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Page 1: Coding Notes - Billing & Coding Pocket Guide
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F. A. Davis Company • Philadelphia

Provider’sCodingNotes

Purchase additional copies of this bookat your health science bookstore ordirectly from F. A. Davis by shoppingonline at www.fadavis.com or by calling800-323-3555 (US) or 800-665-1148 (CAN)

A Davis’s Notes Book

Alice Anne Andress, CCS-P, CCP

Provider’sCodingNotes

Billing and Coding Pocket GuideBilling and Coding Pocket Guide

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F. A. Davis Company1915 Arch StreetPhiladelphia, PA 19103www.fadavis.com

Copyright © 2007 by F. A. Davis Company

Copyright © 2007 by F. A. Davis Company. All rights reserved. This prod-uct is protected by copyright. No part of it may be reproduced, stored ina retrieval system, or transmitted in any form or by any means, elec-tronic, mechanical, photocopying, recording, or otherwise, without writ-ten permission from the publisher.

Printed in China by Imago

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Andy McPheeManager of Content Development: Deborah J. ThorpDevelopmental Editor: Elizabeth LoGiudiceArt and Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clin-ical research, recommended treatments and drug therapies undergochanges. The author(s) and publisher have done everything possible tomake this book accurate, up to date, and in accord with accepted stan-dards at the time of publication. The author(s), editors, and publisher arenot responsible for errors or omissions or for consequences from appli-cation of the book, and make no warranty, expressed or implied, inregard to the contents of the book. Any practice described in this bookshould be applied by the reader in accordance with professional stan-dards of care used in regard to the unique circumstances that may applyin each situation. The reader is advised always to check product infor-mation (package inserts) for changes and new information regardingdose and contraindications before administering any drug. Caution isespecially urged when using new or infrequently ordered drugs.

Authorization to photocopy items for internal or personal use, or theinternal or personal use of specific clients, is granted by F. A. DavisCompany for users registered with the Copyright Clearance Center(CCC) Transactional Reporting Service, provided that the fee of $.10 percopy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923.For those organizations that have been granted a photocopy license byCCC, a separate system of payment has been arranged. The fee code forusers of the Transactional Reporting Service is: 8036-1745-3/07 0 � $.10.

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Waterproof and Reusable

Wipe-Free Pages

Write directly onto any page of Provider’s Coding

Notes with a ballpoint pen. Wipe old entries off

with an alcohol pad and reuse.

TOOLSMODHCPCS

ICD-9-CMMEDRAD

PATHSURGANES

EVALMGMTGENERAL

Place 2 7/8�2 7/8 Sticky Notes here

For a convenient and refillable note pad

HIPAA CompliantOSHA Compliant

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Look for our other Davis’s Notes titlesRNotes®: Nurse’s Clinical Pocket Guide, 2nd editionISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5

Coding Notes: Medical Insurance Pocket GuideISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6

Derm Notes: Dermatology Clinical Pocket GuideISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6

ECG Notes: Interpretation and Management GuideISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8

IV Therapy Notes: Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4

LabNotes: Guide to Lab and Diagnostic TestsISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5

LPN Notes: Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1132-3 / ISBN-13: 978-0-8036-1132-0

MedSurg Notes: Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1115-3 / ISBN-13: 978-0-8036-1115-3

NutriNotes: Nutrition & Diet Therapy Pocket GuideISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6

MA Notes: Medical Assistant’s Pocket GuideISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5

OB Peds Women’s Health Notes: Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1466-7 / ISBN-13: 978-0-8036-1466-6

Ortho Notes: Clinical Examination Pocket GuideISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8

PsychNotes: Clinical Pocket GuideISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0

Screening Notes: Rehabilitation Specialists Pocket GuideISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1

Rehab Notes: Evaluation and Intervention Pocket GuideISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0

IV Med Notes: IV Administration Pocket GuideISBN-10: 0-8036-1446-2 / ISBN-13: 978-0-8036-1466-8

MedNotes: Nurse’s Pharmacology Pocket Guide, 2nd EditionISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1

For a complete list of Davis’s Notes and other titlesfor health care providers, visit www.fadavis.com.

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GENERAL

General Billing and Insurance Guidelines

Patient Registration Form

The patient registration form is one of the most important forms ina medical practice. It contains all necessary information requiredfor billing for services and procedures. This form should be updatedyearly. Patient information should be reviewed and verified at eachpatient encounter to ensure that the practice has the most currentand accurate information on file.Each item on the form should be verified by asking the patient, “Doyou still live at . . . ” instead of using a general statement such as“Has anything changed since your last visit?”A copy of the patient’s health insurance card, both front and back,should be copied during each visit.This form should contain the following information:

Data Reason

Date

Patient’s name

Patient’s address

Patient’s phone number

Patient’s date of birth

Patient’s age

Patient’s social securitynumber

Guarantor’s name, address,and phone number ifpatient is not guarantor

Employer’s name, address,and phone number

Required for billing purposes

Required for billing purposes

Required for billing purposes

Required for billing purposes andto contact patient regardingappointments and testing results

Required for billing purposes

Required for billing purposes

Required for patient identificationpurposes only

Required for billing purposes

Required for billing or if patientneeds to be contacted duringworking hours

(Continued text on following page)

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Data Reason

Spouse’s name

Spouse’s employer’s name,address, and phonenumber

Insurance company name,address, and phonenumber

Insurance identificationand group numbers

Person to be notified incase of emergency

Referred by

Patient’s signatureSome forms will contain

the following:

List of current medicationsPast illnesses/surgeriesAllergies

Review this form for completeness as this information is criticalto the billing process. Any missing information should becompleted by asking the patient questions.There are some key areas to look for that may be “tell-tale”for nonpaying patients. These areas are:■ Incomplete information on the form■ Questionable employment information■ No phone number■ Post office box listed in lieu of a street address■ Motel address■ No insurance information■ No referral information

GENERAL

May be required for billingpurposes

May be required for billing pur-poses or if spouse needs to becontacted during working hours

Required for billing purposes

Required for billing purposes

Required in case of emergency

Required for billing purposes andquality of care purposes

Required for billing purposes

For clinical reasons

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GENERAL

A potential nonpaying patient may sometimes be identifiedby items on the previous list.If any of the listed elements exist, extra care should be takento obtain accurate and complete information.

Patient Encounter Form

One of the most important factors in medical billing is anaccurate billing form. This form has many names, patientencounter form, superbill, fee slip, charge slip, billingform, etc. This form is used to communicate the patientvisit charges to the billing personnel. All information onthis form must be accurate and complete and contain thefollowing information:■ Patient’s name■ Patient’s address■ Patient’s home phone number■ Patient’s account number/medical record number■ Guarantor’s name■ Patient/guarantor’s insurance company and identification

number■ Date of service■ Date of birth■ Provider name■ Diagnosis section■ CPT code section■ Space for next appointment■ Space for provider to complete with any studies that may

need to be orderedThis form must be reviewed and updated twice a year whenthe codes are updated. Deleted codes, new codes, and revisedcodes should be updated when necessary.The patients should be questioned at each visit to identify anychanges that may have occurred since their last visit.

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Life Cycle Of An Insurance Form

New Patient, Office

A new patient is one who has not been seen by the physician orany physician in that specialty group within the last 3 years. Thesevisits are reported using codes 99201–99205. Detailed informationregarding these codes can be found in Tab Two.The steps involved in an office visit for a new patient are:

Step 1 Patient information

The patient arrives at theoffice. The patient is eitherinterviewed or completes apatient registration form toobtain information listed tothe right.

If the patient registration formis not completed in itsentirety, the office staffshould question the patientin order to obtain all thenecessary information.Some offices will have thepatient complete a historyform in addition to theregistration form.

OR

Step 1 Patient information

The patient calls the office tomake an appointment.Information is collectedduring the phone call toobtain information as listedto the right. Patient

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

GENERAL

Patient’s 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

Patient’s nameAddressPhone numberPlace of employmentSpouse name, if applicable

(Continued text on following page)

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GENERAL

Step 1 Patient information

is asked to bring his/herinsurance card to the officevisit.

Step 2 Insurance

The patientarrives atthe officewith his/herinsurancecard.

Emergency contact informationAllergiesReason for the visitType of insuranceAddress of insurance

Patient registration form is completed.Both sides of the insurance card are copied.

This copy is placed in the patient’s chart.All patients with insurance must sign an authori-

zation of benefits form to allow the practice torelease information necessary for payment ofthe claim and to request that payment be madedirectly to the physician practice.

Depending on the insurance, verification ofcoverage may be necessary.

If this is a specialty office and the patient hasa managed care plan, a referral is necessary fortreatment.

Most managed care plans have co-pays, whichmust be paid at the time of the visit.

If the patient has Medicare, a deductible must bemet at the beginning of each calendar year.

If the patient has Medicaid or other insurances,there may be deductibles and co-pays that arenecessary to be paid. This information can befound on the insurance card.

If the patient is a child, be aware of the birthdayrule. If both parents carry insurance, the childwill be covered under the parent whosebirthday is first in a calendar year.

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Step 3 Create the chart

A patient chartis createdwith theforms listedto the right.

Step 4 Data Entry

A patient account is created in the computer using the followingthe information collected from the patient registration formand insurance card.

Step 5 Generate a patient encounter form

A patient encounterform is generatedand placed on thefront of the patient’schart. This documentbecomes the sourceof information forbilling. This docu-ment has manynames, some ofwhich you can seein the column tothe right.

The patient is seen by the physician and is discharged from thatoffice visit.

GENERAL

Place patient registration form and copy ofinsurance card in chart.

Place all other authorization forms in the chart.Any forms used by the practice to record

clinical information, such as medicationlogs, progress note forms, office visittemplates, history forms, problem lists, etc.

Apply appropriate labels to the chart, suchas type of insurance, year of the visit,alphabetize labels indicating the patientname for faster filing.

Fee slipSuperbillCharge slipBilling formCharge capture form

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GENERAL

Established Patient, Office

An established patient is one who has been seen by the physi-cian within the last 3 years. These visits are reported using codes99211–99215. Detailed information regarding these codes can befound in Tab Two.The steps involved in an office visit for an established patient areas follows:

Step 1 Scheduling of appointment

The patient either schedules a follow-up appointment while atthe 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 thepreauthorization to be sure it has not expired. If the referralhas expired, it will be necessary to obtain a new form from theprimary care physician. Most physician offices submit referralselectronically as opposed to paper.

Step 3 Review and update patient registration form

Be sure that all information listed on the patient registrationform is accurate and complete. These forms should becompletely updated yearly, however, at each patient visit, thestaff should inquire as to any changes that may have occurredin the patient’s 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 timeof the service. Medicare is billed and any deductible still dueis deducted from the physician payment. This is stated on theExplanation of Medicare Benefits. The patient is then billed forthe deductible amount.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Generate a patient

Step 5 encounter form

A patient encounter form is generatedand placed on the front of thepatient’s chart. This documentbecomes the source of informationfor billing. This document has manynames, some of which you can seein the column to the right.

The purpose of the patient encounter form is to communicatecharges (services and procedures the patient received) anddiagnoses to the billing department. This form is also used toinform the staff of any diagnostic studies that are to be orderedand to indicate any follow-up appointments that may benecessary.The patient is seen by the physician and is discharged from thatoffice visit.

Patient Discharge

Step 1 Charges

Physician practices will havecheck-out staff procedures.

Step 2 Posting

The patient charges are posted to the patient’saccount in the computer system.

Step 3 Payment

Patient’sfinancials

GENERAL

Fee slip

Superbill

Charge slip

Billing form

Charge capture form

If no insurance, the patient is expected to payat the time of the service.

If the patient has a co-pay that has not beencollected during check-in, they will be expectedto pay at discharge.

The patient charges are totaledon the patient encounter form.

(Continued text on following page)

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GENERAL

Step 3 Payment

The purpose of the CMS 1500 claim form is to create a standard forcollecting Medicare information. The most common claim denialsbased on the claim form is incomplete or inaccurate diagnosiscodes (Box 21) and incorrect place of service codes (Box 24b). TheCMS 1500 form information has been completed, is accurate, andready for submission when all items in the following table havebeen completed.

Step 4 Generate insurance form (CMS 1500 Form)

Step 5 Attachments

For filing paperclaims only

Step 6 Signature, patient

Signatures arean importantpart of theclaim form.

If the patient has insurance, but it does not coveroffice visits, the patient is expected to pay at thetime of service.

Any payment made is then posted to the patient’saccount.

Copy and staple any attachments that are neces-sary to the CMS 1500 form. If no attachmentsare necessary, claim can be sent electronically.

Attachments are needed if there is a concurrentcare situation, if an unusual service or proce-dure was performed.

The patient must sign the CMS claim form if aform is being sent by paper claim.

On claims where the patient has signed anauthorization form, the phrase “SOF” or“signature on file” can print in box 12 on theCMS 1500 paper claim.

