Reporting ESRD

I I I I
The various levels are age-specific. These codes are not billable with hospitalization codes. Codes 9091890921 are used to report consecutive services. Codes 9092290925 are used to report services that are not performed consecutively during the month. I Each month is considered to be 30 days. I Procedures for other medical problems and complications unrelated to ESRD are not included in the monthly ESRD service and are reported separately.
Hemodialysis
Hemodialysis codes are inpatient codes used to report hemodialysis procedures in addition to Evaluation and Management codes for the same day. These services are reported with the following codes:
CPT Code
90935 90937 90940
Description
Hemodialysis procedure with single physician evaluation Hemodialysis procedure requiring repeated evaluations with or without substantial revision of the dialysis prescription Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method
MED
MED
Miscellaneous Dialysis Procedures
There are dialysis procedures other than hemodialysis. These codes are reported using CPT codes 90945 and 90947.
CPT Code
90945
Description
Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated physician evaluations, with or without substantial revision of dialysis prescription Hemoperfusion, e.g., with activated charcoal or resin
90947
90997
Dialysis Training
Dialysis training is reported using CPT codes 9098990993. Code 90989 is used to report the completion of the dialysis-training course. Code 90993 is used to report training per session.
Otorhinolaryngologic Services
Otorhinolaryngology is the study of the ear, nose, and throat. Following is a select list of the most commonly used codes for these services. A complete listing can be found in the Medicine section of the CPT book under subsection Special Otorhinolaryngologic Services. Diagnostic procedures are reported as part of the office visit code and cannot be billed for separately. This includes such tests as otoscopy, rhinoscopy, and tuning fork test, and whispered voice.
154
155
CPT Code
92506 92507
Description
Evaluation of speech, language, voice, communication, and or auditory processing Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
Audiologic Function Tests

Commonly Used Codes
CPT Code
92551 92552 92553 92567 92568 92590 92591 92592 92593 92594 92595
Description
Screening test, pure tone, air only Pure tone audiometry (threshold); air only I Air and bone Tympanometry (impedence testing) Acoustic reflex testing; threshold Hearing aid exam and selection; monaural I Binaural Hearing aid check I Binaural Electroacoustic eval for hearing aid, monaural I Binaural
Cardiovascular Services
Cardiology is the study of the heart and its functions. Following is a select list of most commonly used cardiology codes. A complete listing can be found in the Medicine section of the CPT book under subsection Cardiovascular.
Important Definitions
I Echocardiography: Echocardiography includes obtaining ultrasonic signals from the heart and great arteries, with two-dimensional image and/or Doppler ultrasonic signal documentation, and interpretation and report.
MED
MED
I Cardiac catheterization: Cardiac catheterization is a diagnostic medical procedure that includes introduction, positioning and repositioning of catheter(s), when necessary, recording of intracardiac and intravascular pressure, obtaining blood samples for measurement of blood gases or dilution curves and cardiac output measurements (Fick or other method, with or without rest and exercise and/or studies) with or without electrode catheter placement, final evaluation and report of procedure.
CPT Code
92950 92982 93000 93005 93010 93015
Description
Cardiopulmonary resuscitation (CPR) (cardiac arrest) Percutaneous transluminal coronary balloon angioplasty; single vessel Electrocardiogram, routine ECG, with at least 12 leads; with interpretation and report I Tracing only, without interpretation and report I Interpretation and report only Cardiovascular stress test using maximal or submaximal treadmill or bicycle, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report Rhythm ECG, one to three leads; with interpretation and report Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete
93040 93224
93307
156
157
CPT Code
93320
Description
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); complete Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography) Echocardiography, transthoracic, real-time with image documentation (2D) with or without Mmode recording; during rest and cardiovascular stress test using treadmill, bicycle exercise and/ or pharmacologically induced stress, with interpretation and report Right heart catheterization Left heart catheterization
93325
93350
93501 93510
Electrocardiograms can be called either ECGs or EKGs.
Pulmonary
Pulmonary is the study of the lungs and/or the pulmonary artery. Following is a select list of most commonly used pulmonary codes. A complete listing can be found in the Medicine section of the CPT book under subsection Pulmonary.
CPT Code
94010
Description
Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation Bronchospasm evaluation: Spirometry as in 94010, before and after bronchodilator (aerosol or parenteral) Vital capacity, total (separate procedure)
94060
94150
MED
MED
CPT Code
94656 94657 94660 94664
Description
Ventilation assist and management, initiation of pressure volume preset ventilators for assisted or controlled breathing, first day I Subsequent days Continuous positive airway pressure ventilation (CPAP), initiation, and management Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device
Allergy and Clinical Immunology

Allergy sensitivity testing is the performance and evaluation of selective cutaneous and mucous membrane tests in correlation with the history, physical examination, and other observations of the patient. Immunology is the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage that is maintained as maintenance therapy. A complete listing of codes can be found in the Medicine section of the CPT book under subsection Allergy and Clinical Immunology.
Important Billing and Coding Facts
I Professional services (Evaluation and Management codes) are included in CPT codes 9511595199, which are the allergen immunotherapy codes I Evaluation and Management codes can only be used if there is a separate and identifiable service being performed on the same date. Use modifier 25 with the Evaluation and Management code should this occur I Codes 95115 and 95117 do not include the extract itself, only administration of the allergy injection I Codes 95120 through 95134 include both the administration of the injection and the extract. These are referred to as complete service codes, as they also include the preparation, antigen, supplies, and observation of the patient after injection
158
159
I Code number of allergens correctly; for example: I 95130: Single stinging insect venom I 95131: Two stinging insect venoms I 95132: Three stinging insect venoms
Neurology and Neuromuscular Procedures

Neurology is the study of the nervous system. Following is a select list of most commonly used neurology codes. A complete listing can be found in the Medicine section of the CPT book under Neurology and Neuromuscular Procedures.
Important Billing and Coding Facts
I Hyperventilation and/or phonic stimulation is included in codes 9581295822 and cannot be billed separately I EEG codes are time-based codes and must be chosen correctly based on time of monitoring I Electromyography and nerve conduction tests are based on the number of extremities tested
CPT Codes
95812 95813 95816 95819 95860 95861 95863 95864
Description
Electroencephalogram (EEG) extended monitoring; 4160 minutes I Greater than 1 hour Electroencephalogram (EEG) including recording awake and drowsy I Including awake and asleep Needle electromyography; one extremity with or without related paraspinal areas I Two extremities with or without related paraspinal areas I Three extremities with or without related paraspinal areas I Four extremities with or without related paraspinal
MED
MED
CPT Codes
95900 95903 95904
Description
Nerve conduction, amplitude and latency, velocity study, each nerve; motor, without F-wave study I Motor, with F-wave study I Sensory
Chemotherapy
Chemotherapy is the treatment of various diseases by using chemical agents. Following is a select list of the most commonly used Chemotherapy codes. A complete listing can be found in the Medicine section of the CPT book under Chemotherapy.
Important Facts
I Evaluation and Management codes can be billed with Chemotherapy procedures when warranted I Preparation of the chemotherapy is included in the administration code I When chemotherapy is delivered by different techniques, each code should be billed separately by method of delivery
CPT Code
96401 96402 96409 96413 96415 96420
Description
Chemotherapy administration, subcutaneous or intramuscular, nonhormonal antineoplastic I Hormonal antineoplastic Chemotherapy administration, intravenous; push technique, single or initial substance/drug I Intravenous infusion technique, up to 1 hour, single or initial substance/drug I Intravenous infusion technique, 1 to 8 hours, (list separately in addition to code for primary procedure) Chemotherapy administration, intra-arterial push technique
160
161
CPT Code
96422 96423
Description
I Infusion technique, up to 1 hour I Infusion technique, each additional hour up to 8 hours, each additional (list separately in addition to code for primary procedure) Refilling and maintenance of portable pump Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (e.g., intravenous, intra-arterial)
96521 96522
Moderate Sedation (Conscious)

Moderate (conscious) sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Important Facts
I Pre- and postsedation evaluations are included in these codes and cannot be billed for separately I Does not include maximum allowable concentration (MAC) anesthesia or minimal or deep sedation The following services cannot be billed for separately: I Assessment of the patient I Establishment of IV access and fluids to maintain patency, when performed I Administration of agent(s) I Maintenance of sedation I Monitoring of oxygen saturation, heart rate, and blood pressure I Recovery (not included in intra-service time)
MED
MED
CPT Code
99143
Description
Moderate sedation services (other than 00100 01999), provided by the same physician performing the diagnostic or therapeutic service that the sedation support, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status; under 5 years of age, first 30 minutes intraservice time. I Age 5 years or older, first 30 minutes intraservice time I Each additional 15 minutes intra-service time (list separately in addition to code for primary service) Moderate sedation services (other than 00100 01999), provided by the physician other than the health-care professional performing the diagnostic or therapeutic service that the sedation supports; under 5 years of age, first 30 minutes intra-service time I Age 5 years or older, first 30 minutes intraservice time I Each additional 15 minutes intra-service time (list separately in addition to code for primary service)
99144 99145
99148
99149 99150
162
163
(ICD-9-CM)
The International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM) is the coding system used to report the diagnosis or condition of the patient. This system takes a description of the patients condition, illness, or injury and translates it into numerical and alphanumerical format. The ICD-9-CM manual is published in the Spring and Fall of each year. To ensure that the codes billed are accurate, it is necessary to purchase a new manual each year. These codes provide the medical necessity for the service or procedure that was performed. Dx Codes Medical Necessity Reimbursement
Three Volumes of ICD-9-CM

Volume 1 Volume 2 Volume 3 This volume consists of the most specific information about the conditions, diseases, and injuries This volume contains an alphabetic listing of Volume 1 This volume contains information that is reserved for hospital use
Volume One
A listing of the chapters found in Volume of the ICD-9-CM manual can be found in the following:
Chapter
1 2 3 4
Title
Infectious and Parasitic Diseases Neoplasms Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders Diseases of the Blood and BloodForming Organs
Diagnosis Codes
Codes 001139 Codes 140239 Codes 240279 Codes 280289
ICD-9-CM
ICD-9-CM
Chapter
5 6 7 8 9 10 11
Title
Mental Disorders Diseases of the Nervous System and Sense Organs Disease of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Complications of Pregnancy, Childbirth, and the Puerperium (the period of confinement after labor) Diseases of the Skin and Subcutaneous Tissue Diseases of the Musculoskeletal System and Connective Tissue Congenital Anomalies Certain Conditions Originating in the Perinatal Period (period shortly before and after birth) Symptoms, Signs, and Ill-Defined Conditions Injury and Poisoning
Diagnosis Codes
Codes 290319 Codes 320389 Codes Codes Codes Codes 390459 460519 520579 580629
Codes 630677
12 13 14 15
Codes 680709 Codes 710739 Codes 740759 Codes 760779
16 17
Codes 780799 Codes 800999
Supplemental Chapters
V Codes: Supplemental Classification of Factors of Influencing Health Status and Contact with Health Services E Codes: Supplemental Classification of External Causes of Injury and Poisoning
Diagnosis Codes
Codes V01V83
Codes E800E999
164
165
Appendices
A B C D E
Title
Morphology of Neoplasms (M Codes) Glossary of Mental Disorders Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9CM Equivalents Classification of Industrial Accidents According to Agency Three-Digit Categories
Volume Two
Three Sections
1 Index to Diseases and Injuries 2 Table of Drugs and Chemicals 3 Alphabetic Index to External Causes of Injuries and Poisonings
Easy Diagnosis Coding

Steps
1 2 3 4 5 6
Rules
Determine the main term that best describes the condition or symptom of the patient Use Volume 2 of the ICD-9-CM book to look up that main term; this Volume is alphabetized Read any cross-references such as see also and go to that category Read all subterms and explanations; refer to indented terms under the main term to obtain further clarification Check the code listed in Volume 2 against the tabular listing in Volume 1 Review all instructions and notes in Volume 1 to be sure the code selected is accurate
ICD-9-CM
ICD-9-CM
Coding Conventions
Convention
Typeface
Definition/Example
Bold type indicates main terms and codes in Volume 1. EXAMPLE: CONVULSIONS Brain 780.39 Febrile 780.31 Italicized type This type indicates categories that cannot be reported as a primary diagnosis code. This type is also used for identification of exclusion notes. Example: 250 Diabetes Mellitus Excludes gestational diabetes (648.8) [Bracketed] These are used to enclose synonyms, alternative terminology, or explanatory phrases. Example: 482.2 Pneumonia due to Hemophilus influenza [H. influenza] (Parentheses) These are used to enclose supplementary words that may be present in the description. Example: 198.4 Other parts of nervous system Meninges (cerebral) (spinal) Colons: These are used in the tabular listing after an incomplete term that needs a modifier to make it assignable. Example: 021.1 Enteric tularemia Tuleremia: cryptogenic intestinal Braces These enclose a series of terms, each of which is modified by the statement appearing to the right of the brace. Example: 560.2 Volvulus of intestine, Knotting bowel or colon Strangulation Torsion Twist
166
167
ICD-10
The following list contains changes that exist between the 9th revision of the ICD code book (ICD-9-CM) and the 10th revision. Volume I is a tabular listing that contains alphanumeric codes. Volume II is an instructional manual, which provides rules and regulations for mortality and morbidity coding. Volume III is the alphabetic index, which provides the index to all the codes listed in Volume I. The ICD-10 contains more descriptions.
ICD-9-CM
ICD-10
Old Title: International Classifi- New Title: International Statistical Classification of Diseases cation of Diseases, 9th Reviand Related Health Problems sion, Clinical Modifications Splits out the chapter to the Contains a chapter titled following chapters: Diseases of the Nervous I Diseases of the Nervous System and Sense Organs System I Diseases of the Eye and Adnexa I Diseases of the Ear and Mastoid Process Contains a chapter titled Renames this chapter Mental and Mental Disorders Behavioral Disorders Supplement: Classification of Becomes a chapter and is no Factors Influencing Health longer considered a suppleStatus and Contact with ment to the code book Health Services (V codes) Supplement: Classification of Becomes a chapter and is no External Causes of Injury longer considered a suppleand Poisoning (E codes) ment to the code book Contains codes that require Contains codes that require 4 and 5 digits more than 5 digits
Many other changes were made to the descriptions found throughout the book. This book was published in 1994 and is currently used in Europe. It is expected to be implemented in the United States in the year 2007.
ICD-9-CM
ICD-9-CM
V Codes
V codes describe circumstances surrounding a patients health status and identify reasons for medical treatment other than for a disease process or injury.
Three Categories of V Codes

1 2 3 Problem-Oriented Service-Oriented Fact-Oriented
V codes can be used as primary codes in certain instances. For examples, see the following table:
Scenario
Patient presents for removal of cast Patient presents for preoperative clearance Patient presents for chemotherapy
Code
V54.8 V72.8 V58.1
Problem-Oriented
A problem-oriented V code identifies a factor that may affect the patient, but that is not an injury or an illness. Examples of problem-oriented V codes are: I V76.11: Special screening mammogram for high-risk patients I V46.13: Encounter for weaning from a respirator
Service-Oriented
A service-oriented V code identifies that a service was an examination, therapy, ancillary service, or aftercare. It will identify a patient that is not currently sick, but who is looking for medical services for another reason. Examples of service-oriented V codes are: I V67.2: Follow-up examination following cancer chemotherapy I V58.32: Removal of sutures
168
169
Fact-Oriented
A fact oriented V code simply states a fact. Examples of factoriented V codes are: I V27.2: Outcome of delivery; twins, both live born I V02.6: Viral hepatitis
E Codes
E codes are used to establish medical necessity, identify causes of injury and poisoning, and identify medications. 1 2 3 4 5 6 Can never be primary codes Do not affect the amount of reimbursement Can speed up the reimbursement process by providing additional information to the insurance payor Child abuse takes precedent over all other E codes Cataclysmic events take priority over all other E codes except for abuse Transportation accidents take priority over all other E codes except cataclysmic events and abuse
Examples of E codes are: I E884.0: Fall from playground equipment I E917.0: Struck accidentally by object or persons in sports I E901.0: Excessive cold
Late Effect Codes

Two Types of Late Effects Codes I General I Injury-related Late effect codes should be the primary diagnosis when it is the primary reason for the visit. To use late effect codes, code first the condition of the late effect and code the late effect code second.
ICD-9-CM
ICD-9-CM
For example: I 012.22: Isolated tracheal tuberculosis, bacterial examination unknown I 137.0: Late effects of respiratory tuberculosis
General Late Effect Codes

These codes describe a residual condition produced after the acute phase of an illness (usually 1 year or more). Examples of these codes are: I 137.0: Late effects of tuberculosis I 438._: Late effects of cerebrovascular accident
Late Effects of Injuries, Poisonings, Toxic Effects, and Other External Causes
These codes can be used to indicate a cause of late effect in which the cause is classified elsewhere. These late effect codes can be used at any time after the acute injury. Examples of these codes are: I 906.3: Late effect of contusion I 908.0: Late effect of internal injury to chest
Examples of Late Effects With the Cause

Cause
Fracture Cardiovascular accident Third-degree burn Polio Laceration Breast implants
Late Effect
Malunion Hemiplegia Deep scarring Contractures Keloids Ruptured implant
170
171
Truncated Diagnosis Code
A truncated diagnosis code is one that has not reported with the required 4th or 5th digit. There are fewer than 100 codes that are three-digit codes, all others require additional digits for billing. It is the responsibility of the provider to assign the diagnosis codes. Example: Abdominal Pain 789.0_ (requires a 5th digit) 0 Unspecified site 1 Right upper quadrant 2 Left upper quadrant 3 Right lower quadrant 4 Left lower quadrant 5 Periumbilical 6 Epigastric 7 Generalized 8 Other specified site
Multiple Diagnosis Codes

I All diagnosis codes must be prioritized in order of significance and linked to the appropriate procedure or service. I When coding both surgical and medical problems on the same patient, list the surgical problem first. When the severity of the medical problem supersedes the importance of the surgical problem, the medical problem is then listed first. I A maximum of four diagnosis codes can be submitted per claim.
Nonspecific/Unspecified Codes
Codes that are referred to as nonspecific or unspecified are not the most specific codes possible for the reporting of the diagnosis or condition of the patient. In Volume 1, these codes are listed as
ICD-9-CM
ICD-9-CM
NOS (not otherwise specified) and in Volume 2, they are listed as NEC (not elsewhere classified). An example of these codes would be: I 420.90: Acute pericarditis, unspecified NOS I 682.9: Cellulitis, NOS I 599.0: Infection, genitourinary tract NEC
Signs and Symptom Codes

When a definitive diagnosis code is not available, use a sign or symptom code. Example: Suspected pneumonia, but not sure until x-ray. Diagnoses used for this visit would be the symptoms of the patient. I Wheeze I Shortness of breath I Cough Example: Possible fracture of wrist, but not sure until x-ray. Diagnoses used for this visit would be the symptoms of the patient. I Swelling I Pain in wrist
ICD-9-CM Guidelines for Coding and Reporting

I Identify each service, procedure, or supply with a diagnosis code I Chronic diseases should be reported if appropriate I Always use the code with the highest degree of specificity; add 4th and 5th digits when appropriate I Properly link all diagnosis codes to the CPT code I Do not code using rule-out, suspected, probable, questionable, etc. I Use signs and symptoms when a definitive diagnosis code is not available
172
173
I Code the primary diagnosis code first, followed by the secondary, tertiary, and so on I Do not code a diagnosis code that is no longer applicable I For surgical procedures, code the diagnosis applicable to the procedure; if at the time the claim is filed the postoperative diagnosis is different from the preoperative diagnosis, use the postoperative diagnosis for billing
Principal Versus Primary Diagnosis Code