If claim is being submitted electronically, “SOF”or “signature on file” can print in box 12.

When an illiterate or physically handicappedpatient signs by a mark (X), a witness mustenter his or her name and address next tothe mark on the claim form.

(Continued text on following page)

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GENERAL

A representative may sign the claim on thepatient’s behalf if the patient is physically ormentally unable to sign. When this occurs,the signature line must indicate the patient’sname followed by the word “by,” therepresentative’s name, address, relationshipto the patient, and the reason the patientcannot sign.

If there is no signature, the claim will not betransferred automatically to Medigap.

The claim must be signed by the provider or anauthorized representative if the claim is beinggenerated on paper.

No signature is necessary if the claim is beingsent electronically.

A signature stamp may be used if theprovider’s name is typed below.

If the claim is manually produced (paper), aninsurance log must be kept with informationsuch as the patient name, amount of claim,insurance carrier, and date submitted.

If the claim is submitted electronically, thecomputer will provide the practice with areport.

(Continued text on following page)

Step 6 Signature, patient

Step 6 Signature, provider

Signaturesare animportantpart of theclaim form.

Step 7 Insurance tracking

Submittedclaimsshould betracked.

Step 8 Submit claim

Either mail or submit the claim electronically.Claims should be submitted daily for better

cash flow.

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GENERAL

Step 8 Submit claim

When submitting a claim electronically, run apresubmission report to identify any errors,which may cause denials and correct thembefore submission.

Step 9 Check is mailed

A check alongwith anexplanationof benefits(EOB) ismailed tothe providerif the pro-vider isparticipating.

Preauthorization/Precertification

Preauthorization:

Some insurance carriers require permission to perform a serviceor procedure before it is done. This preauthorization identifieswhether the insurance program will allow the service orprocedure to be performed based on the medical necessityinformation provided by provider.Precertification:

Identifies whether the service or procedure is covered underthe patient’s insurance plan. It is not based on the medicalnecessity of the procedure, but on whether or not the patienthas coverage.Although proper steps have been taken to obtain preauthoriza-tion/precertification, there is no guarantee that services will becovered.

Information is taken from EOB and postedto the patient’s account.

Any claim denials must be thoroughlyreviewed, corrected, and resubmitted ifpossible.

Automatic rebilling of claims to the carrierwithout investigation and analysis of theclaim can result in duplicate claims andduplicate payments. This can be construedas fraudulent billing.

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Documentation

Documentation is the story of patient visit, a legal document, andserves as the groundwork for reimbursement of health-careservices and procedures. It explains to the carrier what you did,why, and how.In Tab 2, the Evaluation and Management codes are discussedin detail to illustrate the various components necessary forchoosing the appropriate level of service.Proper documentation will:

■ Allow your billing staff to identify the services and proceduresthat you performed.

■ Allow for appropriate reimbursement.

General Instructions for Good Documentation■ Make sure that you have the correct chart.■ Be sure to write the patient’s name on each page when

documenting (this can be done by office staff).■ Make sure all entries in the medical record are legible and

preferably written in black ink.■ Be sure to date, sign (hard copy, or authenticate an electronic

signature) each entry.■ For inpatient records, document the time using military time and

the service you are on, i.e., medicine, surgery, cardiology, etc.■ Use standard abbreviations (it is a good idea to obtain a listing

from the hospital; most use Stedman’s).■ Avoid “canned verbiage.” No two patients are the same.■ Avoid vague language such as, “routine visit,” “follow-up,”

“doing well,” “check up,” “ exam unchanged,” etc.■ Make sure there is a record of all prescriptions refilled and all

telephone calls with patients.■ Be sure to either dictate or hand write the documentation as

soon as possible after the patient encounter (memories fade).■ Document specifics of any unusual procedure or service that

requires more time than usual (document such things as thetime it took, what you did that took the extra time, or anydifficulties that you may have had either with the procedure

GENERAL

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GENERAL

itself or the patient). These procedures would be reported using the – 22 modifier (see Tab 7).

■ Document the difference between an acute and a chroniccondition.

■ Be sure to include your reasoning to support the medicalnecessity for the visit.

■ Document nonresponses to treatments or medications and anynewly developed symptoms.

■ Do not dictate the phrase “Dictated, not read” on your dictations.You are responsible for verifying that the dictation is true andcorrect.

Completion of a CMS 1500 Form

The CMS 1500 was revised to accommodate many changesincluding addition of the NPI number for providers. The revisionsbegan in June of 2004 and the new form was released in Januaryof 2007.

CMS Areas Completion Instructions

Box 1: Type ofinsurance

Box 1a: Insured’sID number

Box 2: Patientname

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Indicate the type of health insurance coverage:Medicare, Medicaid, Champus/Tricare,Champva, group health plan, FECA/blacklung, other

Contains the patient’s health insurance number

Enter patient’s name exactly as it is on theinsurance card

Address, phone number

Do not leave a space between a prefix and aname

For hyphenated names, capitalize both namesand separate by a hyphen

Leave a space between the last name and a suffix

(Continued text on following page)

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CMS Areas Completion Instructions

Box 3: Patient’sdate of birthand sex

Box 4: Insured’sname

Box 5: Patient’saddress

Box 6: Patientrelationshipto the insured

Box 7: Insured’saddress

Box 8: Patient’sstatus

Box 9: Otherinsured’sname

GENERAL

Enter the date of birth using two digits for themonth, two for the day, and four for theyear.

Check the box that indicates the sex of thepatient; the sex of the patient must be validfor the diagnosis of the patient

For Medicare: Enter the name of the insuredperson only if that person’s insurance isprimary to Medicare; if Medicare is primary,leave it blank

Enter the complete mailing address andtelephone number

If the patient lives in a nursing home, list thenursing home address as the patient’s

Do not place punctuation in a city name thatcontains 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 patient’s marital status andemployment 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 isenrolled in a Medigap policy if the name isdifferent from the name shown in Box 2;enter the word “same” if it is the same

(Continued text on following page)

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GENERAL

CMS Areas Completion Instructions

Box 9a: OtherInsured’s Policyor GroupNumber

Box 9b: Otherinsured’s dateof birth, sex

Box 9c: Employer’sName or SchoolName

Box 9d: Insuranceplan name orprogram name

Box 10: Is patient’scondition relatedto:

Box 10a: Employ-ment

Box 10b: Autoaccident

Box 10c: Otheraccident

Box 10d: Reservedfor local use

Box 11: Insured’spolicy, group, orFECA number

Enter the policy or group number of the otherinsured (Box 9)

Enter the 8-digit date of birth, two digits for themonth, two digits for the day, and four digitsfor the year

Enter the name of the other insured’semployer or school.

Enter the other insured’s insurance plan orprogram name

If the patient’s condition is related toemployment, an automobile accident, orsome other accident

This information is used for coordination ofbenefits

If the patient’s condition is not related to any ofthese, place an X in the “no” box for eachitem

Yes or No

Yes or No

Yes or No

Enter information when asked by local carrier

Enter the insured’s policy, group, or FECAnumber. If Box 4 is completed, then this fieldneeds to be completed

(Continued text on following page)

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CMS Areas Completion Instructions

Box 11a: Insured’sdate of birth,sex

Box 11b: Insured’semployer’s name

Box 11c: Insuranceplan name orprogram name

Box 11d: Is thereanother healthbenefit plan?

Box 12: Patient’sor authorizedperson’ssignature

Box 13: Insured’sor authorizedperson’ssignature

Box 14: Date ofcurrent illness,injury orpregnancy

Box 15: If patienthas had sameor similarillness

GENERAL

Date of birth and sex of the individual whocarries the insurance

Name of the employer of the individual whocarriers the insurance

Name of insurance plan of the individual whocarriers the insurance

Answer as to whether or not there is asecondary insurance

Enter the signature of the patient or thepatient’s representative and the date

This signature allows for the release of infor-mation necessary to process the claim

The insured’s signature must be entered inthis block; if the insured’s signature is onfile, enter SOF

Enter the date if the current illness (firstsymptom), injury (accident), or pregnancy(last menstrual period)

If an accident date is entered, complete Box10b or 10c

For chiropractic services, enter the date of theinitiation of the course of treatment and thex-ray date in Box 19

Do not complete this area for Medicarepatients

For all other insurer’s, the date should matchthe same date or be later than the dateentered in Box 24a

(Continued text on following page)

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GENERAL

CMS Areas Completion Instructions

Box 16: Datespatient unable towork in currentoccupation

Box 17: Name ofreferring provideror other source

Box 17a: ID numberof referring orordering provider

Box 17b: NPInumber

Box 18:Hospitalizationdates related tocurrent services

Box 19: Reservedfor Local Use

This block provides the dates that the patientwas employed but unable to work

This field MUST be completed for all Workers’Compensation claims.

Enter the name and credentials of theprofessional who requested the service

The qualifying number should be listed justleft of the other ID number of the referringor ordering provider. The qualifyingnumbers are:OB State license number1B BS provider number1C Medicare provider number1D Medicaid provider number1G Provider UPIN number1H CHAMPUS ID numberE1 Employer’s ID numberG2 Provider commercial numberLU Location numberN5 Provider plan network ID numberSY SSI numberX5 State industrial accident provider

numberZZ Provider taxonomy

Enter the NPI number of the referring orordering provider

Enter the admission and discharge dates

If the services were rendered in a facility otherthan the patient’s home or a physician’soffice, provide the name and address ofthat facility in Box 32

Enter information when asked by local carrier.

(Continued text on following page)

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CMS Areas Completion Instructions

Box 20: Outsidediagnosticservices/charges

Box 21: Diagno-sis or natureof illness orinjury

Box 22: Medicaidresubmission

Box 23: Priorauthorizationnumber

Box 24a: Date(s)of service

Box 24b: Placeof service

Box 24c: EMG

Box 24d: Proce-dures, service,or supplies

GENERAL

Place a “Yes” in the box when a provider,other than the provider billing for theservice, performed the diagnostic test;when “Yes” is checked, Box 32 must becompleted

Enter the purchase price of the tests in thecharges column; show the dollars andcents, omitting the dollar sign

Enter the ICD-9-CM code for the diagnoses,conditions, problems, or other reasonsfor the visit

Report at least one diagnosis per claim

Only four diagnosis codes can be submitted

Enter the codes and original Medicaidreference number of a Medicaid claim

This area must be completed whenresubmitting a claim to Medicaid

Enter the number assigned by the peer revieworganization

For laboratory services performed by aphysician office lab (POL), enter the 10-digitCLIA certification number

Enter the beginning and ending date ofservice for the entire period reflected by theprocedure code.

Enter the appropriate 2-digit place of servicecode

Yes or No

Enter the appropriate CPT or HCPCS code forthe service, procedure, or supply

(Continued text on following page)

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GENERAL

CMS Areas Completion Instructions

Box 24e:Diagnosispointer

Box 24f: Charges

Box 24g: Days orunits

Box 24h: EPSDT

Box 24i: IDqualifier

Enter the appropriate diagnosis code referencenumber (pointer) that is linked to the service,procedure, or supply

Enter the amount charged by the provider foreach of the services or procedures listed onthe claim

Do not bill a flat fee for multiple dates of service

Enter the number of days or units of proce-dures, 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 are12 or younger and receive medical benefitsthrough Medicaid

Enter the qualifier identifying if the number isa non-NPI.

The qualifying numbers are:OB State license number1B BS Provider number1C Medicare provider number1D Medicaid provider number1G Provider UPIN number1H CHAMPUS ID numberE1 Employer’s ID numberG2 Provider commercial numberLU Location numberN5 Provider plan network ID numberSY SSI numberX5 State industrial accident provider numberZZ Provider taxonomy

(Continued text on following page)

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CMS Areas Completion Instructions

Box 24j: Renderingprovider number

Box 24: Supple-mental informa-tion (gray area)

Box 25: Federaltax ID number

Box 26: Patient’saccountnumber

Box 27: Acceptassignment?

Box 28: Totalcharge

Box 29: Amountpaid

Box 30: Balancedue

Box 31: Signatureof physician orsupplier, includ-ing degrees orcredentials

GENERAL

Enter the number of the rendering physician

Supplemental information such as anesthesiaduration in hours and/or minutes with startand end times, narrative descriptions ofunspecified codes, NDC for drugs, vendorproduct numbers, product numbers forHealth Care Uniform Code Council, can beentered in the shaded areas of this box

Enter the tax ID number or social securitynumber of the physician or supplier

Enter the patient’s account number in thisarea; this will then be referenced on theexplanation of benefits for easier postingof monies to the patient account

Check “Yes” when the physician acceptsassignment for the claim

Enter the total amount charged for allservices, procedures, and supplies in Boxes24f, lines 1 through 6

Enter the dollars and cents without the dollarsign

Enter the dollar amount paid toward the totalcost of the service

Enter the dollar amount due after subtractingthe amount paid

If the claim is Medicare, leave this area blank

The provider or his or her representative mustsign the provider’s name

A stamp may be used, but the provider’s fullname must be typed below the stamp

(Continued text on following page)

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GENERAL

CMS Areas Completion Instructions

Box 32: Servicefacility locationinformation

Box 32a: NPInumber

Box 32b: Other IDnumber

Box 33: Physician’ssupplier’s billingnames, address,zip code, phonenumber

If services were provided in a hospital, clinic,laboratory, or any facility other than thephysician’s office or the patient’s home, thisarea must be completed

Enter NPI number of the service facilitylocation

Enter the two digit qualifier identifying thenon-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 Employer’s 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, andtelephone number of the physician orsupplier who furnished the service

(Continued text on following page)

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GENERAL

Enter NPI number of the service facilitylocation

Enter the two-digit qualifier identifying thenon-NPI number followed by the IDnumber.