I Principal diagnosis: reported on inpatient hospital claims (facility, Part A Medicare); reported on UB-92 forms; the principal diagnosis is the condition determined after the study that resulted in the patients admission to the hospital I Primary diagnosis: reported by the physician (professional, Part B Medicare); reported on HCFA 1500 claim forms; the primary diagnosis is the most significant condition for which services and/or procedures were provided
Hypertension/Hypertensive Table
The hypertension table is a complete listing of hypertension codes and conditions associated with hypertension. The table consists of three columns: 1. Malignant 2. Benign 3. Unspecified Malignant hypertension is a form with vascular damage and a diastolic blood pressure reading of 130mm HG or greater. Benign is a form of mild or controlled hypertension with no damage to the patients vascular system or organs. Unspecified hypertension is where there is no notation of benign or malignant status found in the patients medical record.
ICD-9-CM
ICD-9-CM
Neoplasm Table
Neoplasms are new growths in which cell reproduction is out of control. It is important to know whether the tumor is malignant or benign. Malignant is when the growth is cancerous, invasive, or capable of spreading to other parts of the body. Benign is when the growth is noncancerous, nonmalignant, noninvasive. The Neoplasm Table is arranged by anatomical site and contains four classifications:
Type of Neoplasm
Malignant I Primary
Description
I Primary malignant growth is the original tumor site. All malignant tumors are considered primary unless otherwise noted as metastatic or secondary. I Secondary malignant growth is where the tumor has metastasized (spread) to a secondary site, either adjacent to the primary site or to a remote region of the body. I Ca in Situ is a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to other tissues or organs). I A benign growth is a noninvasive, nonspreading, nonmalignant tumor. I Uncertain behavior is a type of growth in which it is not possible to predict subsequent morphology or behavior from the submitted specimen. In order to assign a code from this column, the pathology report must specifically indicate the uncertain behavior of the neoplasm.
I Secondary
I Ca in Situ
Benign Uncertain behavior
174
175
Type of Neoplasm Unspecified nature Description
I Unspecified nature is a type of growth in which a neoplasm is identified, but there is no further indication of the histology or nature of the tumor reflected in the documented diagnosis. Assign a code from this column when the neoplasm was destroyed or removed and a tissue biopsy was performed and results are pending.
Hint: If the statement does not classify the neoplasm, refer to the Index to Diseases entry for the condition documented instead of the table. That entry will contain a code that can be cross-checked in the table.
Primary Malignancies
Primary malignancies are coded if the note in the medical record states: I Metastatic from a site I Spread from a site I Primary neoplasm of a site I A malignancy for which no specific classification is documented I A recurrent tumor Example: Carcinoma of the cervical lymph nodes, Metastatic from the breast. Primary: breast Secondary: cervical lymph nodes
Secondary Malignancies
Secondary malignancies are Metastatic and indicate that a primary cancer spread to another part of the body. Example: Metastatic carcinoma from breast to lung Assign two codes: 1. Primary malignant neoplasm of the breast: 174.9 2. Secondary neoplasm of the lung: 197.0
ICD-9-CM
ICD-9-CM
The following table lists secondary sites for malignancies: 1 2 3 4 5 6 7 8 9 10 11 12 Bone Brain Diaphragm Heart Liver Lymph Nodes Mediastinum Meninges Peritoneum Pleura Retroperitoneum Spinal Cord
Re-excision
A re-excision is when a pathologist recommends that the surgeon perform a second excision to widen the margins of the original tumor site. The pathology report may not specify a malignancy at this time, but the patient is still under treatment for the original neoplasm.
M Codes
M codes are morphology of neoplasm codes. They are used to report the type of neoplasm. They are used by the hospital to report neoplasms to the cancer registry. An example of these codes would be: I M8041/3: Small cell carcinoma NOS I M8000/0: Neoplasm, benign
176
177
Table of Drugs and Chemicals
The table of drugs and chemicals lists drugs and chemicals that have caused a poisoning or adverse effect. It is divided into six external cause codes:
External Cause
1 Poisoning
Description
These codes are assigned according to the classification of the drug or chemical involved in the poisoning These codes are used for accidental overdoing, wrong substance given or taken, drug inadvertently taken, or accidents in the use of drugs and chemical substances during a medical or surgical procedure These codes are used for the external effect caused by correct substance properly administered in therapeutic or prophylactic dosages These codes are used to report self-inflicted poisonings These codes represent a poisoning inflicted by another person who intended to kill or injure the patient These codes are used if the record does not state whether the poisoning was intentional or accidental
Codes
960989
Accident
E850E869
Therapeutic use
E930E952
4 5
Suicide attempt Assault
E950E952 E961E962
Undetermined
E980E982
ICD-9-CM
ICD-9-CM
Fracture Coding
When coding fractures, if the note does not state whether or not the fracture is open or closed, assume that it is closed and code it appropriately. When dealing with multiple injuries, list them in descending order of severity.
Types of Fractures Types of Closed Fractures

Comminuted
Description
Has more than two fragments of bone that are broken off; it is unstable and contains many bone fragments and tissue damage The fracture runs along the length of the bone The bone is broken as a result of a twisting motion and is sometimes confused with an oblique fracture Skull fracture with the bone forced inward Fracture does not break the skin and has little, if any tissue damage The vertebral column is compressed and then breaks under the pressure Fracture that severely damages the soft tissue around the fracture site A fracture caused by repeated stress to the bone Multiple fractures of the same bone occurring at the same time Bendlike fracture found mostly on children; the bone is not broken through.
Linear Spiral
Depressed Simple Impact/ Compression Complex Stress Double Greenstick
178
179
Types of Fractures (Continued) Types of Closed Fractures
Impacted
Description
The bones are broken and the ends are smashed together in a head-on fashion A fracture where the trauma leaves many Fragmented broken bones inside the patient Fracture forms an oblique break in the bone; Oblique very rare Also known as a hairline fracture; minimal Fissure trauma to the bone and tissues; it is an incomplete fracture, as it is not all the way through the bone There is a fracture with no broken skin Closed A fracture where the area has become infected Infected Compound/Open A fracture that breaks the skin Fracture is caused by some type of disease Pathological process
Miscellaneous Commonly Used Codes

Codes
278.02 305.1 333.94 338.1 338.2 519.11 528.3
Description
Overweight Tobacco use disorder Restless leg syndrome (RLS) Acute pain Chronic pain Acute bronchospasm Cellulitis and abscess
ICD-9-CM
ICD-9-CM
Miscellaneous Commonly Used Codes (Contd)

Codes
649.5 784.91 781.2 783.2 795.81 V58.32 V72.11
Description
Spotting complicating pregnancy Postnasal drip Abnormality of gait Abnormal loss of weight and underweight Elevated CEA (carcinoembryonic antigen) Encounter for removal of sutures Encounter for hearing examination following failed hearing screening
180
181
Modifiers
Modifiers are two- to five-digit numeric or alphanumeric characters that can be reported with CPT codes. They provide additional information regarding the code to which they are attached. These codes indicate that the CPT code has been altered in some way, but the basic code is the same. When to use a modifier: 1. When only part of a service or procedure is performed 2. When a service or procedure has been reduced 3. When a service or procedure has been increased 4. When unusual circumstances surround the service or procedure 5. The service or procedure was performed multiple times 6. The procedure was bilateral 7. The procedure can be reported either as a technical or professional service 8. When an adjunctive service was performed 9. When the service or procedure was performed by more than one physician 10. When the service or procedure was performed in more than one location 11. For anesthesia: when the physical status of the patient needs to be reported for the administration of anesthesia Some modifiers are informational only and do not affect reimbursement of the claim.These informational modifiers can affect whether or not the claim will be paid or denied. Others, however, can affect reimbursement.
Types of Modifiers Abbreviation

E A S
Modifier Use With:
Code Range
Evaluation and Management Codes 9920199499 Anesthesia Codes 0010001999 Surgery Codes 1002169990
MOD HCPCS
MOD HCPCS
Abbreviation
R P M
Modifier Use With:

Radiology Codes Pathology & Laboratory Codes Medicine Codes
Code Range
7001079999 8004889356 9028199602
Evaluation and Management (E&M) Code Modifiers

The modifiers used with E&M codes are 21, 24, 25, 32, 52, 57.
Modifier 21
Description
Prolonged E&M Service
Effect on Payment
No effect
Accepted by Medicare
Yes
Explanation This modifier is used to identify face-to-face time with a patient that is prolonged or greater than normal. Can only be used on the highest level of E&M service within each category. CPT codes that can be used with the 21 modifier are 99205, 99215, 99220, 99223, 99233, 99236, 9938199387, and 9939199397.
Modifier 24
Description
Effect on Payment
Yes
Unrelated E&M Failure to use service by same modifier physician during may cause the postop period claim denials
Explanation It may be necessary to indicate that the E&M service performed during a postoperative period was not related to the procedure performed. CPT codes that can be used with the 24 modifier are 9920199499 and 9200292014.
182
183
Modifier 25 Description Effect on Payment Accepted by Medicare
Yes Significant sepaFailure to use rately identifiable modifier E&M service by may cause the same physiclaim denials cian on the same day of procedure
Explanation It may be necessary to perform a separate service, above and beyond the procedure performed. Should also be used with Preventive Medicine services when patient also presents with a complaint that requires further treatment or testing. CPT codes that can be used with the 25 modifier are 9200292014 and 9920199499.
Modifier 32
Description
Mandated service
Effect on Payment
No effect
Yes
Explanation It may be necessary to provide an E&M service at the request of a third-party carrier, government, or peer review organization. Use this modifier to identify mandated consultations. Commonly used with Workers Compensation cases. CPT codes that can be used with the 32 modifier are 9920199499, 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 52
Description
Reduced service
Effect on Payment
Yes
Yes
Explanation It may be necessary to report a reduced E&M service, when a complete service is not performed. This is not commonly used with E&M services, however, can be used with Preventive Medicine services. CPT codes that can be used with the 52
MOD HCPCS
MOD HCPCS
modifier are 9920199499, 0010001999, 1004069979, 70010 79999, 8004989399, and 9070099199. Codes 9920199499 cannot use this modifier on Medicare claims.
Modifier 57
Description
Decision for surgery
Effect on Payment
Yes
Yes
Explanation It may be necessary to report an E&M service that resulted in a decision to perform surgery. This service would be performed the day prior to and/or day of the surgery. CPT codes that can be used with the 57 modifier are 9200292014 and 9920199499.
Anesthesia Modifiers
The modifiers used with anesthesia codes are 22, 23, 32, 47, 51, 53, 59.
Modifier 22
Description
Effect on Payment
Yes
Yes
Explanation It may be necessary to report a procedure that is greater than that normally required. Overuse of this modifier may trigger an audit. Appropriate documentation must accompany the claim to establish the medical necessity for the unusual service. CPT codes that can be used with the modifier 22 are 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 23
Description
Unusual anesthesia
Effect on Payment
Yes
Yes
184
185
Explanation It may be necessary to report a procedure that usually requires no anesthesia or local anesthesia, or requires general anesthesia. This modifier is used only by anesthesia. CPT codes that can be used with the modifier 23 are 0010001999.
Modifier 32
Description
Mandated service
Effect on Payment
No effect
Yes
Modifier 47
Description
Effect on Accepted by Payment Medicare
Anesthesia by surgeon No effect No Explanation Is used when regional or general anesthesia is provided by the surgeon without an anesthesiologist or CRNA involvement. Does not include local anesthesia.
Modifier 51
Description
Multiple procedures
Effect on Payment
Yes
Yes
Explanation Is used when multiple procedures, other than E&M services, are performed at the same session by the same provider. The additional procedure is identified by the addition of the 51 modifier. This modifier is not used for the billing of trigger point injections. CPT codes that can be used with the 51 modifier are 0010001999, 1004069979, 7001079999, and 9070099198.
MOD HCPCS
MOD HCPCS
Effect on Payment
Yes
Modifier 53
Description
Discontinued procedure
Yes
Explanation Is used when procedures are terminated after they are started, or after anesthesia is started due to extenuating circumstances or a threat to the patients health. Cannot be used for elective cancellation of a procedure. CPT codes that can be used with the 53 modifier are 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 59
Description
Effect on Payment
Yes
Yes
Explanation Is used when procedures not usually performed together are performed, are distinct, and medically necessary. CPT codes that can be used with the 59 modifier are 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Surgery Modifiers
The modifiers used with surgery codes are 22, 26,32, 47, 50, 51, 52, 53, 54, 55, 56, 58, 59, 62, 66, 76, 77, 78, 79, 80, 81, 82, 99.
Modifier 22
Description
Effect on Payment
Yes
Yes
186
187
Modifier 26
Description
Effect on Payment
Yes
Yes
Explanation It may be necessary to report only a physicians interpretation of a test. CPT codes that can be used with the modifier 26 are 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 32
Description
Effect on Payment
Mandated service No effect Yes Explanation It may be necessary to provide an E&M service at the request of a third-party carrier, government, or peer review organization. Use this modifier to identify mandated consultations. Commonly used with Workers Compensation cases. CPT codes that can be used with the 32 modifier are 9920199499, 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 47
Description
Effect on Payment
Anesthesia by surgeon No effect Yes Explanation Is used when regional or general anesthesia is provided by the surgeon without an anesthesiologist or CRNA involvement. Does not include local anesthesia.
MOD HCPCS
MOD HCPCS
Effect on Payment Accepted by Medicare
Modifier 50
Description
Yes Yes Bilateral procedure Explanation It is used to report bilateral procedures performed at the same operative session. Add the 50 modifier to the second procedure. Do not use with codes that are performed bilaterally. CPT codes that can be used with the 50 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 51
Description
Effect on Payment
Multiple procedures Yes Yes Explanation Is used when multiple procedures, other than E&M services, are performed at the same session by the same provider. The additional procedure is identified by the addition of the 51 modifier. This modifier is not used for the billing of trigger point injections. CPT codes that can be used with the 51 modifier are 0010001999, 1004069979, 7001079999, and 9070099198.
Modifier 52
Description
Effect on Payment
Reduced service Yes Yes Explanation It may be necessary to report a reduced E&M service when a complete service is not performed. This is not commonly used with E&M services, however, can be used with Preventive Medicine services. CPT codes that can be used with the 52 modifier are 9920199499, 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199. Codes 9920199499 cannot use this modifier on Medicare claims.
188
189
Modifier 53 Description
Effect on Payment
Yes
Yes
Explanation Is used when procedures are terminated after they are started, or after anesthesia is started due to extenuating circumstances or a threat to the patients health. Cannot be used for elective cancellation of a procedure. CPT codes that can be used with the 53 modifier are 0010001999, 1004069979, 7001079999, 80049 89399, and 9070099199.
Modifier 54
Description
Surgical care only
Effect on Payment
Yes
Yes
Explanation It is used to report a procedure when a surgeon performs the procedure, but another physician performs the postoperative care. CPT codes that can be used with the 54 modifier are 1004069990 and 9028199199.
Modifier 55
Description
Postoperative care only
Effect on Payment
Yes
Yes
Explanation It is used to report a procedure when a physician performs the postoperative care only and another surgeon performs the procedure. CPT codes that can be used with the 55 modifier are 1004069990 and 9028199199.
Modifier 56
Description
Preoperaative care only
Effect on Payment
Yes
No
MOD HCPCS
MOD HCPCS
Explanation It is used to report when one physician performs the preoperative care and the other physician performs the procedure. CPT codes that can be used with the 56 modifier are 1004069979.
Modifier 58
Description
Staged or related procedure or service by same physician during the postoperative period

Yes Yes
Explanation It is used to report when the same physician performs a staged or related procedure during the postoperative period. CPT codes that can be used with the 58 modifier are 1004069990, 7001079999, and 9028199199.
Modifier 59
Description
Effect on Payment
Yes
Yes
Modifier 62
Description
Two surgeons
Effect on Payment
Yes
Yes
Explanation Is used when two surgeons work together as primary surgeons if the procedure is so complex that it requires two surgeons to manage. Each surgeon is of a different specialty. CPT codes that can be used with the 62 modifier are 1004069979, 7001079999, 9028199199.
190
191
Modifier 66 Description Effect on Payment Accepted by Medicare
Yes Yes Surg team Explanation Is used when procedures that are extremely complex are performed under a surgical team concept. CPT codes that can be used with the 66 modifier are 1004069979 and 7001079999.
Modifier 76
Description
Repeat procedure by same physician
Effect on Payment
Yes
Yes
Explanation Is used when the same physician repeats the exact same service. CPT codes that can be used with the 76 modifier are 10040 69979, 7001079999, and 9028199199.
Modifier 77
Description
Repeat procedure by another physician
Effect on Payment
Yes
Yes
Explanation Is used when a procedure is repeated by a different physician, at a separate time on the same day. CPT codes that can be used with the 77 modifier are 1004069979, 7001079999 and 9028199199.
Modifier 78
Description
Return to operating room for related procedure during the postoperative period
Effect on Payment
Yes
Yes
MOD HCPCS
MOD HCPCS
Explanation Is used when a patient needs to return to the operating room to treat complications of the original surgery. CPT codes that can be used with the 78 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 79
Description
Unrelated procedure or service by the same physician during the postoperative period
Effect on Payment
Yes
Yes
Explanation Is used when an unrelated procedure is performed by the same physician during the postoperative period of the original procedure. CPT codes that can be used with the 79 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 80
Description
Assistant surgeon
Effect on Payment
Yes
Yes
Explanation Is used to identify the services of an assistant surgeon necessary for a procedure. CPT codes that can be used with the 80 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 81
Description
Minimum assistant surgeon
Effect on Payment
Yes
Yes
Explanation Is used when the services of additional surgeons (second or third assistant) are required for a procedure. CPT codes that can be used with the 81 modifier are 1004069979, 7001079999, and 9028199199.
192
193
Assistant surgeon, when a qualified resident is unavailable
Effect on Payment
Yes
Yes
Explanation Is used when a surgical assist is necessary for a procedure, but there is no resident available. CPT codes that can be used with the 82 modifier are 1004069979, 7001079999, and 90281 99199.
Modifier 99
Description
Multiple modifiers
Effect on Payment
No effect
Yes
Explanation Is used to report that there are multiple modifiers being used for this claim. CPT codes that can be used with the 99 modifier are 1004069979, 7001079999, and 9028199199.
Radiology Modifiers
The modifiers used with radiology codes are 22, 26,32, 50, 51, 52, 53, 58, 59, 62, 76, 77, 78, 79, 80, 99.
Modifier 22
Description
Effect on Payment
Yes
Yes
MOD HCPCS
MOD HCPCS
Effect on Payment
Yes
Modifier 26
Description
Yes
Modifier 32
Description
Mandated service
Effect on Payment
No effect
Yes
Modifier 50
Description
Bilateral procedure
Effect on Payment
Yes
Yes
Explanation It is used to report bilateral procedures performed at the same operative session. Add the 50 modifier to the second procedure. Do not use with codes that are performed bilaterally. CPT codes that can be used with the 50 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 51
Description
Multiple procedures
Effect on Payment
Yes
Yes
Explanation Is used when multiple procedures, other than E&M services, are performed at the same session by the same provider. The
194
195
additional procedure is identified by the addition of the 51 modifier. This modifier is not used for the billing of trigger point injections. CPT codes that can be used with the 51 modifier are 0010001999, 1004069979, 7001079999, and 9070099198.
Modifier 52
Description
Effect on Payment
Reduced service Yes Yes Explanation It may be necessary to report a reduced E&M service, when a complete service is not performed. This is not commonly used with E&M services, however, can be used with Preventive Medicine services. CPT codes that can be used with the 52 modifier are 9920199499, 0010001999, 1004069979, 70010 79999, 8004989399, and 9070099199. Codes 9920199499 cannot use this modifier on Medicare claims.
Modifier 53
Description
Effect on Payment
Yes
Yes
Explanation Is used when procedures are terminated after they are started, or after anesthesia is started due to extenuating circumstances or a threat to the patients health. Cannot be used for elective cancellation of a procedure. CPT codes that can be used with the 53 modifier are 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 58
Description
Effect on Payment
Yes
Yes
MOD HCPCS
MOD HCPCS
Modifier 59
Description
Effect on Payment
Yes
Yes
Modifier 62
Description
Two surgeons
Effect on Payment
Yes
Yes
Explanation Is used when two surgeons work together as primary surgeons if the procedure is so complex that it requires two surgeons to manage. Each surgeon is of a different specialty. CPT codes that can be used with the 62 modifier are 1004069979, 7001079999, 9028199199.
Modifier 76
Description
Effect on Payment
Yes
Yes
Explanation Is used when the same physician repeats the exact same service. CPT codes that can be used with the 76 modifier are 1004069979, 7001079999, and 9028199199.
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197
Effect on Payment
Yes
Yes
Explanation Is used when a procedure is repeated by a different physician, at a separate time on the same day. CPT codes that can be used with the 77 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 78
Description
Return to operating room for a related procedure during the postoperative period
Effect on Payment
Yes
Yes
Modifier 79
Description
Unrelated procedure or service by same physician during the postoperative period
Effect on Payment
Yes
Yes
MOD HCPCS
MOD HCPCS
Effect on Payment
Yes
Modifier 80
Description
Assistant surgeon
Yes
Explanation Is used to identify the services of an assistant surgeon necessary for a procedure. CPT codes that can be used with the 80 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 99
Description
Multiple modifiers
Effect on Payment
No effect
Yes
Explanation Is used to report that there are multiple modifiers being used for this claim. CPT codes that can be used with the 99 modifier are 1004069979, 7001079999, and 9028199199.
Pathology and Laboratory Modifiers