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 Employer’s ID number

G2 Provider commercial number

LU Location number

N5 Provider plan network ID number

SY SSI number

X5 State industrial accident providernumber

ZZ Provider taxonomy

CMS Areas Completion Instructions

Box 33a: NPI number

Box 33b: OtherID number

Place of Service Codes

When submitting a claim for reimbursement, a place of servicecode must be placed in Item 24b on a CMS 1500 form. Not all ofthe codes listed below are approved by all carriers. Whenperforming the billing function, the carrier should be contactedto verify that the place of service code is valid.

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GENERAL

Code Type Description

0304

05

06

07

08

11

12

SchoolHomeless shelter

Indian HealthService/FreeStandingFacility

Indian HealthService/Free-standing facility

Tribal 638 Free-standing facility

Tribal 638 Free-standing facility

Office

Home

Service is provided at a schoolService is provided at a shelter

that serves as temporaryhousing for the patient

Service is provided at a facilitythat is operated by the IndianHealth Service where patientsare not admitted

Service is provided at a facilitythat is operated by the IndianHealth Service where patientsare admitted as outpatients orinpatients

Service is provided at a facilitythat is operated by the IndianHealth Service under a 638agreement, which providesdiagnostic, therapeutic, andrehabilitation services to thosewho are not admitted

Service is provided at a facilitythat is operated by the IndianHealth Service under a 638agreement, which providesdiagnostic, therapeutic, andrehabilitation services to thosewho are admitted as outpa-tients or inpatients

Service is provided in an officesetting

Service is provided in thepatient’s or caregiver’s home

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Code Type Description

13

14

15

20

21

22

23

GENERAL

Assisted-livingfacility

Group home

Mobile unit

Urgent carefacility

Inpatient hospital

Outpatienthospital

EmergencyRoom-Hospital

Service is provided in aresidential facility with self-contained living units thatprovides support 24 hours aday; this facility has thecapacity to arrange for otherservices if needed

Service is provided at a sharedliving residence, where patientsreceive supervision and otherservices such as social,behavioral, and custodial

Service is provided at a facilitythat moves from place to placeto provide preventive services,screening, diagnostic, andtreatment services

Service is provided at a facility,separate from a hospitalemergency room (ER), wherepatients can be diagnosed andtreated for illness or injury;these patients requireimmediate medical attention

Service is provided at a hospital

Service is provided at a portion ofthe hospital that providesdiagnostic, therapeutic, andrehabilitation services topatients who do not requireadmission to the hospital

Service is provided at a hospitalemergency department

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GENERAL

Code Type Description

24

25

26

31

32

33

34

41

Ambulatorysurgical center

Birthing center

Military treat-ment facility

Skilled nursingfacility

Nursing facility

Custodial care

Hospice

Ambulance: land

Service is provided at afreestanding facility wheresurgical and diagnostic servicesare provided on an ambulatorybasis; cannot be provided in aphysician’s office

Service is provided at a facility,separate from a hospital orphysician’s office, wherematernity facilities are available

Service is provided at a facilityoperated by the UniformedServices

Service is provided at a facilitythat provides inpatient skillednursing care

Service is provided at a facilitythat provides patients withskilled nursing care and relatedservices

Service is provided at a facilitythat provides room and boardand other assistance to patientson a long-term basis without amedical component

Service is provided at a facilityother than the patient’s home,where palliative and supportivecare for the terminally ill isprovided

A land vehicle equipped toprovide transportation and life-saving care to patients

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Code Type Description

42

49

50

51

52

GENERAL

Ambulance:air/water

Independentclinic

Federallyqualifiedhealth center

Inpatientpsychiatricfacility

Psychiatricfacility: partialhospitalization

An air or water vehicle equippedto provide transportation andlife-saving care to patients

Service is provided at a clinic,which is not part of a hospitalthat is organized and operatedto provide preventive,diagnostic, therapeutic,rehabilitative, or palliativeservices to patients

Service is provided at a facilitylocated in a medicallyunderserved area that providesMedicare patients withpreventive care under thedirection of a physician

Service is provided at a facilitythat provides inpatient psychi-atric care for the diagnosis andtreatment of mental illness on a24-hour basis

Service is provided at a facility forthe diagnosis and treatment ofmental illness that provides aplanned therapeutic programfor patients who do not requirefull-time hospitalization, butwho need broader programsthat are not offered asoutpatients

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GENERAL

Code Type Description

53

54

55

56

57

Community mentalhealth center

Intermediate carefacility/mentallyretarded

Residential sub-stance abusetreatment facility

Psychiatric residen-tial treatmentcenter

Nonresidential sub-stance abusetreatment facility

Service is provided at a facility thatprovides the following services:outpatient services for children,elderly, individuals who arechronically ill, and residents ofthe center who were dischargedfrom inpatient treatment; daytreatment, partial hospitalization,screening for patients beingconsidered for admission tostate mental health facilities todetermine the appropriatenessof such admission and consul-tation and education services

Service is provided at a facilitythat provides health-related careand services above the level ofcustodial care to mentallyretarded patients

Service is provided at a facilitythat provides treatment forsubstance abuse to live-inresidents who do not requireacute medical care

Service is provided at a facility forpsychiatric care that provides atotal 24-hour therapeutically andprofessionally staffed groupliving and learning environment

Service is provided at a facilitythat provides treatment forsubstance abuse on anambulatory basis

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Code Type Description

60

61

62

65

71

GENERAL

Mass immuniza-tion center

Comprehensiveinpatientrehabilitationfacility

Comprehensiveoutpatientrehabilitationfacility

End-stage renaldisease treat-ment facility

State or localpublic healthclinic

Service is provided at a facility whereproviders administer pneumo-coccal pneumonia and influenzavaccines and submit these servicesfor billing; can be a public healthcenter, pharmacy, or mall

Service is provided at a facility thatprovides comprehensive rehabili-tation services under the supervi-sion of a physician to inpatientswith physical disabilities; servicesinclude physical therapy (PT),occupational therapy (OT), speechpathology, psychological services,and orthotics and prosthetics

Service is provided at a facility thatprovides comprehensive rehabili-tation services under the super-vision of a physician to outpatientswith physical disabilities; servicesinclude PT, OT, speech pathology,psychological services, andorthotics and prosthetics

Service is provided at a facility otherthan a hospital, which providesdialysis treatment, maintenance,and/or training

Service is provided at a facilitymaintained by the state or localhealth departments that providesambulatory primary care underthe direction of a physician

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GENERAL

Code Type Description

72

81

99

Claims Submission Issues

There are some common problems identified with claimssubmissions:■ Incorrect insurance number■ Incorrect physician NPI number■ Submission to an incorrect carrier■ Incorrect diagnosis code (missing, incomplete)■ Patient’s name, address, etc. as listed does not match

insurance carrier records■ Gender of patient is incorrect■ Incorrect date of service■ Incorrect place of service code■ Incorrect or missing modifier(s)■ Incorrect units billed■ Missing provider ID number■ Illegible claim form

Rural health clinic

Independentlaboratory

Other place ofservice

Service is provided at a facility,which is certified as a ruralunderserved area, that providesambulatory primary care underthe direction of a physician

Service is provided at anindependent laboratory that iscertified to perform diagnosticand/or clinical tests

Other place of service notidentified

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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 thereason for denial. An EOB contains the following information:

Components of an Explanation of Benefits

Patient NamePatient ID number or HIC numberClaim processing ID numberProvider nameDate of serviceProcedure codeDiagnosis codeAllowable chargeSubmitted chargeWhat portion is deductible and/or co-payWhat is paid and to whomPatient responsibility amountIf no payment, the reason code for the nonpayment

EOBs will not be sent to providers who do not accept assign-ment on claims. This is prohibited by the Federal Privacy Actof 1974. In this case, the EOB will be sent to the patient. If anappeal is required on a non-assigned claim, the patient mustprovide the EOB along with a letter stating the provider ispermitted to assist in the appeal. The EOBs should be reviewedperiodically to ensure that the provider is receiving accuratereimbursement.

GENERAL

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GENERAL

Denial of Claims

There are some common denials identified with claims submis-sions. Below you will find a listing with a recommendation tofollow.

Rejected claims Recommendation

Claims are many timesrejected due to incorrect orinvalid information (date ofbirth, transposed numbers,provider numbers, dates ofservice, incorrect gender,etc.) submitted to the carrier.

Delays in payment Recommendation

Claims that are delayed canresult due to claim being“in process,” where thecarrier is awaiting addi-tional informationrequested from theprovider or beneficiary.

Service was not

covered by insurance Recommendation

Some services are notconsidered to be a coveredservice, i.e., hearing test,eyeglasses, preventivemedicine services, etc.

Review all claim information foraccuracy and completenessbefore submission. Correct allrejected claims and resubmit.

Correct claims quickly andresubmit so that cash flow isnot interrupted. Claims thathave been suspended awaitinginformation from the patientare more difficult to handle.Once the practice verifies thatthe delay lies with the patient,the practice should call thepatient to suggest perhapsthat they could help to providethis information.

Send the patient a letter explain-ing that the claim was denieddue to lacking coverage.

This charge now becomes thepatient’s responsibility.

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Service provided was for

a pre-existing condition Recommendation

Some services cannot bereimbursed as the patienthas a pre-existingcondition (a condition forwhich they have alreadyobtained care).

Deductible is not met Recommendation

The patient is responsible fora certain dollar amount ofdeductible each year.Payment cannot be madeuntil that deductible is met.

GENERAL

When the patient presents to theoffice as a new patient, askabout any pre-existingconditions. When performinga service or procedure thatmay fall under that condition,always check with the carrierto see if a pre-existing clauseexists. If so, discuss thecharge with the patient toidentify whether or not thepatient wants to proceed withthe understanding that theywill have to pay.

Ask the patient when they arrivefor their appointment whetheror not they have seen anyother physicians since January1 of that calendar year. Thismay provide some insight intowhat may have already beenapplied to the deductible. Thebest practice is to submit thebill to the insurance carrierand to review the EOB/remittance advice to identifywhat dollar amount has beenapplied to the deductible.Once that figure is obtained,bill the patient for thedeductible amount.

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GENERAL

Check Verification

A personal check is the most common form of payment in amedical office. Important facts regarding checks:■ Always check the name and address on a personal check

against the patient’s driver’s license.■ 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 acceptout-of-town checks; however, some practices are located inresort areas where out-of-town checks are common. In thiscase, attempt to have the patient pay by credit/debit card.

■ Do not accept third-party checks.■ Do not cash checks over the amount due to give the patient

cash back.■ 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.

■ Be sure the check is signed. If the unsigned check is from anestablished patient and merely an oversight, the practiceshould try to reach the patient and request that they stop byto sign the check. If it is difficult for the patient to return tosign the check, it can be handled in the following manner:

■ Write the word “over” on the signature line of the check.■ On the back of the check in the endorsement area, write “Lack

of signature guaranteed,” the practice’s name, and one’s ownname and title. This tells the bank that the practice will acceptthe loss in such a case where the patient would not honor thecheck.

Returned Checks

The most common reason for a check to be returned, is fornonsufficient funds (NSF). When this occurs, the following stepsshould be followed:■ Redeposit the check or call the patient to see if the check can

be redeposited. Most banks will allow a redeposit one time.

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■ If the check cannot be redeposited, ask the patient how theywould like to cover this outstanding balance. Credit card, debit,cash, etc.

■ If the check is returned after the second deposit, call the patientand ask how they intend to resolve this matter. If this phone callbecomes difficult send a letter demanding payment. This lettershould include the following information:

■ Check date■ Check number■ The bank on which it was drawn■ The name of the person who wrote the check■ The name of the person who the check was payable to■ The amount of the check■ The number of days the patient has to correct the matter

Some offices charge an additional administrative fee for returnedchecks. 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 reasonableattempt to collect would be demonstrated by the following:■ Any collection process used to collect an amount from a non-

Medicare patient■ Patient statements are sent to either the patient or guarantor■ Collection letters or telephone calls in an effort to collect

payment; all telephone calls should be documented to create apaper trail

Once it has been determined that the patient is a true hardshipcase, the provider must determine the patient’s ability to paythrough a review of additional information requested from thepatient.■ Request a copy of the patient’s tax form from the previous year

or a copy of their W-2 or statement of earnings from the SocialSecurity Administration

■ Some practices have developed financial determination formsfor the patient to complete

GENERAL

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GENERAL

Unpaid Claims

An Aged Trial Balance report should be obtained from thepractice computer. This report should be used to follow upon all unpaid claims. This report can be run by the insurancecarrier or as one general report.