The modifiers used with pathology and laboratory codes are 22, 26,32, 52, 53, 59, 90, 91.
Modifier 22
Description
Effect on Payment
Yes
Yes
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199
Modifier 26 Description Professional component Effect on Payment
Yes
Yes
Modifier 32
Description Mandated service
Effect on Payment No effect
Accepted by Medicare Yes
Modifier 52
Description Reduced service
Effect on Payment Yes
Accepted by Medicare Yes
Explanation It may be necessary to report a reduced E&M service when a complete service is not performed. This is not commonly used with E&M services, however, can be used with Preventive Medicine services. CPT codes that can be used with the 52 modifier are 9920199499, 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199. Codes 9920199499 cannot use this modifier on Medicare claims.
MOD HCPCS
MOD HCPCS
Modifier 53
Description
Discontinued procedure Yes Yes Explanation Is used when procedures are terminated after they are started, or after anesthesia is started due to extenuating circumstances, or a threat to the patients health. Cannot be used for elective cancellation of a procedure. CPT codes that can be used with the 53 modifier are 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 59
Description
Effect on Payment
Yes
Yes
Explanation Is used when procedures not usually performed together are performed, are distinct, and medically necessary. CPT codes that can be used with the 59 modifier are 0010001999, 10040 69979, 7001079999, 8004989399, and 9070099199.
Modifier 90
Description
Reference (outside) laboratory
Effect on Payment
No effect
No
Explanation Is used when laboratory tests are performed by a laboratory other than the reporting physician. Any laboratory or pathology CPT code could be used with the 90 modifier.
Modifier 91
Description
Repeat clinical diagnostic laboratory test
Effect on Payment
Yes
Yes
200
201
Explanation Is used when laboratory tests are performed on specimens from the same patient source more than one time on the same day. This code is not used when a test is rerun to confirm results. This modifier may be used on a patient who has diabetes and requires multiple glucose tests on the same day. Failure to use this modifier may result in claim denial as they may be viewed as duplicate claims. Any laboratory or pathology CPT code could be used with the 91 modifier.
Medicine Modifiers
The modifiers used with pathology and laboratory codes are 22, 26,32, 50, 51, 52, 53, 55, 56, 58, 59, 76, 77, 78, 79, 99.
Modifier 22
Description
Effect on Payment
Yes
Yes
Modifier 26
Description

Yes Yes
MOD HCPCS
MOD HCPCS
Effect on Payment No effect Accepted by Medicare Yes
Modifier 32
Description Mandated service
Modifier 50
Description
Bilateral procedure
Effect on Payment
Yes
Yes
Explanation It is used to report bilateral procedures performed at the same operative session. Add the 50 modifier to the second procedure. Do not use with codes that are performed bilaterally. CPT codes that can be used with the 50 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 51
Description
Multiple procedures
Effect on Payment
Yes
Yes
Explanation Is used when multiple procedures, other than E&M services, are performed at the same session by the same provider. The additional procedure is identified by the addition of the 51 modifier. This modifier is not used for the billing of trigger point injections. CPT codes that can be used with the 51 modifier are 0010001999, 1004069979, 7001079999, and 9070099198.
Modifier 52
Description
Reduced service
Effect on Payment
Yes
Yes
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203
Explanation It may be necessary to report a reduced E&M service when a complete service is not performed. This is not commonly used with E&M services, however, can be used with Preventive Medicine services. CPT codes that can be used with the 52 modifier are 9920199499, 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199. Codes 9920199499 cannot use this modifier on Medicare claims.
Modifier 53
Description
Effect on Payment
Yes
Yes
Explanation Is used when procedures are terminated after they are started, or after anesthesia is started due to extenuating circumstances, or a threat to the patients health. Cannot be used for elective cancellation of a procedure. CPT codes that can be used with the 53 modifier are 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199.
Modifier 55
Description
Postoperative care only
Effect on Payment
Yes
Yes
Explanation It is used to report a procedure when a physician performs the postoperative care only and another surgeon performs the procedure. CPT codes that can be used with the 55 modifier are 1004069990 and 9028199199.
Modifier 56
Description
Preoperative care only
Effect on Payment
Yes
No
MOD HCPCS
MOD HCPCS
Explanation It is used to report when one physician performs the preoperative care and the other physician performs the procedure. CPT codes that can be used with the 56 modifier are 1004069979.
Modifier 58
Description
Staged or related procedure or service by same physician during the postoperative period.

Yes Yes
Modifier 59
Description
Effect on Payment
Yes
Yes
Modifier 76
Description
Effect on Payment
Yes
Yes
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205
Effect on Payment
Yes
Yes
Explanation Is used when a procedure is repeated by a different physician at a separate time on the same day. CPT codes that can be used with the 77 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 78
Description
Return to operating room for related procedure during postoperative period
Effect on Payment
Yes
Yes
Modifier 79
Description
Unrelated procedure or service by same physician during the postoperative period
Effect on Payment
Yes
Yes
MOD HCPCS
MOD HCPCS
Modifier 99
Description
Multiple modifiers No effect Yes Explanation Is used to report that there are multiple modifiers being used for this claim. CPT codes that can be used with the 99 modifier are 1004069979, 7001079999, and 9028199199.
Ambulatory Service Centers (ASC)/ Hospital Outpatient Modifiers

The modifiers used in ASC billing are 25, 27, 50, 52, 58, 59, 73, 74, 76, 77, 78, 79, 91.
Modifier 25
Description
Significant separately identifiable E&M service by the same physician on the same day of procedure
Effect on Payment
Yes, failure to use modifier may cause claim denials
Yes
Explanation It may be necessary to perform a separate service, above and beyond the procedure performed. Should also be used with Preventive Medicine services when patient also presents with a complaint that requires further treatment or testing. CPT codes that can be used with the 25 modifier are 9200292014 and 9920199499.
Modifier 27
Description
Multiple outpatient hospital E&M services on same date
Effect on Payment
Yes
Yes
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207
Explanation This modifier is to be used for facility billing only. It is used to report the utilization of hospital resources related to separate and distinct E&M services performed in multiple outpatient hospital settings on the same date.
Modifier 50
Description
Effect on Payment
Bilateral procedure Yes Yes Explanation It is used to report bilateral procedures performed at the same operative session. Add the 50 modifier to the second procedure. Do not use with codes that are performed bilaterally. CPT codes that can be used with the 50 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 52
Description
Effect on Payment
Reduced service Yes Yes Explanation It may be necessary to report a reduced E&M service when a complete service is not performed. This is not commonly used with E&M services, however, can be used with Preventive Medicine services. CPT codes that can be used with the 52 modifier are 9920199499, 0010001999, 1004069979, 7001079999, 8004989399, and 9070099199. Codes 9920199499 cannot use this modifier on Medicare claims.
Modifier 58
Description
Effect on Payment
Yes
Yes
MOD HCPCS
MOD HCPCS
Modifier 59
Description

Yes Yes
Modifier 73
Description
Discontinued outpatient hospital/ambulatory surgery center (ASC) prior to the administration of anesthesia