Step 1

Step 2

Step 3a

Step 3b

Step 4a

Step 4b

Step 5

Run computer-generated Aged Trial Balance report.Report can be generated with the followingparameters:

■ By insurance carrier■ By provider■ By codes■ By dollar amount■ By practice (includes all providers, all codes, all

carriers)

Begin follow-up by starting with the largest dollaramount listed and continue through the smallestamount.

If no EOB was received, call carrier to obtain statusof claim.

If EOB was received, review the EOB to ascertain thereason for the denial.

If claim requires additional information from theprovider, this should be completed and thenresubmitted.

Follow up on denial reason code. Correct error andresubmit.

Never resubmit a claim without proper

investigation into why it has not been paid.

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Insurance Commissioner

There is an insurance commissioner in each state whereinsurance problems can be reported for further action. Examplesof some of these problems are:■ Delays in payment by third-party carriers■ Incorrect denial of claims■ Incorrect termination of a policyHave information available when contacting the commissioner.Such information would be:■ Patient name, address, phone number■ Insured’s name address, phone number■ Name of insurance company■ Policy number■ 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 thetable below to check this law.

Oral Written Promissory Open

State Agreements Contracts Notes Accounts

AK 6 6 6 6AL 6 6 6 3AR 3 5 6 3AZ 3 6 5 3CA 2 4 4 4CO 6 6 6 6CT 3 6 6 6DC 3 3 3 3DE 3 3 6 3

GENERAL

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GENERAL

Oral Written Promissory Open

State Agreements Contracts Notes Accounts

FL 4 5 5 4

GA 4 6 6 4

HI 6 6 6 6

IA 5 10 5 5

ID 4 5 10 4

IL 5 10 6 5

IN 6 10 10 6

KS 3 5 5 3

KY 5 15 15 5

LA 10 10 10 3

MA 6 6 6 6

MD 3 3 6 3

ME 6 6 6 6

MI 6 6 6 6

MN 6 6 6 6

MO 5 10 10 5

MS 3 3 3 3

MT 5 8 8 5

NE 4 5 6 4

NH 3 3 6 3

NJ 6 6 6 6

NM 4 6 6 4

NV 4 6 3 4

NC 3 3 5 3

ND 6 6 6 6

NY 6 6 6 6

OH 6 15 15 �

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Oral Written Promissory Open

State Agreements Contracts Notes Accounts

OK 3 5 5 3OR 6 6 6 6PA 4 6 4 6RI 15 15 10 10SC 10 10 3 3SD 6 6 6 6TN 6 6 6 6TX 4 4 4 4UT 4 6 6 4VA 3 5 6 3VT 6 6 5 6WA 3 6 6 3WI 6 6 10 6WV 5 10 6 5WY 8 10 10 8

*Reported in years.

Collection Abbreviations

Abbreviation Description

AttyBBalBTTRCCBCLMDFB

GENERAL

Place with AttorneyBankruptBalanceBest time to reachCollectionsCall backClaimDemand for balance

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GENERAL

Abbreviation Description

DCEOMEOWFNHSBHHCHUINSIPL1, L2, L3LBLMLMVMMRNANFANPNSFPAPHPFPMPMTPNPOEPOWPPPTSSEPSK

DisconnectedEnd of monthEnd of weekFinal NoticeHusbandHave husband callHung upInsuranceInsurance pendingLetter 1, letter 2, letter 3Line busyLeft messageLeft message, voice mailMail returnNo answerNo forwarding addressNo phoneNonsufficient fundsPayment arrangementPhonesPayment in fullPayment in mailPaymentPrivate numberPlace of employmentPayment on the wayPartial paymentPatientSpouseSeparatedSkipped town

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Abbreviation Description

TWUEUTCVEVI

Bankruptcy

Some patients file for bankruptcy in order to obtain relief of theirdebts. The types of bankruptcy are:

Type Description

Chapter 7

Chapter 9

Chapter 11

Chapter 12

Chapter 13

GENERAL

Talked withUnemployedUnable to contactVerified employmentVerified insurance

All nonexempt assets of the patient are sold withthe proceeds distributed to the creditors.Secured creditors are first to be paid. Unsecured(like medical bills) are last to be paid. This isconsidered an absolute bankruptcy in whichmany or all debts are wiped out.

Not relevant for medical bills. Used for reorganiza-tion of a town.

Not relevant for medical bills. Used for reorganiza-tion of a business, when they want to continuedoing business.

Used for reorganization for a farmer who cannotmeet financial obligations.

Referred to as a wage earner’s bankruptcy. Pro-tects the wage earner from creditors while thewage earner makes arrangements to repay all orsome of the debts over 3–5 year. At the end of3–5 years, the balance of what is owed on mostdebts is erased. Portion the bills (about 75%)over a fixed period.

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GENERAL

Overpayments

An overpayment can result when:

■ Payment results from two different sources for the same serviceor procedure

■ Payment should have been sent to the patient■ Payment resulted in more dollars than the allowed amount■ Payment is the result of a computer or data entry error

All overpayments must be returned to the carrier within areasonable amount of time (2–4 weeks). If check is for multiplepatients, make a copy of the check and then deposit it. If check isfor that one patient only, copy check and return it to the carrier.Attach a copy of the EOB/remittance advice so that the carrier canidentify the patient. Keep a copy of all correspondence regardingthis overpayment in a file.

Billing for Relatives

Medicare does not permit providers to bill for relatives or membersof their households.Household members would include anyone living in the house aspart of the family, such as nanny, maid, butler, chauffeur, medicalcaregiver, or assistant. Individuals considered to be boarders(college students renting a room) would not be included. Relativesthat would be considered immediate are:

■ Spouse■ Parent, child, brother, sister■ Grandparents/grandchild and spouse■ Stepparent, stepchild, stepbrother, stepsister

CPT (HCPCS Level I)

The CPT book is released in the later part of August or earlySeptember of each year. The codes found in this book becomeeffective on January 1 the following year. It is imperative that anew book be purchased each year due to revisions, new codes,and deleted codes.

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Sections of the CPT Book

Code Range Section Heading

99201–99499

00100–01999

99100–99140

10021–69990

70010–79999

80048–89356

90281–99199

99500–99602

Each section contains guidelines for the codes in that specificsection. These guidelines should be reviewed before using thecodes listed in that section.In the event that a specific CPT code does not exist for theprocedure performed, each section contains unlisted codes forthis purpose. For example, unlisted procedure, pharynx,adenoids, or tonsils, 42999.

CPT Symbols

Symbol Description

•▲

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

GENERAL

Evaluation and ManagementAnesthesiology

SurgeryRadiologyLaboratory/PathologyMedicine

New code

Revised code

New or revised descriptionCodes include conscious sedationCodes exempt from use of modifier �51Codes that can be added onto a procedure

or service

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GENERAL

Clean Claim

A clean claim is one that has been submitted within the proper timeperiod and contains all the necessary information. This allows for theclaim to be paid promptly, as additional information does not have tobe requested.A clean claim means:■ It has no deficiencies and passes all the edits.■ The third-party carrier does not have to obtain additional

information before processing the claim.■ The claim may be investigated in a “postpayment” state, rather

than holding payment until any investigation that may take placeis completed.

Other claim-related terms:■ Incomplete: A claim that is missing required information. The

provider is notified so that information can be sent.■ Rejected: A claim that requires investigation and needs further

clarification. This claim would need to be resubmitted with thenecessary information.

■ Invalid: A claim that contains complete, necessary information, butis incorrect. This claim would need to be resubmitted with theproper corrections.

■ Dirty: A claim submitted with errors, a claim that requires manualprocessing, or a claim that has been rejected for payment.

■ Dingy: A claim that cannot be processed for the service orprocedure, or bill type.

■ Paper: A claim that is submitted on paper, whether typed orcomputer generated.

■ Electronic: A claim that is submitted to the carrier through a centralprocessing 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 physician’spractice and treat patients as if the practice was their own.Established patients are still billed as established patients, as allbilling is reported under the regular physician. See the followinglisting of conditions that must be met to bill for locum tenens:

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■ The patient’s regular physician is not available.■ The regular physician pays the locum tenens a per diem fee.■ The locum tenens cannot provide services to Medicare

patients for more than 60 days.■ 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.■ HMO—health maintenance organization■ PPO—preferred provider organization■ IPA—independent practice association■ EPO—exclusive provider organization■ POS—point of service

Managed Co-pay Authorization

Care Plan Deductible Payment Required

HMO

PPO

IPA

EPO

POS

GENERAL

Co-pay is fixed

Co-pay is fixedDeductible

Co-pay is fixed

Co-pay is fixed

Co-pay is fixedDeductible

CapitatedFee for service

carve-outs

Fee for service

CapitatedFee for service

carve-outs

CapitatedFee for service

carve-outs

CapitatedFee for service

carve-outs

Yes

Yes

Yes

Yes

Yes

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GENERAL

Do’s and Dont’s of Working with Managed Care

Do

■ Label each patient’s chart with the name of the patient’smanaged care organization. Bill each organization the sameday of the service.

■ Monitor the number of days it takes to be paid under a fee-for-service method. Document any late capitation checks.Promptly call your provider representative with the results.

■ Appeal inconsistent fee-for-service payments for the sameCPT code or unreasonable payments inconsistent with thecontracted fee schedule.

■ Appeal problem payment decisions directly to the medicaldirector of each organization.

■ Request financial reports each year and have the doctorsreview them before contacting time. Network with otherpractices involved with the managed care organization ifdissatisfied.

■ Read the regulations and requirements of the managed carecarrier and incorporate them into the policy and proceduremanual of the practice.

Don’t

■ Bill a patient who is a member of a managed care organiza-tion unless it is for a deductible, co-payment, or excludedbenefit.

■ Let your doctors accept the decision of a nurse reviewer ifyou feel the patient’s care would be compromised. Have yourdoctor always speak to a medical director when services havebeen denied.

■ Let the doctors discharge a patient or cancel a test they feel ismedically necessary when benefits have been denied. Discussthe managed care carrier negatively with your patients.

■ Discriminate against managed care organization patients bynot giving them timely appointments.

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Quick Guide To Managed Care

Entity Advantages Disadvantages

Patient

ManagedCarePlan

Hospital

Physician

Medicare

Nonparticipating Providers

Providers that do not participate in Medicare are subject to a certaindollar amount that they can charge. This charge is referred to as a“limiting charge.” The Medicare Fee Schedule contains a columnlisting the limiting charge. A federal law prohibits a nonparticipatingprovider from charging more than this limiting charge.

Deductibles and Co-pays

Medicare deductibles and co-pays cannot be waived on a routinebasis. If this should occur routinely, the practice could be inviolation of the Anti-Kickback Statute or False Claims Act.

GENERAL

Cost reductionBetter benefits

Fixed ratesCost reductionEasy claim paymentSmall number of providers

Possible volume increasePrompt payment

Possible volume increasePrompt paymentMaintaining current patients

Less attentionRestricted use of

providersGeneral confusion

Contract demandsAdverse member

reactionsMultiple contract rates

Reduced feesContract demandsComplex billing

Reduced feesContract demandsComplex billingUpsets patient relationsUpsets referral patterns

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GENERAL

The following listing contains examples of inappropriate waivingof Medicare deductibles and co-pays.■ Routine reason of “financial hardship” given to patient

without proper investigation of finances.■ Routine waiving of a specific group of individuals in order to

obtain additional patients (for example, all Medicare patientsliving in the XYZ senior home).

Medicare Secondary Payor (MSP)There are cases where another health insurance pays before thepatient’s Medicare benefits. In these cases, the other health insur-ance is primary with Medicare being the secondary insurance.This situation will arise under the following conditions:

MSP Billing Guide

Primary Insurer: Primary Insurance:

Medicare Other Insurance

The patient is 65 or olderand is retired or disabled.

The patient works for themilitary and carries Tricareinsurance coverage.Medicare is primary andTricare is secondary.

The patient has Medicaid.Medicaid becomes the se-condary payor and coversthe patient’s deductible.

The patient is 65 or olderand retired. The patient’sspouse works, but has nohealth insurance coveragethrough the employer.

The patient is 65 or older and isstill employed and coveredunder an employer’s insurancecontract.

The patient has VeteransAdministration benefits thatcover all services andprocedures.

The patient has RailroadRetirement benefits.

The patient is 65 or older andretired. The patient’s spouseworks and both the spouse andpatient have coverage throughthe spouse’s employer.

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MSP Billing Guide

Primary Insurer: Primary Insurance:

Medicare Other Insurance

The patient has coverageunder a self-employedplan, such as real estateagents.