Yes Yes
Explanation Is used when there are extenuating circumstances that may threaten the well-being of the patient and cause the physician to cancel or postpone the procedure. The cancellation of the procedure must take place before the administration of anesthesia, however, may take place after the administration of surgical prep sedation.
Modifier 74
Effect on Accepted by Description Payment Medicare Discontinued outpatient Yes Yes hospital/ambulatory surgery center (ASC) after administration of anesthesia
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209
Explanation Is used when there are extenuating circumstances that may threaten the well-being of the patient and cause the physician to cancel or postpone the procedure after administration of anesthesia.
Modifier 76
Description
Effect on Payment
Yes
Yes
Modifier 77
Description
Effect on Payment
Yes
Yes
Explanation Is used when a procedure is repeated by a different physician, at a separate time on the same day. CPT codes that can be used with the 77 modifier are 1004069979, 7001079999, and 9028199199.
Modifier 78
Description
Return to operating room for a related procedure during the postoperative period

Yes Yes
MOD HCPCS
MOD HCPCS
Effect on Payment
Yes
Modifier 79
Description
Unrelated procedure or service by the same physician during the postoperative period
Yes
Modifier 91
Description
Repeat clinical diagnostic laboratory test
Effect on Payment
Yes
Yes
Explanation Is used when laboratory tests are performed on specimens from the same patient source more than one time on the same day. This code is not used when a test is rerun to confirm results. This modifier may be used on a patient who has diabetes and requires multiple glucose tests on the same day. Failure to use this modifier may result in claim denial as they may be viewed as duplicate claims. Any laboratory or pathology CPT code could be used with the 91 modifier.
Teaching Physician Modifiers

The following two modifiers are used in a teaching physician setting when a resident is involved in the service. These modifiers have no effect on payment and are only used to track the medical education funds.
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211
Modifier GC Description
The service has been performed in part by a resident under the direction of a teaching physician
Effect on Payment
No effect
Yes
Explanation When a teaching physicians services are billed using this modifier, the physician is certifying that he/she was present for the key portion of the services and was immediately available during the other portions of the service.
Modifier GE
Description
The service has been performed by a resident without the presence of a teaching physician
Effect on Payment
No effect
Yes
Explanation This modifier is used when services are provided under the primary care exemption. The primary care exemption must be obtained prior to following the guidelines for use of this modifier. Once all criteria have been met, residents may provide services to patients without the presence of the teaching physician.
MOD HCPCS
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Important Numbers
Physician Name: Home: Cell: Car: Beeper: Physician Name: Home: Cell: Car: Pager: Physician Name: Home: Cell: Car: Pager: Physician Name: Home: Cell: Car: Pager: Physician Name: Home: Cell: Car: Pager: Physician Name: Home: Cell: Car: Pager:
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213
Important Hospital Numbers:
Main Number: Laboratory: X-ray: PT: EKG/EEG: Outpatient Scheduling: Emergency room: Admissions: Billing office: Medical records: Medical staff office: Office managers home number: Office managers cell: Other important numbers: 1. 2. 3. 4. 5. 6. 7 8. 9.
Frequently Called Offices

Dr. Address: Phone: Fax:
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Dr. Address: Phone: Fax: Dr. Address: Phone: Fax: Dr. Address: Phone: Fax: Dr. Address: Phone: Fax:

Code
11 12 21
Place of Service
Doctors Office (O) Patients Home (H) Inpatient Hospital (IH)
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Code
22 23 24 25 26 31 32 33 34 35 41 42 50 51 52 53 54 55 56 60 61 62 65 71 72 81 99
Place of Service
Outpatient Hospital (OH) (urgent care also) Emergency Dept. Hospital (OH) Ambulatory Surgery Center (ASC) Birthing Center (OL) Military Treatment Facility (OL) Skilled Nursing Facility (SNF) Nursing Facility (NF) Custodial Care Facility (OL) Hospice (OL) Adult Living Care Facility Ambulance land Ambulance air, water Federally Qualified Health Center (FQHC) Inpatient Psychiatric Facility (OL) Psychiatric Facility Partial Hospitalization Community Mental Health Care (CMHC) Immediate Care Facility mentally retarded (STF) Residential Substance Abuse Treatment Facility (RTC) Psychiatric Residential Treatment Center (RTC) Mass Immunization Center Comprehensive Inpatient Rehab Facility (OL) Comprehensive Outpatient Rehab Facility (CORF)(COR) End-stage Renal Disease Treatment Facility (KDC) State or Local Public Health Clinic (OL) Rural Health Clinic (RHC)(OL) Independent Laboratory (IL) Other Unlisted Facility (OL)
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State Medicare Carriers

State
Alabama
Medicare Carrier
Blue Cross/Blue Shield of Alabama PO Box 830139, Birmingham, AL 352830139 Phone: 2059882100 Fax: 2059814841 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Arkansas Blue Cross/Blue Shield, A Mutual Insurance Company 601 Gaines St Little Rock, AR 72201 Phone: 5013782000 Fax: 5013782804 National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Trailblazer Health Enterprises, LLC PO Box 660156 Dallas, TX 75266 Phone: 9727666900 Fax: 9727661765
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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217
State
Delaware
Medicare Carrier
Trailblazer Health Enterprises, LLC PO Box 660156 Dallas, TX 75266 Phone: 9727666900 Fax: 9727661765 Trailblazer Health Enterprises, LLC PO Box 660156 Dallas, TX 75266 Phone: 9727666900 Fax: 9727661765 Blue Cross/Blue Shield of Florida, Inc. 532 Riverside Ave Jacksonville, FL 32202 Phone: 9047916111 Fax: 9049056020 Blue Cross/Blue Shield of Alabama PO Box 830139, Birmingham, AL 352830139 Phone: 2059882100 Fax: 2059814841 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Connecticut General Life Insurance Company Hartford, CT 06152 Phone: 6157824576 Fax: 6152446242 National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182 AdminaStar Federal, Inc. 8115 Knue Road Indianapolis, IN 46250 Phone: 3178414400 Fax: 3178414691
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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State
Iowa
Medicare Carrier
Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Blue Cross/Blue Shield of Kansas, Inc. 1133 Topeka Ave Topeka, KS 66629 Phone: 7852917000 Fax: 7852917098 AdminaStar Federal, Inc. 8115 Knue Road Indianapolis, IN 46250 Phone: 3178414400 Fax: 3178414691 Arkansas Blue Cross/Blue Shield, A Mutual Insurance Company 601 Gaines St Little Rock, AR 72201 Phone: 5013782000 Fax 5013782804 National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182 Trailblazer Health Enterprises, LLC PO Box 660156 Dallas, TX 75266 Phone: 9727666900 Fax: 9727661765 National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
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219
State
Michigan
Medicare Carrier
National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182 Wisconsin Physicians Insurance Corporation PO Box 8190 Madison, WI 53708 Phone: 6082214711 Fax: 6082233614 Wisconsin Physicians Insurance Corporation PO Box 8190 Madison, WI 53708 Phone: 6082214711 Fax: 6082233614 Blue Cross/Blue Shield of Kansas, Inc. 1133 Topeka Ave Topeka, KS 66629 Phone: 7852917000 Fax: 7852917098 Blue Cross/Blue Shield of Montana, Inc. PO Box 4310, 340 N. Last Chance Gulch Helena, MT 59604 Phone: 4064448350 Fax: 4064429968 Blue Cross/Blue Shield of Kansas, Inc. 1133 Topeka Ave Topeka, KS 66629 Phone: 7852917000 Fax: 7852917098 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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State
New Jersey
Medicare Carrier
Highmark, Inc C/O HGS Administrators PO Box 8900065 Camp Hill, PA 17089 Phone: 7177633151 Fax: 7179757045 Arkansas Blue Cross/Blue Shield, A Mutual Insurance Company 601 Gaines St Little Rock, AR 72201 Phone: 5013782000 Fax: 5013782804 Empire Medicare Services PO Box 2280 Peekskill, NY 10566 Phone: 8668370241 Fax: 8667091905
New Mexico
New York Counties of Bronx, Columbia, Delaware, Duchess, Greene, Kings, Nassau, New York, Orange, Putnam, Richmond, Rockland, Suffolk, Sullivan, Ulster, Westchester Queens
Other parts of the state
Group Health Incorporated 88 West End Avenue New York, NY 10023 Phone: 2127211300 Fax: 2127210580 Healthnow New York, Inc. Upstate Medicare Division Operations 33 Lewis Road, PO Box 80 Binghampton, NY 13905 Phone: 7168876900 Fax: 6077796395
Medicare Carriers
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221
State
North Carolina
Medicare CarrierQueens
Connecticut General Life Insurance Company Hartford, CT 06152 Phone: 6157824576 Fax: 6152446242 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Nationwide Mutual Insurance Company PO Box 16788 Columbus, OH 43216 Phone: 6142497111 Fax: 6142493732 Arkansas Blue Cross/Blue Shield, A Mutual Insurance Company 601 Gaines St Little Rock, AR 72201 Phone: 5013782000 Fax: 5013782804 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Highmark, Inc C/O HGS Administrators PO Box 8900065 Camp Hill, PA 17089 Phone: 7177633151 Fax: 7179757045 Blue Cross/Blue Shield of Rhode Island 444 Westminster Street Providence, RI 02903 Phone: 4014591000 Fax: 4014591709
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
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State
South Carolina
Medicare Carrier
PGBA 17 Technology Circle Columbia, SC Phone: 8037351034 Fax: 8039350081 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Connecticut General Life Insurance Company Hartford, CT 06152 Phone: 6157824576 Fax: 6152446242 Trailblazer Health Enterprises, LLC PO Box 660156 Dallas, TX 75266 Phone: 9727666900 Fax: 9727661765 Regence Blue Cross/Blue Shield of Utah 2890 E. Cottonwood Parkway Salt Lake City, UT 84121 Phone: 8013332000 Fax: 8013336510 National Heritage Insurance Company 402 Otterson Drive Chico, CA 95928 Phone: 5308967400 Fax: 5308967182 Trailblazer Health Enterprises, LLC PO Box 660156 Dallas, TX 75266 Phone: 9727666900 Fax: 9727661765
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
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State
Washington
Medicare Carrier
Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Nationwide Mutual Insurance Company PO Box 16788 Columbus, OH 43216 Phone: 6142497111 Fax: 6142493732 Wisconsin Physicians Insurance Corporation PO Box 8190 Madison, WI 53708 Phone: 6082214711 Fax: 6082233614 Noridian Mutual Insurance Company 4305 13th Ave SW Fargo, ND 58103 Phone: 7012821100 Fax: 7012821002 Triple-S, Inc PO Box 71391 San Juan, PR 00936 Phone: 7877494080 Fax: 7877494092 Triple-S, Inc PO Box 71391 San Juan, PR 00936 Phone: 7877494080 Fax: 7877494092
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Islands
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Websites
Organization/Association
Agency for Healthcare Policy and Research Center for Medicare and Medicaid Services Code of Federal Regulations Department of Health and Human Services FDA Medical Bulletin Government Printing Office Joint Commission on Accreditation of Healthcare Organizations Local Carrier InfoMedicare National Committee for Quality Assurance Office of Inspector General Workplan Office of Inspector General Compliance Plans Social Security Online American Academy of Professional Coders American College of Healthcare Executives
Website
www.ahcpr.gov www.cms.gov www.access.gpo.gov/nara/cfr www.dhhs.gov www.fda.gov/medbull www.access.gpo.gov www.jcaho.org
www.cms.gov/regions/default.htm www.ncqa.org www.hhs.gov/progorg/wrkpln/ index.html www.dhhs.gov/progorg/oig
www.ssa.gov/SSA-Home.html www.aapcnatl.org www.ache.org
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225
Websites
Organization/Association American Health Management Information Association Healthcare Financial Management Association Medical Group Management Association Center for Healthcare Information Management Health Hippo Human Anatomy
Medical Abbreviations
Website www.ahima.org
www.hfma.org www.mgma.com www.chim.org Hippo.findlaw.com/hippol.html www.mnsu.edu/emuseum/biology/ humananatomy/index.shtml www.pharma-lexicon.com/
United States Units of Measure