Physician Assistant Billing

Medicare pays the PAs’ employers in all settings at 85 percent ofthe physician’s fee schedule. This includes:■ Hospitals (inpatient, outpatient, and emergency departments)■ Nursing facilities■ Home■ Offices and clinics■ First assisting at surgeryImportant billing facts:■ Assignment is mandatory, state law determines supervision

and scope of practice.■ Medicare pays the PAs’ employers for medical services

provided

GENERAL

■ The patient is a member of theUnited Mine Workers ofAmerica.

■ The patient’s injury or conditionis a result of a motor vehicleaccident.

■ The patient’s injury or conditionis a result of employment.

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GENE

RAL

Supervision Reimbursement

Setting Requirement Rate Services

Office/clinic whenphysician is not onsite

Office/clinic whenphysician is on site

Home visitHouse callSkilled nursing facility

& nursing facilityHospital

First assisting at sur-gery in all settings

Federally certifiedrural health clinics

HMO

State law

Physician mustbe in the suiteof the office

State law

State law

State law

State law

State law

State law

85% of physician’s feeschedule

100% of physician’s feeschedule

85% of physician’s feeschedule

85% of physician’s feeschedule

85% of physician’s feeschedule

85% of physician’s firstassist fee schedule

Cost-basedreimbursement

Reimbursement is oncapitation basis

All services PA is legallyauthorized to provide thatwould have been coveredif provided personally bya physician

Same as above

Same as above

Same as above

Same as above

Same as above

Same as above

All services contracted for aspart of an HMO contract

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Nurse Practitioner (NP) Billing

Important facts:■ NPs must submit their own billing number for all professional

services “furnished in facility or other provider settings.”■ A UPIN billing number must be obtained and submitted on all

claims. In situations when NPs are members of a grouppractice, the group practice PIN number will be entered onone line of the claim form and the NP UPIN in another.

■ Modifiers are now only applicable when submitting “assistantat surgery” claims.

■ Payments to NPs now equal “80 percent of the lesser of eitherthe actual charge or 85 percent of the physician fee scheduleamount.

■ For assistant at surgery services, payments equal 80 percentof the lesser of either the actual charge or 85 percent of thephysician fee schedule amount paid to a physician serving asan assistant at surgery.”

■ Nurse practitioners will be unable, however, to receiveseparate Medicare payments in rural health clinic (RHC) andfederally qualified health center (FQHC) settings.

Medicare Fee Schedule

There are three reimbursement columns in a Medicare feeschedule:

PARNon-PARLC

GENERAL

Participating provider feeNonparticipating provider feeLimiting charge fee

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GENERAL

Medical Supplies and Equipment

Medicare can be billed for any supply and equipment that will beused in a patient’s home. Medicare’s definition of a homeincludes the following locations:■ The patient’s home■ A relative’s home where the patient is living■ A home for senior citizens■ A homeless shelterNursing homes cannot be considered a patient’s home andtherefore medical supplies and equipment cannot be billed.

Medicare Covered/Noncovered Services

Some of the most common covered and noncovered servicesare listed in the following table. The Medicare manual for eachstate will provide a comprehensive listing of these services.

Medicare Part B Medicare Part B

Covered Services Noncovered Services

Provider services (office visits,hospital visits, consultations,nursing home visits, etc.)

X-rays, laboratory testing, PT,OT, and other outpatientdiagnostic testing

Ambulatory surgical center(ASC) services

Surgical dressings, casts,splints, etc.

Certain braces

Durable medical equipment

Cosmetic surgery

Dental services

Custodial care

Services resulting fromworkers’ compensation ormotor vehicle accident

Services deemed notmedically necessary

Routine physical examinations

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Medicare Billing Summary

CMS-1500form isused tosubmitclaims

Deadline forprocessingclaims isDec. 31 ofthe yearfollowingthe DOS

Medicare Review Process

The following steps illustrate the Medicare review process. TheMedicare manual in each state will provide the details necessaryto begin this process.

Steps Action Key Points

1

2

GENERAL

Review

Fair hearing

■ Claim must be requested within6 months of the date on theExplanation of Benefits.

■ Claim must be requested inwriting within 6 months of theresult of the review.

■ Claim must exceed $100 inamount.

Deductibles:$100 forphysicianservicesand out-patient

A minimumof 45 daysmust passbefore aclaim canbe sub-mitted

Allowable feeswill vary ac-cording to theplan; mostuse Usual,Customary,and Reason-able basis

Coal minerclaims sentto: FederalBlack LungProgramBox 828Lanham-Seabrook, MD20703–0828

A Surgical Finan-cial DisclosureForm isrequired for allnonassignedclaims of $500or more

Durable medicalequipment(DME) claimsmust be sentto the appro-priate DMEregional carrier

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GENERAL

Steps Action Key Points

3

4

5

Advance Beneficiary Notice (ABN)

When a service is provided to a Medicare patient that Medicareconsiders not medically necessary, the physician should notifythe patient by using an Advance Beneficiary Notice (ABN). Thisnotice must be completed, signed, and dated. The modifier –GAmust be used when submitting the claim for a service or proce-dure where an ABN is on file in the physician’s office. The follow-ing table contains a list of reasons that the physician practice

Administrativelaw judgehearing

Appeals councilreview

Federal districtcourt hearing

■ Hearings take place over thephone, face-to-face, or on-the-record (where the decision isautomatically based on the factssubmitted).

■ Claim must be requested in writingwithin 60 days of the result of thefair hearing.

■ Claim must exceed $500 inamount.

■ Claim must be requested in writingthrough the Social SecurityAdministration (SSA) Office ofHearings and Appeals within 60days of the result of theadministrative law judge hearing.

■ Claim must exceed $500 in amount.■ Civil action must be filed in federal

district court within 60 days of theresult of the Appeals Councildecision.

■ The claimant must be representedby an attorney.

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believes the service or procedure may not be covered. Thisreason must be stated clearly on the ABN that the patient signs.

123

45

6

These ABN notices should be completed by all Medicarepatients, only when there is a possibility of noncoverage of theservice or procedure. Having patients sign ABNs blanketly is nota good practice.

Medicaid

Medicaid Services Available

■ 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

GENERAL

Medicare does not usually pay for this many servicesMedicare does not usually pay for this serviceMedicare does not pay for this because it is a treatment

that has not been proven effectiveMedicare does not pay for such extensive treatment(s)Medicare does not pay for this equipment for the

diagnosis statedMedicare does not pay for this many services within the

time frame reported

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GENERAL

Confirming Medicaid Eligibility

Steps Procedure

Step 1

Step 2

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:■ Elective admissions

■ Reason for inpatient treatment■ Admission diagnosis and outline of treatment plan

■ Emergency admissions■ Medical justification for inpatient treatment■ Date of admission

■ Admission diagnosis and outline of treatment plan

The patient must present a valid ID card.Eligibility can change monthly since it is based

on monthly income, so always verify using thededicated phone line.

Confirmation of eligibility should be obtainedand maintained in the patient’s chart in caseof future denial of claim.

Confirmation can also be obtained through a“swipe” box. A print-out will indicate coverage.

Retroactive eligibility is sometimes granted topatients whose income has fallen below the“state-set” eligibility level and who had highmedical expenses prior to filing for Medicaid.

The office must verify any patient notificationof retroactive eligibility. If the patient madepayments for services during that time frame,the payments must be returned to the patient,and Medicaid should be billed.

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■ Preoperation days greater than 1■ Reason why surgery cannot be performed within 24 hours

of time need was established■ Number of additional days requested

■ Outpatient procedure performed as an inpatient■ Code and description of surgical procedure■ Medical justification for performing the surgery as an

inpatient■ Exceeding hospital stay limit (set by state) due to

complications■ Beginning and ending dates originally authorized■ Statement describing the complications■ Date complications presented■ Diagnosis for first illness■ Diagnosis stated on original preauthorization request■ Diagnosis for secondary disorder

Extension of Inpatient Days■ 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 anyone individual procedure

■ Development of postoperative complications or a medicalhistory that dictates longer than usual postoperativeobservation by medical staff

Physician Assistant (PA) Billing

Important facts:

■ 50 states cover medical services provided by PAs under theirMedicaid programs.

■ The rate of reimbursement, which is paid to the employingpractice and not directly to the PA, is either the same as orslightly lower than that paid to physicians.

GENERAL

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GENERAL

Nurse Practitioner (NP) Billing

Important facts:

■ Federal law mandates direct reimbursement to pediatric (PNP)and family (FNP) nurse practitioners providing services tochildren.

■ Physician collaboration is not required within the federalmandate.

■ Each state will determine the reimbursement rate for nursepractitioners.

Medicaid Billing Summary

CMS-1500form is usedto submitclaims

A minimumof 45 daysmust passbefore aclaim can beresubmitted.

Deadlines forprocessingclaims isdeterminedby eachindividualstate

Deductibles:There is adeductiblefor patientswho aremedicallyindigent

All nonemergencyhospitalizationsmust be preau-thorized

Co-payments arerequired bymost states,generallyranging from$2–$10 perencounter

Allowablefees willvaryaccordingto eachstate

There is noMedicaidpremium

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Tricare

TRICARE is a health-care program for:■ Active duty members of the military and their qualified family

members■ CHAMPUS-eligible retirees and their qualified family

members■ Eligible survivors of members of the uniformed ser-

vicesIt consists of three plans with varying benefits:1. TRICARE Prime2. TRICARE Extra3. TRICARE StandardTRICARE 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:

■ TRICARE covers all medically necessary services providedby a physician assistant.

■ The PA must be supervised in accordance with state law.■ The supervising physician must be an authorized TRICARE

provider.■ The employer bills for the services provided by the PA.

■ The allowable charge for all medical services provided byPAs under TRICARE Standard, the fee-for-service program,except assisting at surgery, is 85% of the allowable fee forcomparable services rendered by a physician in a similarlocation.

■ Reimbursement for assisting at surgery is 65% of thephysician’s allowable fee for comparable services.

GENERAL

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GENERAL

■ PAs are eligible providers of care under TRICARE’s twomanaged care programs, TRICARE Prime and Extra.■ TRICARE Prime is similar to an HMO.■ TRICARE Extra is run like a preferred provider organization

in which practitioners agree to accept a predetermined dis-counted fee for their services.

Workers’ Compensation

Eligibility consists of an on-the-job injury or a condition that is thedirect result of their job.The law states that a waiting period must elapse before incomebenefits are payable. This period is determined by each individ-ual state.Classifications of workers’ compensation consist of:

■ Medical claims with no disability■ Temporary disability■ Permanent disability■ Vocational rehabilitation■ Death of a worker

The provider must accept workers’ compensation as payment infull and cannot bill any additional fees.Fees are reimbursed either by the Medicare fee schedule or aprivate fee schedule and are determined by each individual state.

Miscellaneous Terms/Facts

■ Guarantor: the individual who is responsible for paymentof the medical bill. For children to be guarantors, they mustbe either 18 or 21 years of age (depending on the stateregulations)

■ Major Medical: an insurance policy that covers medi-cal expenses resulting from catastrophic or prolongedillness/injuries, or coverage for such things as officevisits that are not included in the plan’s coverage

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Miscellaneous Facts

■ Claims denied as “not medically necessary” cannot be billedto the patient, unless an ABN has been completed acknowl-edging a patient’s understanding of the service and why itmay or may not be covered. The burden of medical necessityis placed on the provider and is the primary reason forMedicare denials across the country.

■ Use an Evaluation and Management (E&M) code whenpronouncing death of a patient.

GENERAL

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EVALMGMT

Evaluation and Management Services

Evaluation and Management (E&M) codes are CPT codes usedfor the reporting of certain services such as office visits, con-sultations, inpatient services, emergency room services, nursingfacility services, domiciliary care services, and home services.Each category of E&M service contains two to seven levels forbilling. Each level requires a specific amount of documentationto be billable.These services are listed in the following Table of Evaluationand Management Services.

CPT Codes Description

99201–99205

99211–99215

99221–99223

99231–99233

99241–99245

99251–99255

99234–99236

99217–99220

99281–99285

99304–99306

99318

99307–99310

99293–99294

99295–99296

99298–99300

99341–99345

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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

(Continued text on following page)

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CPT Codes Description

99347–99350

99324–99328

99334–99337

99381–99387

99391–99397

99354–99355

99356–99357

99358–99359

The Principles of Documentation were released in 1995 ascollaboration between the American Medical Association (AMA)and the Centers for Medicare and Medicaid Services (CMS,known then as Health Care Finance Administration). Theseguidelines were revised in 1997 and 2000 and are stillundergoing revisions. Until the final guidelines are released,CMS instructs providers to use either the 1995 or 1997 guide-lines; the decision becomes the provider’s.

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, physicalexamination, review of diagnostic test results and anyother ancillary services.

b. the provider’s assessment of the patient’s condition, clinicalimpressions, or diagnoses.

c. a plan of care/treatment plan.d. the date and legible identity of the person who provided

the service.

EVALMGMT

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

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EVALMGMT

4. should contain the rationale for ordering diagnostic services.5. should contain accessibility to past and present diagnoses.6. should contain appropriate health risk factors.7. should contain the patient’s 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. History2. Examination3. Medical Decision-Making4. Counseling5. Coordination of Care6. Nature of Presenting Problem7. TimeThe first three items above (history, examination, and medicaldecision-making) are the key components in choosing a levelof service.

Time

Time, which is No. 7 on the list, is only a consideration ifcounseling is 50% or more of the visit.Some CPT codes are time-based codes. Time-based codes arechosen by the time associated with the service provided. Thesecodes are used to report episodes of Critical Care andPsychology service areas. The only time-based codes listed inthe Table of Evaluation and Management Services are theprolonged care codes. When choosing an E&M code basedon time, the documentation requirements are very specific.The documentation in the medical record must illustrate thatcounseling is 50% or more of the visit. For example, a noteshould look like this:

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“I spent 45 minutes with Barbara Smith and her husband today.Of that 45 minutes, 30 minutes was spent discussing the resultsof her abnormal echocardiogram.”The note should then provide a summary of the key componentsof the discussion. This documentation illustrates that counselingwas more than 50% of the visit.The following note does not meet this criterion:“I spent 30 minutes with Barbara discussing the results of herabnormal echocardiogram.”This note does not illustrate that the time spent counselingBarbara Smith was 50% or greater than the total time of theoffice visit.

History

There are four levels of history:

Level Description

1

2

3

4

Within these four levels, there are four types of history:

Types Description

1

2

3

4

EVALMGMT

Problem focused

Expanded problem focused

Detailed

Comprehensive

Chief compliant

History of present illness

Review of systems

Past, family, and social history

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EVALMGMT

Chief complaint (written as cc)

The chief complaint is the reason for the visit, or why thepatient sought care. This is generally in the patient’s ownwords and is a short phrase or two. It is important to bespecific when documenting this element and to not usevague language as this may disqualify the patient encoun-ter for reimbursement. For example, the following tableillustrates language that is vague; it does not state whythe patient sought care.

Incorrect

cc - check-up

Follow-up visit✓ upRoutine visit

To elicit the chief complaint, ask broad questions such as:■ What brings you in today?■ Tell me what’s been going on?

History of Present Illness (written as HPI)

The history of present illness is a description of the presentillness from the beginning of symptoms to the time of thepatient encounter.This is an expansion of the chief complaint and should containall the information necessary for a differential diagnosis.Begin with open-ended questions such as:■ Tell me more about the pain.■ What else is going on?■ What was that like for you?

cc - check-up on high blood pressure

Follow-up visit for back pain✓ up on diabetesRoutine visit for reflux

Correct

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Use facilitating expressions to encourage the patient to continue,such as:

■ Mmm Hmm■ Yes?■ Uh Huh?■ And what else?

Now use more directed questions to complete this history,such as:

■ 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:

■ Do you have nausea, vomiting, constipation, or diarrhea?■ Is the headache sharp, dull, shooting?

Use Yes or No questions, such as:

■ Do you have a headache every day?■ Do you have any allergies?

Use quantitative questions, such as:

■ How many loose stools do you have a day?■ How many dizzy spells do you have in a day?

Avoid leading questions, such as:

■ You don’t smoke do you?■ You haven’t had any dizziness, have you?

Avoid compound questions, such as:

■ Do you have trouble urinating? When does it botheryou?

There are eight elements of the history of present illness.They are:

66

EVALMGMT

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EVALMGMT

HPI Elements

1

2

3

4

5

6

7

8

There are two levels of HPI:

1. Brief: documentation of one to three elements from theprevious list.

2. Extended: documentation of four or more elements from theprevious list OR the status of three chronic conditions.

A brief history focuses on the patient’s problem, while anextended history will go beyond that to obtain information thatmay support multiple diagnoses. An example of a brief HPI is asfollows:cc - complaining of knee painHPI - pain has been present in left knee (location) for 2 weeks(timing)In the previous example, left knee is the location and 2 weeks isthe timing. Two elements of HPI are met, location and timing.Continuing to build on this note will provide more informationabout the patient’s complaint and justify an extended HPI. Seethe following example:cc - complaining of knee pain

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 usedescriptive words such as mild, severe, etc.

Duration: How long have you had the injury or illness?

Timing: When did you first experience the symptom orproblem?

Context: What were you doing when this occurred?

Modifying factors: What have you done to improve yoursymptoms? Laid down, took analgesics?

Associated signs & symptoms: What else bothers youwhen this occurs?

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HPI - pain has been present in left knee for 2 weeks. Patientstates that pain has gotten so severe (severity), that Advil usedto help but now it doesn’t (modifying factors). Patient reportspain started when she played softball (context) with her son andfell running to a base.In the last note, left knee is the location and 2 weeks is thetiming, pain is so severe, analgesics do not relieve it anymore,pain started when playing softball. In this note, five elements ofHPI are met, location, timing, severity, modifying factors, andcontext.

Review of Systems (written as ROS)

An ROS is an accounting of signs and symptoms of variousorgan systems obtained through a series of questions. There are14 systems contained in an ROS. These systems are:

Organ Systems

1

2

3

4

5

6

7

8

9

10

11

12

13

14

68

EVALMGMT

Constitutional

Eyes

Ears, nose, mouth, throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematological/lymphatic

Allergic/immunological

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EVALMGMT

There are three levels of ROS:

Level Description

1

2

3

A problem pertinent ROS involves a review of system(s) that canbe affected by, play a role in, or are likely to be involved in thepatient’s problem.An extended review includes a more in-depth review of system(s).A complete review includes 10 of the 14 systems listed above. Thistype of review is considered comprehensive in nature.

Past, Family, Social History (written as PFSH)

A past history contains information about the patient’s pastexperiences with illnesses, injuries, and treatments. This mayinclude information about the following:

■ 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 patient’s family.This may include information as:

■ Diseases of either the mother, father, siblings, children■ Health status or cause of death of any of the above■ Diseases of family members that may be hereditary or cause

the patient to be at risk

Problem pertinent

Extended

Complete

Review and documentationof one system

Review and documentationof two to nine systems

Review and documentationof at least 10 systems

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A social history contains information about past or currentactivities and/or conditions. This may include such informa-tion as:■ Marital status■ Employment■ Use of controlled substances■ Use of alcohol■ Living arrangements■ Current employment■ Occupational history■ Level of education■ Sexual history

The two levels of PFSH

Level Description

1

2

A complete history must contain the documentation ofeither two or three history areas, depending on the cate-gory of E&M service. The following tables identify whichtypes of service require the documentation of two his-tory areas (2 out of 3 rule) and which type of servicerequires the documentation of three history areas(3 out of 3 rule).

3 Out of 3 RuleWhen the service type is one of an “initial” contact, all threehistory areas must be documented.

70

EVALMGMT

Pertinent

Complete

Documentation of one historyarea

Documentation of twoto three history areas,depending on the cate-gory of E&M service

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Visit Types

1.

2.

3.

4.

5.

6.

7.

8.

2 Out of 3 RuleWhen the service type is one of an established service, only twoof the three history areas must be documented.

Visit Types

1.

2.

3.

4.

5.

6.

History Summary

Type of History CC HPI ROS PFSH

Problemfocused

Expanded prob-lem focused

DetailedComprehensive

71

EVALMGMT

New office serviceConsultation, outpatientConsultation, inpatientInitial hospital serviceInitial nursing facility serviceHome services, new patientObservation servicesObservation services or inpatient hospital

Established office serviceConsultation, follow-up inpatientSubsequent hospital serviceSubsequent nursing facility serviceHome services, established patientEmergency services

Present

Present

PresentPresent

Brief

Brief

ExtendedExtended

N/A

ProblemPertinent

ExtendedComplete

N/A

N/A

PertinentCompre-

hensive

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72

EVALMGMT

Examination

The examination portion of the visit contains documentation ofthe objective findings of the provider of the service. There arecurrently two sets of examination guidelines; 1995 and 1997. The1995 guidelines are somewhat subjective, whereas the 1997guidelines are very specific. The provider of the service maychoose which guideline set he/she wants to use.

1995 Examination Guidelines

Level Description

Problem focused

Expanded prob-lem focused

Detailed

Comprehensive

Body Areas

Chest (including breasts and axillae)AbdomenBack (including spine)NeckGenitalia, groin, buttocksHead (including the face)Extremities, each one would be an area

A limited examination of the affected bodyarea or organ system

A limited examination of the affected bodyarea or organ system and othersymptomatic or related organ systems

An extended examination of the affectedbody area(s) and other symptomatic orrelated organ system(s)

A general multisystem examination or a com-plete examination of a single organ system

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EVALMGMT

Organ Systems

ConstitutionalEyesEars/Nose/Mouth/ThroatRespiratoryCardiovascularGastrointestinalGenitourinaryMusculoskeletalNeurologicalIntegumentaryPsychiatricHematological/lymphatic/immunological

1997 Examination Guidelines

The 1997 examination guidelines contain a multisystemexamination, plus 10 single specialty examinations. Theseexaminations are as follows:

General Multisystem

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

CardiovascularEars, Nose, Mouth, ThroatEyeGenitourinaryHematological/Lymphatic/ImmunologicalMusculoskeletalNeurologicalPsychiatricRespiratoryIntegumentary

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Under the general multisystem examination, the followingrequirements must be met:

Level Description

Problem focused

Expanded prob-lem focused

Detailed

Comprehensive

A detailed listing of these requirements by body areas and organsystems can be found in the Federal Register.Under the specialty guidelines, the following requirements mustbe met:

Level Description

Problem focused

Expanded prob-lem focused

Detailed

Comprehensive

74

EVALMGMT

Perform and document 1 to 5 elementsidentified by a bullet.

Perform and document at least 6 elementsidentified by a bullet.

Perform and document at least 2 elementsidentified by a bullet from each of 6 areas/systems or at least 12 elements identifiedby a bullet in 2 or more areas/systems.

Perform all elements identified by a bullet inat least 9-organ system or body areas anddocument at least 2 elements identified bya bullet from each of 9 areas/systems.

Perform and document 1 to 5 elementsidentified by a bullet.

Perform and document at least6 elements identified by a bullet.

Perform and document at least 12 elementsidentified by a bullet.

Perform all elements identified by a bulletand document every italicized element ina shaded area and at least 1 nonitalicizedelement in each of the nonshaded areas.

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EVALMGMT

Medical Decision-Making

The medical decision-making portion of the visit entails thecomplexity of establishing the diagnosis and/or managementoption(s). Medical decision-making is measured by the followingthree components:

Components of Medical Decision-Making

The number of diagnoses and/or management optionsThe amount and/or complexity of medical records, diagnostic

tests, and other information to be reviewed and analyzedThe risk of significant complications, morbidity and/or mortality

The Four Levels of Medical Decision-Making

Number of Risk of Com-

Diagnoses/ Amount and/or plication and/

Management Complexity of or Morbidity

Level Options Data Reviewed orMortality

Straight-

forward

Low com-

plexity

Moderate

complexity

High

complexity

Two of the three above indicators will establish the level ofmedical decision-making.If a patient presents with multiple diagnoses and multiplemanagement options must be considered, the complexity of themedical decision-making is increased. The amount and/or com-

Minimal

Limited

Multiple

Extensive

Minimal/None

Limited/Low

Moderate

Extensive

Minimal

Low

Moderate

High

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plexity of data that must be obtained, reviewed, and analyzedduring the patient encounter must be clear and concise.For test results, document thought processes, analysis, andevaluation of both positive and negative findings. Their impacton treatment should be documented. Review of the patientmedical record, past and present, should be documented withcomments. Note the extent of records and data that is reviewedwith an analysis.The potential risk to the patient is an important element inassessing the complexity of this key component of medicaldecision making. The following table can be used to identify risk:

Table of Risk

Type of Problem Description

Minimal

Self-limited/

minor

Low severity

Moderate

severity

High severity

76

EVALMGMT

May not require presence of physician, butservice provided under the physician’ssupervision

Runs definite and prescribed course; tran-sient in nature and not likely to perma-nently alter health status; or has a goodprognosis with management/compliance

Risk of morbidity without treatment low; littleto no risk of mortality without treatment;full recovery without functional impairmentexpected

Risk of morbidity without treatmentmoderate; moderate risk of mortalitywithout treatment; uncertain prognosisor increased probability of prolongedfunctional impairment

Risk of morbidity high to extreme; moderateto high risk of mortality without treatmentor high probability of severe, prolongedfunctional impairment

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EVALMGMT

Examples of various types of risk are illustrated in the followingtable:

Diagnostic

Level of Presenting Procedures Management

Risk Problems Ordered Options Selected

Minimal

Low

Moderate

High

Medical Necessity

Although the service may `contain a properly documented history,examination, and medical decision-making, if there is no medicalnecessity for the level of service chosen for billing, the service maybe downcoded by the carrier. The government definition of medicalnecessity is that it is a service that is reasonable and necessary forthe diagnosis or treatment of illness or injury, or to improve thefunctioning of a malformed body member.