Apothecaries Fluid Measure 60 minims 8 fluid drams 16 fluid ounces 2 pints 4 quarts Avoirdupois Weight 27 11/32 grains 16 drams 16 ounces Troy Weight 24 grains 20 pennyweights 12 ounces 1 1 1 1 1 fluid dram fluid ounce pint quart gallon
1 dram 1 ounce 1 pound 1 pennyweight 1 ounce 1 pound
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Metric Units of Measure

Linear Measure 10 millimeters 10 centimeters 10 decimeters Weight 10 milligrams 10 centigrams 10 decigrams 1 centimeter 1 decimeter 1 meter 1 centigram 1 decigram 1 gram
U.S. and Metric Equivalents

Linear Measure U.S. Unit 1 inch 1 foot 0.03937 inch Liquid Measure U.S. Unit 1 fluid ounce 1 quart 1 gallon 0.033814 fluid ounce 1.0567 quarts 0.26417 Weights U.S. Units 1 grain 1 avoirdupois ounce 1 troy ounce 1 avoirdupois pound 1 troy pound 15.432 grains 0.032151 troy ounce 2.2046 avoirdupois Metric Unit 2.54 centimeters 0.3048 meters 1 millimeter Metric Unit 29.573 millimeters 0.94635 liter 3.7854 liter 1 milliliter 1 liter 1 liter Metric Unit 0.064799 gram 28.350 grams 31.103 grams 0.453359 kilogram 0.37324 1 gram 1 gram 1 kilogram
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Index
A Abdomen, ultrasound examination of, 129 ABN (Advance beneficiary notice), 5354 Add-on codes, 141142 Adults, treatment of burns in, 117 Advance beneficiary notice (ABN), 5354 Allergy and clinical immunology, 158159 Ambulatory service centers (ASC)/hospital outpatient modifiers, 206210 A-mode, in diagnostic ultrasound, 128 Anesthesia conscious sedation, 107 facts, 103 HCPCS modifiers, 105 medically directed services, 105 moderate (conscious) sedation, 105 modifiers, 184186 monitored care, 104 physical status modifiers, 105106 Annual nursing facility assessment, 89 Arthroscopy, surgical, 119 Assistant surgeon, 106 Audiologic function tests, 157 B B scan, in diagnostic ultrasound, 128 Bankruptcy, 40 Benefits, explanation of, 30 Benign growth, 174 Benign hypertension, 173 Bilateral surgeries, 107 Biofeedback, 152 Body areas examination, 72 Brachytherapy, clinical, 132 Bronchospasm, acute, 179 Burns, 116117 C Ca in Situ, 174 Carcinoembryonic antigen (CEA), elevated, 180 Cardiac catheterization, 156 Cardiovascular services, 155157 CC (Chief complaint), 65, 71 Cellulitis and abscess, 179 Checks personal, verification of, 33 returned, 3334 Chemotherapy, 160161 Chief complaint (CC), 65, 71 Children, treatment of burns in, 117 Claim(s) clean, 43 denial of, 3132, 60 unpaid, 35, 36 Claims submission issues explanation of benefits, 30 problems with, 29 Clean claim, 43 Clinical brachytherapy, 132 Clinical treatment planning, 130132 CMS 1500 form completion instructions, 1322 in Medicare, 52 place of service codes, 2229 Codes/coding. See also Specific topics add-on, 141142 conventions, 166 E, 169 easy diagnosis, 165 late effect, 169170 M, 176 miscellaneous commonly used, 179180 nonspecific/unspecified, 171172 place of service, 2229, 214215 principal vs. primary diagnosis, 173 signs and symptoms, 172 V, 168169 Collections abbreviations, 3840 bankruptcy, 40 billing for relatives, 41 overpayments, 41 statute of limitations by state, 3638 Colonoscopy, 149 Computerized tomography (CT), 123
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Concurrent care, 101 Consultations documenting, 102 inpatient, 83 outpatient, 82 three Rs of, 102 types of, 101 x-ray, 122 Continuing intensive care, 94 Cosurgeon, 106 CPT (HCPCS Level I) codes, 41 CPT book sections, 42 symbols, 42 Critical care services billing codes examples, 9798 codes, 97 conditions for providing, 97 inpatient neonatal and pediatric, 99 preoperative and postoperative, 108 time spent for providing, 97 C-section, 118 D Denial of claims, 3132, 60 Diagnostic radiology, 127128 Diagnostic ultrasound clinical brachytherapy, 132 clinical treatment planning, 130 hyperthermia, 132 proton beam definitions, 131 radiation oncology, 129 terminology, 128129 therapeutic radiology simulation definitions, 130131 Dialysis end-stage renal disease (ESRD), 153 hemodialysis, 153 miscellaneous procedures, 154 training, 154 Discharge services decision matrix for, 89 hospital discharge day, 82 Documentation of consultations, 102 medical record, 6263 operative report, 109 patient visit, 1213 SNOCAMP, 101102 SOAP, 100 Domiciliary care established patient, 93 new patients, 92 Drugs and chemicals table, 177 E E codes, 169 Easy diagnosis coding, 165 Echocardiography, 156157 Elective surgery notice, 113 Electroencephalogram (EEG), 159 Electrocardiogram, 156 Electromyography, 159 E&M services. See Evaluation and Management (E&M) services Emergency(ies) after hours codes, 87 room services, 86 X-rays, 122 Endocardiography, 157 Endoscopy, surgical, 118 End-stage renal disease (ESRD), 153 EOB. See Explanation of benefits (EOB) ESRD. See End-stage renal disease (ESRD) Established patient(s) domiciliary care, 92, 93 home services, 91 office, 78, 79 preventive medicine services, 95 Evaluation and Management (E&M) services billing, 119 code modifiers, 182184 codes, 60, 61 components of, 63 examination in, 7274 history in, 6468 list of services, 6162 time in, 6364 Examination, in E&M services body areas, 72 1995 guidelines, 72
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1997 guidelines, 7374 organ systems, 73 Explanation of benefits (EOB), 30 External causes effects, 170, 177 F Fact-oriented V code, 169 Financial hardship, patients with, 34 Foreign bodies removal, 115 Form(s) CMS 1500 form, 1322 frequently called offices, 213214 important hospital numbers, 213 important numbers, 212 patient encounter form, 3 patient registration form, 13 Fracture(s) coding, 117 types of, 178179 G Gait, abnormality of, 180 Gastroenterology important definitions, 149151 surgical codes, 149 General late effect codes, 170 Global surgeries, 106107 Guarantor, 59 H HCPCS anesthesia services modifiers, 105 Health Maintenance Organization (HMO), Medicaid plans and, 5556 Hearing examination, 180 Hemodialysis, 153 History chief complaint (CC), 65, 71 in evaluation and management services, 6468 levels and types of, 64 past, family, social history, 6971 of present illness, 6568, 71 review of systems, 6869, 71 summary, 71 History of present illness (HPI), 6568, 71 Home services established patient, 91 new patient, 90 Hospital observation or inpatient care, 84 Hospital observation services, 85 HPI (History of present illness), 6568, 71 Hypertension/hypertensive table, 173 Hyperthermia, 132 Hyperventilation and/or phonic stimulation, 159 Hysterectomies, 119 I ICD-10, 167 ICD-9-CM about, 163 coding and reporting guidelines, 172173 surgical and postoperative codes, 112 three volumes, 163165 vs. ICD-10, 167 Immunization administration codes for vaccines, 144 Incision and drainage, 114 Infusions, diagnostic, 146 Initial hospital patients, 80 Initial nursing facility, 87 Injections of immune globulins, 143146 Injuries, late effects of, 170 Injury-related late effect codes, 169 Inpatient pediatric critical care, 94 Inpatient(s). See also Outpatient(s) consultations, 83 extension of days, Medicaid and, 56 hospital observation, 8485 neonatal critical care, 94, 99 pediatric critical care services, 94, 99 prolonged care services, 96 Insurance commissioner, 36 Insurance form life cycle established patient, office, 78 new patient, office, 46 patient discharge, 811
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Integumentary system coding, 114117 International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM). See ICD-9-CM Interventional radiology procedures, 132133 L Laboratory areas of, 134136 modifiers, 198201 Late effect codes of external causes, 170 general, 170 types of, 169170 Locum tenens providers, 43 M M codes, 176 Magnetic resonance imaging (MRI), 123 Major Medical, 59 Malignancies primary, 175 secondary, 174176 Malignant hypertension, 173 Managed care dos and donts of working with, 45 quick guide to, 46 summary of plans, 4446 Medicaid billing summary, 57 confirming eligibility, 55 extension of inpatient days, 56 nurse practitioner billing, 57 physician assistant billing, 56 preauthorization, 5556 services available, 54 Medical decision-making components of, 75 four levels of, 7576 table of tasks, 7677 Medical necessity about, 77 after hour codes for emergencies, 87 annual nursing facility assessment, 89 continuing intensive care, 94 discharge services, 82, 89 domiciliary care, 92, 93 emergency room services, 86 established office patients, 79 home services, 90, 91 hospital observation or inpatient care, 8485 initial hospital patients, 80 inpatient consultation, 83 inpatient neonatal critical care, 94 inpatient pediatric critical care, 94 new office patients, 78 outpatient consultation, 82 preventive medicine services, 95 prolonged care services, 96 subsequent hospital patients, 81 subsequent nursing facility, 88 Medical record documentation, 6263 Medically directed anesthesia services, 105 Medicare advance beneficiary notice (ABN), 5354 billing summary, 52 covered/noncovered services, 51 deductibles and co-pays, 4647 emergency department x-rays, 122 fee schedule, 50 medical supplies and equipment billing, 51 MSP billing guide, 4748 nonparticipating providers billing, 46 nurse practitioner billing, 50 patients out-of pocket expenses, 113114 physical medicine and, 147148 physician assistant billing, 4849 review process, 5253 state carriers, 216223 surgical tray, 108 Medicare secondary payor (MSP), 47 billing guide, 4748 physician assistance billing, 4849 Medicine modifiers, 201206 Minimum (word), in billing, 129 Minor surgeries, 107 M-mode, in diagnostic ultrasound, 128 Modifiers
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about, 181 ambulatory service centers/hospital outpatient, 206210 anesthesia, 184186 anesthesia services, HCPCS, 105 evaluation and management services code, 182184 with global surgery, 107 laboratory, 198201 medicine, 201206 pathology, 138140, 198201 physical status, 103104 radiology, 125129, 193198 surgery, 112, 186193 teaching physician, 210211 types of, 181182 MSP. See Medicare secondary payor (MSP) Multiple diagnosis codes, 171 Multiple procedure services, 143 Multiple surgeries, 108 N Neonatal critical care inpatient, decision matrix for, 94 inpatient services, 99 Neoplasm table, 174176 Nerve conduction, 161, 162 Neurology, 159160 Neuromuscular procedures, 159160 New patient(s) domiciliary care, 92 home services, 90 office visit, 46, 78 1995 examination guidelines, 72 1997 examination guidelines, 7374 Nonspecific/unspecified codes, 171172 Nonsufficient funds (NSF), 33 NP (Nurse practitioner) billing, 50 NSF. See Nonsufficient funds (NSF) Nuclear medicine diagnostic, 132 procedures, 123 therapeutic, 133 Numbers hospital, 213214 physicians, 212 Nurse practitioner (NP) billing in Medicaid, 57 in Medicare, 50 O Office patients established, 78, 79 new, 46, 78 visit steps, 78 Offices, frequently called, 213214 Operative report components in coding from, 109112 documenting, 109 surgical and postoperative codes, 112114 Ophthalmology, 151152 Organ systems examination, 73 Organization/association Web sites, 224225 Otorhinolaryngologic services, 154155 Outpatient(s) ambulatory service centers/hospital modifiers, 206210 consultations, 82 prolonged care services, 96 Overpayments, 41 P Pacemaker replacement code, 118 Pain acute, 179 chronic, 179 postoperative, 108 Past, family, social history (PFSH), 6971 Pathology areas of, 134136 modifiers, 138140, 198201 surgical, 137138 Patient(s). See also Established patient(s); Inpatient(s); New patient(s); Outpatient(s) discharge of, 811 encounter form, 3 initial hospital, 80 out-of-pocket expenses, 113114 registration form, 13 visit documentation, 1213
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Pediatric critical care services, inpatient, 94, 99 PET scan (Positron emission tomography), 124 PFSH (Past, family, social history), 6971 Physical medicine, 147148 Physical status modifiers, 103104 Physician assistant (PA) billing Medicaid, 56 Medicare Secondary Payor (MSP) billing, 4849 Tricare, 58 Place of service codes, 2229, 214215 Poisoning late effect codes, 172 late effects of, 170 Positron emission tomography (PET scan), 122 Postnasal drip, 180 Preauthorization, 11 Precertification, 11 Pregnancy, spotting complicating, 180 Preventive medicine services, 95 Primary diagnosis code, principal vs., 173 Primary malignancies, 174, 175 Principal vs. primary diagnosis code, 173 Problem-oriented V code, 168 Prolonged care services, 96 Prolonged intravenous injections, 146 Proton beam definitions, 131 Providers locum tenens, 43 nonparticipating in Medicare, 46 Psychiatry, 146147 Pulmonary, 157158 R Radiation oncology, 129130 Radiology basic definitions, 133134 billing and coding, 120127 computerized tomography, 123 consultations, 122 with contrast, 121 diagnostic, 127128 diagnostic procedures, 122 diagnostic ultrasound, 128132 emergency department x-rays, 122 interventional procedures, 132133 magnetic resonance imaging, 123 modifiers, 125129, 193198 nuclear medicine, 123, 132133 positron emission tomography, 122 ultrasound procedures, 123 Real-time scan, in diagnostic ultrasound, 128 Re-excision, 176 Rehabilitation, 147148 Relatives, billing for, 41 Repairs burns, 116117 coding for wound, 116 considerations for, 115 types of, 115 Restless leg syndrome (RLS), 179 Retroperitoneum, ultrasound examination of, 129 Returned checks, 3334 Review of systems (ROS), 6869, 71 Rule of nines, in burns, 116 S Secondary malignancies, 174, 175176 Sedation, moderate (conscious), 105, 161162 Separate procedures, 143 Service-oriented V code, 168 Sigmoidoscopy, 149 Signs and symptoms codes, 172 Sleep studies, 119 SNOCAMP documentation, 100101 SOAP documentation, 100 State Medicare carriers, 216223 Subsequent hospital patients, 81 Subsequent nursing facility, 88 Surgery(ies) bilateral, 107 elective notice, 115 global, 106107 important definitions, 106 integumentary system coding, 114117 minor, 107
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modifiers, 112, 186193 multiple, 108 patients out-of-pocket expenses, 113114 physical status modifiers, 103104 postoperative pain, 108 preoperative and postoperative billing, 108 Surgical and postoperative codes, 112114 Surgical arthroscopy, 119 Surgical endoscopy, 118 Surgical pathology, 137138 Surgical tray, 108 Sutures, 180 Symbols, CPT, 42 T Teaching physician modifiers, 210211 Team surgery, 106 Terminology, diagnostic ultrasound, 128129 Therapeutic diagnostic infusions (excludes chemotherapy), 146 Therapeutic radiology simulation definitions, 130131 Time, in E&M services, 6364 Tobacco use disorder, 179 Toxic effects codes, 170 Toxoids, 147 Transcatheter services, 128 Treatment planning, for radiation oncology, 130 Tricare definition and plans, 58 physician assistant billing, 5859 workers compensation, 59 Truncated diagnosis code, 171 U Ultrasound diagnostic, terminology, 128129 procedures, 123, 125 Unbundling, 141 Underweight, abnormal loss of, 180 United States metric equivalents, 226 units of measure, 225 Units of measure metric, 226 United States, 225 Unpaid claims, 35, 36 Unspecified hypertension, 173 V V codes fact-oriented, 169 problem-oriented, 168 service-oriented, 168 Vaccines, common, 147 W Web sites, organization/association, 224225 Weight, abnormal loss of, 180 Workers compensation, in Tricare, 59 Wound repairs, coding, 116 X-rays, 122 X
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Patient Encounter Form

Life Cycle Of An Insurance Form

Create the chart

Generate a patient encounter form

Preauthorization of services or procedures

Review and update patient registration form

Collect co-pays and deductibles

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Generate insurance form (CMS 1500 Form) Attachments

General Instructions for Good Documentation

Completion of a CMS 1500 Form

Box 4: Insureds name

Box 5: Patients address

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Place of Service Codes

Indian Health Service/Free Standing Facility Indian Health Service/Freestanding facility

Tribal 638 Freestanding facility

Tribal 638 Freestanding facility

Urgent care facility

Inpatient hospital Outpatient hospital

Military treatment facility Skilled nursing facility Nursing facility

Federally qualified health center

Inpatient psychiatric facility

Psychiatric facility: partial hospitalization

Intermediate care facility/mentally retarded

Residential substance abuse treatment facility

Psychiatric residential treatment center

Nonresidential substance abuse treatment facility

Comprehensive outpatient rehabilitation facility

Other place of service

Claims Submission Issues

Components of an Explanation of Benefits

Service was not covered by insurance

Deductible is not met

Step 3a Step 3b Step 4a

Collection Abbreviations Abbreviation

Billing for Relatives

CPT (HCPCS Level I)

CPT Symbols Symbol

Locum Tenens Providers

Managed Care Plan

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Co-pay is fixed Deductible

Managed Care Plan Hospital

Deductibles and Co-pays

Medicare Secondary Payor (MSP)

MSP Billing Guide Primary Insurer: Medicare

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Primary Insurance: Other Insurance

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Physician must be in the suite of the office State law

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