Insect bite,cold, Tineacorporis

Cystitis, sprains,controlled DM,controlled BP

Lump in breast,colitis,pneumonia

Acute MI, psychillnessw/threat, TIA,trauma

ECG, chestx-ray, KOH,UA

Pulmonaryfunctions, BE,skin biopsies

Arteriogram,lumbarpuncture,endoscopies/no risk

CV imagingstudiesw/contrast,endoscopiesw/risk

Rest, gargle,bandages

OTC drugs, PT,OT, IV fluids,minor surgery/no risk

Rx mgmt, IVfluids w/meds,closed treat-ment of frac-ture, electivemajor surgery

Emergencymajor surger-ies, DNRs,monitoringtoxic drugs

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The Decision Matrix for New Office Patients

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99201

99202

99203

99204

99205

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

78

EVAL

MGMT

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Compre-hensive

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Compre-hensive

Straight-forward

Straight-forward

Low

Moderate

High

Self-limited/minor

Low tomoderate

Moderate

Moderateto high

High

Yes

Yes

Yes

Yes

Yes

10

20

30

45

60

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EVAL

MGMT

The Decision Matrix for Established Office Patients

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99211

99212

99213

99214

99215

Requires all two of the three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Generallydoes notrequire aphysician

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

5

10

15

25

40

No

Yes

Yes

Yes

Yes

Minimal

Self-limited/minor

Low tomoderate

Moderateto high

Moderateto high

Straightfor-ward

Low

Moderate

High

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EVAL

MGMT

Detailed/Compre-hensive

Compre-hensive

Compre-hensive

Detailed/Compre-hensive

Compre-hensive

Compre-hensive

Straight-forwardor low

Moderate

High

Yes

Yes

Yes

30

50

70

Low

Moderate

High

The Decision Matrix for Initial Hospital Patients

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99221

99222

99223

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

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EVAL

MGMT

The Decision Matrix for Subsequent Hospital Patients

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99231

99232

99233

Requires all two of the three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Problemfocused

Expandedproblemfocused

Detailed

Problemfocused

Expandedproblemfocused

Detailed

Straightfor-ward/Low

Moderate

High

Yes

Yes

Yes

15

25

35

Patient isstable, recov-ering, orimproving

Respondinginadequatelyor minorcomplication

Unstable ordevelopedsignificantcomplicationof problem

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Problemfocused

Expanded prob-lem focused

Detailed

Comprehensive

Comprehensive

Problemfocused

Expanded prob-lem focused

Detailed

Comprehensive

Comprehensive

Straight-forward

Straight-forward

Low

Moderate

High

Self-limited/minor

Low

Moderate

Moderate to high

Moderate to High

Yes

Yes

Yes

Yes

Yes

15

30

40

60

80

Discharge Services

Code Hospital Discharge Day

99238

99239

The Decision Matrix for Consultation, Outpatient

Medical Nature of Counseling/Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99241

99242

99243

99244

99245

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

82

EVAL

MGMT

Includes final exam, discussion of hospital stay, instructions for carePreparation of discharge recordsIncludes final exam, discussion of hospital stay, instructions for carePreparation of discharge records

30 minutes or less

Over 30 minutes

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83

EVAL

MGMT

The Decision Matrix for Consultation, Inpatient

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99251

99252

99253

99254

99255

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Problemfocused

Expandedproblemfocused

Detailed

Comprehensive

Comprehensive

Problemfocused

Expandedproblemfocused

Detailed

Comprehensive

Comprehensive

Straight-forward

Straight-forward

Low

Moderate

High

Self-limited/minor

Low

Moderate

Moderate tohigh

Moderate toHigh

Yes

Yes

Yes

Yes

Yes

20

40

55

80

110

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EVAL

MGMT

The Decision Matrix for Hospital Observation or Inpatient Care

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99234

99235

99236

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Detailed/Com-prehensive

Comprehensive

Comprehensive

Detailed/Com-prehensive

Comprehensive

Comprehensive

Straight-forwardor low

Moderate

High

Low

Moderate

High

Consistentwith natureof problems

Consistentwith natureof problems

Consistentwith natureof problems

N/A

N/A

N/A

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85

EVAL

MGMT

The Decision Matrix for Hospital Observation Services

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99218

99219

99220

99217

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Detailed/Com-prehensive

Comprehensive

Comprehensive

Detailed/Com-prehensive

Comprehensive

Comprehensive

Straight-forwardor low

Moderate

High

Low

Moderate

High

Consistentwith natureof problems

Consistentwith natureof problems

Consistentwith natureof problems

N/A

N/A

N/A

Discharge Day—Can only be used if discharge is on other than the initial dateof N/A observation status.

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The Decision Matrix for Emergency Room Services

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99281

99282

99283

99284

99285

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

86

EVAL

MGMT

Problemfocused

Expandedproblemfocused

Expandedproblemfocused

Detailed

Comprehensive

Problemfocused

Expandedproblemfocused

Expandedproblemfocused

Detailed

Comprehensive

Straight-forward

Low

Moderate

Moderate

High

Self-limited/minor

Low tomoderate

Moderate

High

High

Consistentwith natureof problems

Consistentwith natureof problems

Consistentwith natureof problems

Consistentwith natureof problems

Consistentwith natureof problems

N/A

N/A

N/A

N/A

N/A

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EVAL

MGMT

After Hours Codes For Emergencies

99052

99054

The Decision Matrix for Initial Nursing Facility

Comperhensive Medical Nature of Counseling/

New or Decision- Presenting Coordination

established History Examination Making Problem of Care Time

99304

99305

99306

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Services requested between 10 pm and 8 am, report in addition to the basicservice code

Services requested on Sundays and holidays in addition to the basic service code

Detailed

Compre-hensive

Compre-hensive

Comprehensive

Comprehensive

Comprehensive

Straight-forwardor low

Moderate

Moderateto High

Low

Moderate

High

Yes

Yes

Yes

30

40

50

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EVAL

MGMT

The Decision Matrix for Subsequent Nursing Facility

Subsequent Medical Nature of Counseling/

New or Decision- Presenting Coordination

Established History Examination Making Problem of Care Time

99307

99308

99309

99310

Requires two of the three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Straight-forward

Low

Moderate

High

Patient is stable, recov-ering, or improving

Respondinginadequately ordeveloped minorcomplication

Patient has devel-oped a significantcomplication or asignificant newproblem

Unstable or developedsignificant compli-cation or newsignificant problem

Yes

Yes

Yes

15

25

35

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89

EVAL

MGMT

The Decision Matrix For Annual Nursing Facility Assessment

Code History Examination Medical Decision-Making Nature of Presenting Problem

99318

Requires all three key components to be documented.

The Decision Matrix for Discharge Services

Code Nursing Facility Discharge Day Management

99238

99239

*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Detailed Comprehensive Low to moderate Patient is stable,recovering, orimproving

30 minutes or less

Over 30 minutes

Includes final exam, discussion of hospital stay,instructions for care, prescriptions, preparationof discharge records

Includes final exam, discussion of hospital stay,instructions for care, prescriptions, preparationof discharge records

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The Decision Matrix for Home Services, New Patient

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99341

99342

99343

99344

99345

Requires all three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

90

EVAL

MGMT

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Compre-hensive

Problemfocused

Expandedproblemfocused

Detailed

Comprehen-sive

Comprehen-sive

Straight-forward

Straight-forward

Moderate

Moderate

High

Low

Low

High

High

Unstable problem,requiresimmediateattention

Yes

Yes

Yes

Yes

Yes

20

30

45

60

75

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91

EVAL

MGMT

The Decision Matrix for Home Services, Established Patient

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99347

99348

99349

99350

Requires all two of the three key components to be documented.*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Problemfocused,interval

Expandedproblemfocused,interval

Detailed,interval

Compre-hensive,interval

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Straight-forward

Low

Moderate

Moderate

Self-limited orminor

Low to moderate

Moderate to high

Moderate to high

Yes

Yes

Yes

Yes

15

25

40

60

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92

EVAL

MGMT

The Decision Matrix for Domiciliary Care, New Patient

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99324

99325

99326

99327

99328

*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Compre-hensive

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Compre-hensive

Straight-forward

Low

Moderate

Moderate

High

Low severity

Moderate severity

Moderate to highseverity

High severity

Patient may be unsta-ble or may havedeveloped a signi-ficant new problemrequiring immediatephysician attention

Consistentwithproblem

Consistentwithproblem

Consistentwithproblem

Consistentwithproblem

Consistentwithproblem

20

30

45

60

75

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EVAL

MGMT

The Decision Matrix for Domiciliary Care, Established Patient

Medical Nature of Counseling/

Decision- Presenting Coordination

Code History Examination Making Problem of Care Time

99334

99335

99336

99337

*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Problemfocused

Expandedproblemfocused

Detailed

Compre-hensive

Straight-forward

Low

Moderate

Moderateto high

Self-limited orminor

Low to moderateseverity

Moderate to high

Patient may beunstable or mayhave developed asignificant newproblem requir-ingimmediate physi-cian attention

Consistentwithproblem

Consistentwithproblem

Consistentwithproblem

Consistentwithproblem

15

25

40

60

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The Decision Matrix for Inpatient Pediatric Critical Care

Code Description

99293

99294

The Decision Matrix for Inpatient Neonatal Critical Care

Code Description

99295

99296

The Decision Matrix for Continuing Intensive Care

Code Description

99298

99299

99300

94

EVALMGMT

Initial inpatient pediatric critical care, per day, for theevaluation and management of a critically ill infant oryoung child, 29 days through 24 months of age

Subsequent inpatient pediatric critical care, per day, forthe evaluation and management of a critically ill infantor young child, 29 days through 24 months of age

Initial inpatient neonatal critical care, per day, for theevaluation and management of a critically ill neonate,28 days of age or less

Subsequent inpatient neonatal critical care, per day, forthe evaluation and management of a critically ill

neonate, 28 days of age or less

Subsequent intensive care, per day, for the evaluationand management of the recovering very low birthweight infant (present body weight less than 1500grams)

Subsequent intensive care, per day, for the evaluationand management of the recovering low birth weightinfant (present body weight less than 1500–2500grams)

Subsequent intensive care, per day, for the evaluationand management of the recovering infant (presentbody weight less than 2501–5000 grams)

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EVALMGMT

The Decision Matrix for Preventive Medicine

Services, New Patient

Initial preventive medicine service including a comprehensivehistory and examination, counseling; anticipatory guidance/riskfactor reduction interventions, and the ordering of appropriatelaboratory/diagnostic procedures.

Code Description

99381

99382

99383

99384

99385

99386

99387

The Decision Matrix for Preventive Medicine

Services, Established Patient

Periodic preventive medicine re-evaluation including a com-prehensive history and examination, counseling; anticipatoryguidance/risk factor reduction interventions, and the orderingof appropriate laboratory/diagnostic procedures.

Code Description

99391

99392

99393

99394

99395

99396

99397

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Infant, under 1 year of ageEarly childhood, age 1–4 yearsLate childhood, age 5–11 yearsAdolescent, age 12–17 yearsAge 18–39 yearsAge 40–64 yearsAge 65 years and over

Infant, under 1 year of ageEarly childhood, age 1–4 yearsLate childhood, age 5–11 yearsAdolescent, age 12–17 yearsAge 18–39 yearsAge 40–64 yearsAge 65 years and over

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The Decision Matrix for Prolonged Care Services, Outpatient

Code Description Time

99354

99355

The Decision Matrix for Prolonged Care Services, Inpatient

Code Description Time

99356

99357

The Decision Matrix for Prolonged Care Services,

Without Direct Patient Contact

Code Description Time

99358

99359

Critical Care

Critical care services are not site specific. They can be performedin any location of the hospital. They are provided for episodes ofconditions that are generally life-threatening. They are not used for

96

EVALMGMT

Prolonged physician service in theoffice or outpatient setting requiringdirect (face-to-face) patient contactbeyond the usual service

Each additional 30 minutes

Prolonged physician service in theoffice or outpatient setting requiringdirect (face-to-face) patient contactbeyond the usual service

Each additional 30 minutes

First hour

30

First hour

30

Prolonged physician service in theoffice or outpatient setting requiringdirect (face-to-face) patient contactbeyond the usual service

Each additional 30 minutes

First hour

30

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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97

EVALMGMT

inpatient days when a patient is in the Intensive Care Unit or CardioCare Unit of a hospital. In these cases, the appropriate inpatientcodes should be utilized. There is no limit to the number of criticalcare services that can be provided and billed each day. Theseservices may be provided to patients under the following conditions:

■ Central nervous system or circulatory system failure■ Hepatic, renal, or respiratory failure■ Severe infection■ Postoperative complications

The time spent providing critical care services may be time spentproviding the following services:

■ Direct care to the patient■ Review of studies and test results■ Discussion of patient with other team members■ Documentation of critical care in the medical record■ Time spent with family members or patient decision makers

Critical care codes are time-based and are billed as follows:

■ 99291 Critical care, first 30-74 minutes■ 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 Billing for Critical Care

Less than 30 minutes

30–74 minutes

75–104 minutes

105–134 minutes

135–164 minutes

165–194 minutes

194 minutes or more

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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 lengthof time spent

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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

These cannot be billed separately when billing for critical care.

98

EVALMGMT

Introduction of needle or intracatheter, veinVenipuncture, child over age 3 or adult, requiring

physicianCollection of venous blood by venipunctureCollection of blood specimen from a completely

implantable venous access deviceArterial puncture, blood for diagnosisNaso- or orogastric tube placement with fluoroscopic

guidanceChest x-ray, single view, frontalChest x-ray, stereo, frontalChest x-ray, two views, frontal and lateralGastric intubation, aspiration/lavage for treatmentTemporary transcutaneous pacingIndicator dilution studies, arterial/venous catheter

with cardiac output measureSubsequent measurement of cardiac outputVentilation management, first daySubsequent daysContinuous positive airway pressure (CPAP),

initiation/managementContinuous negative pressure ventilation (CNP),

initiation/managementNoninvasive oximetry for oxygen saturation, single

determinationBy continuous overnight monitoringAnalysis of information/data in computersRoutine venipuncture for collection of specimen

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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99

EVALMGMT

Inpatient Neonatal and Pediatric Critical Care Services

99293

99294

99295

99296

99298

99299

99300

Care rendered to patients with CPT codes 99293–99292 include: ■ Management■ Monitoring and treatment

■ Respiratory■ Pharmacologic control of the circulatory system■ Enteral and parenteral nutrition■ Metabolic and hematologic maintenance

■ Parent/family counseling■ Case management services■ Personal direct supervision of the health-care team

Initial inpatient pediatric critical care, per day, for theevaluation and management of a critically ill infant oryoung child, 29 days through 24 months of age

Subsequent inpatient pediatric critical care, per day, forthe evaluation and management of a critically ill infantor young child, 29 days through 24 months of age

Initial inpatient neonatal critical care, per day, for theevaluation and management of a critically ill neonate,28 days of age or less

Subsequent inpatient neonatal critical care, per day, forthe evaluation and management of a critically illneonate, 28 days or less

Subsequent intensive care, per day, for the evaluationand management of the recovering very low birthweight infant (present weight less than 1500 grams)

Subsequent intensive care, per day, for the evaluationand management of the recovering low birth weightinfant (present body weight of 1500–2500 grams)

Subsequent intensive care, per day, for the evaluationand management of the recovering infant (presentbody weight of 2501–5000 grams)

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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EVALMGMT

Documentation Formats

The most commonly used format, of the three currently useddocumentation formats, is SOAP.

Description

S

O

A

P

The next most commonly used is SNOCAMP:

Description

S

N

O

C

A

ubjective

bjectivessessment

lan

Includes patient complaints, history of illness orinjury, answers to questions about organ sys-tems, and past, family and/or social history

Includes findings on examination of the patientIncludes the prognosis and/or differential

diagnosis of the patient and diagnosticstudies

Includes patient instructions, testing to beperformed, next appointment, prescriptions,referrals

ubjective

ature of present-ing problem

bjectiveounseling/coor-

dination ofcare

ssessment

Includes patient complaints, history ofillness/injury, answers to questionsabout organ systems, and PFSH.

Includes a disease, illness, injury, symp-tom, or finding that relates to the chiefcomplaint

Findings on patient examPatient visits where counseling con-

stitutes more than 50% of the visit

Includes prognosis and/or differentialdiagnosis of the patient and diagnosticstudies

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EVALMGMT

Description

M

P

Concurrent Care

Concurrent care is the provision of similar services to the samepatient by more than one provider on the same day. When bothproviders bill the same diagnosis code, a claim denial mayoccur. If there is no documentation to support the medicalnecessity for the second provider, the provider who sends theclaim in first gets paid, the second claim gets denied.To eliminate this claim denial, document the need for the secondprovider to be involved in the patient’s care. Generate a paperclaim (CMS 1500 form) and attach the documentation to theform. The claim form should be completed with the appropriateCPT and ICD-9-CM codes.

Consultations

Consultations are requested when an opinion is asked of acolleague regarding a patient. There are two types ofconsultations:■ Inpatient (99241–99245)■ Outpatient (99251–99255)

edicaldecision-making

lan

Complexity of the visit and physician’s thoughtprocess; this component is subjective and isbased on three components:1) number of diagnoses/management

options2) amount and/or complexity of data3) risk of mortality/morbidity

Includes patient instructions, tests to beperformed, next appointment, Rx, referrals

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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When documenting a consultation, the following informationmust be present:■ The reason for the consult■ Who requested the consult■ The appropriate level of history, examination, and medical

decision-making■ A diagnosis or impression and treatment plan■ Disposition of patient, “Will follow” or “Patient will return

to your office in follow-up”

The Three Rs of a Consultation1. Request2. Render an opinion3. ReportIf all of the above are not met, consultation codes cannot bebilled. Consultation codes can be used by primary care physi-cians when they examine their patients and submit a reportfor medical clearance prior to surgery.

102

EVALMGMT

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SURGANES

Surgery Coding/Anesthesia Coding/Anesthesia

Facts:■ Anesthesia is billed using time units that equal 10 to 15

minutes per unit (based on state regs).■ Time begins when the physician or certified registered nurse

anesthetist (CRNA) prepares the patient for induction andends when the patient is released from anesthesia care inthe recovery room.

■ Time is rounded to one decimal place, when necessary.■ Time is not used when administering local medications

intravenously.Physical Status Modifiers are used to report that the anesthesiaadministered was complicated by the physical status of thepatient.

Important facts:■ Some payers will reimburse a higher amount when these

modifiers are used.■ In other cases, such as Medicare, payers do not recognize

these modifiers.■ Each case is carrier-specific and the reporting rules for

the carrier must be obtained prior to submission of theclaim.

Physical Status Modifiers

Modifier Description

P1

P2

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

A normal healthypatient

A patient with amild systemicdisease

This modifier indicates that thepatient was healthy.

This modifier indicates that thepatient had some type ofmild disease process, suchas hypertension.

(Continued text on following page)

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SURGANES

Physical Status Modifiers

Modifier Description

P3

P4

P5

P6

Monitored Anesthesia Care

Monitored anesthesia consists of the following:■ Preanesthesia evaluation■ Perianesthesia evaluation■ Postanesthesia evaluation■ Patient evaluation on admission and discharge from anesthesia

care■ Time-based records of vital signs and level of consciousness

A patient with asevered systemicdisease

A patient with asevere systemicdisease that is athreat to life

A moribund patientwho is not expectedto survive withoutthe procedure

A declared brain-deadpatient whoseorgans are beingremoved fortransplant

This modifier indicates that thepatient had a severe systemicdisease that could affect thecare of the patient. Thismodifier may be used witha patient who is a brittlediabetic with complications ofcongestive heart failure anduncontrolled hypertension.

This modifier indicates that thepatient has a severe diseasethat is a threat to life, such asa patient who has had a heartattack and now requires anangioplasty.

This modifier is used forcritically injured patients whorequire emergency surgery.

This modifier is used for apatient who is brain-deadbeing maintained on lifesupport waiting for organharvesting.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Medically Directed Anesthesia Services

Medically directed services occur when a physician is responsiblefor the direction of 2, 3, or 4 concurrent cases involving CRNAs.These medically directed services are reported using themodifier –QX.

Moderate (Conscious) Sedation

Moderate (conscious) sedation occurs when sedation is achievedwith or without the administration of an analgesic. This sedationplaces the patient into a lower level of consciousness, allowingfor certain procedures to be carried out.Medicare does not permit these codes (99143 and 99145) to bebilled separately and considers them bundled into the procedure.

HCPCS Modifiers for Anesthesia Services

Modifier Description

AA

AD

G8

G9

QK

QS

QX

QY

QZ

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Anesthesia services performed personally by ananesthesiologist

Medical supervision by a physician; more than fourconcurrent 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 historyof severe cardiopulmonary condition

Medical direction of 2, 3, or 4 concurrent anesthesiaprocedures 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

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Surgery

The operative record is a major part of the medical record, as itis the direct source for reporting procedures performed.Accurate operative records will translate into accurate billing andproper reimbursement.

Important Definitions

■ Assistant surgeon: Assists the primary surgeon in chargeof the case with a specific surgical procedure.

■ Cosurgeon:Two surgeons of different specialties arerequired for a specific surgical procedure.

■ Team surgery: A single procedure requires more than twodifferent surgeons of two different specialties.

Global Surgeries

Components of a global surgery package are:■ Preoperative visits■ Intraoperative services■ Complications following surgery■ Postoperative visits and pain management■ Supplies■ Miscellaneous services such as staple and suture removal,

casts, splints, removal of catheters, etc.■ These items cannot be billed separately since they are

considered part of the surgical package.Services that can be billed separately are as follows:■ Separately identifiable service from the surgery (use separate

diagnosis code when reporting)■ Diagnostic testing and procedures■ Second procedures that are distinct from the original

procedure

SURGANES

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■ Initial consultation that prompted the decision for surgery■ History and physical that is performed more than 1 day before

the surgery■ Reoperations due to complications■ Dialysis■ Immunosuppressive drug therapy for organ transplants■ Critical care

Modifiers Used with Global Surgery Billing

■ Modifier –24■ Modifier –25■ Modifier –57■ Modifier –58■ Modifier –76■ Modifier –77■ Modifier –78■ Modifier –79See Tab 7 for details of these modifiers.

Bilateral Surgeries

Important facts:■ If code indicates the procedure is performed on both sides of

the body, then the second side cannot be billed separately■ If additional procedures are billed by the same physician

on the same day, use modifier –51 (See Tab 7)

Minor Surgeries

Important facts:■ They are not usually global■ If there is a 10-day postoperative period, all surgery and

postsurgery visits would be included in the global fee■ Underlying conditions can be billed separately■ The day of the procedure is not counted in the global fee

period

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Multiple Surgeries

Important facts:■ When two physicians of different specialties perform separate

procedures during the same session, each surgeon will bill forthe specific procedure performed; there is no modifier required.

■ When billing a procedure code that takes one or more sessions,third-party carriers will pay one time during the global feeperiod.

■ When more than one procedure is performed at the sameoperative session, list the major procedure first, followed by thelesser procedures.

Critical Care

Critical care can be billed separately for preoperative andpostoperative care when the following conditions exist:

■ Constant attention is required by the physician■ Care is unrelated to the surgical procedure performed

Postoperative Pain

■ Bill code 62319 for the first day of pain management bycontinuous epidural

■ Bill code 01996 for daily management of the epidural drug afterthe catheter was inserted.

■ Physician services related to PCA (patient-controlled analgesia) isincluded in the global fee.

Surgical Tray

Medicare can be billed for a surgical tray when performing certainsurgical procedures. Billing surgical trays with other third-partycarriers is carrier specific and requires the provider to check witheach carrier individually. The code for billing surgical tray is A4550.

SURGANES

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Documenting the Operative Report

The documentation of a procedure requires documentation ofthe complete story. It explains what procedure was performed,how they were performed, what tissues, organs, or bones wereinvolved, and why it was necessary to perform the procedure.All information must be complete, consistent, and in a form thatis 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. Heading

2. History or indication for surgery

3. Body (operation(s)/procedure(s) in detail)

4. Findings

The heading consists of five major components:

Components of the Heading

1. Hospital-specific information

2. Patient-specific information

3. Date of operation or surgery

4. Specific information regarding operation

5. Operation(s) or procedure(s) performed

Depending on the type of operation and the courseof surgery, other information may be found in theheading.

(Continued text on following page)

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SURGANES

Components Involved in Coding

from Operative Reports (Continued)

Components of the Heading

1. Hardware

2. Components

3. Grafts

4. Complications

5. Drains

6. Tourniquet time

7. Other material left in place

Heading

Hospital-Specific Information

1. Name of hospital

2. Address of hospital

3. Patient’s medical record or other number used to trackthe patient

4. Admission date

Heading

Patient-Specific Information

1. Name

2. Date of birth and/or age

3. Sex

Heading

Date of Operation or Surgery

Example: 11/10/05

(Continued text on following page)

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SURGANES

Components Involved in Coding

from Operative Reports (Continued)

Heading

Specific Information Regarding Operation

1. Attending surgeon: all surgeons involved should be listed, i.e., primary surgeon, cosurgeons, andassistant surgeons

2. Cosurgeon3. Surgery resident, if applicable4. Surgery assistants, if applicable5. Anesthetic (general, local)6. Complications7. Estimated blood loss

Diagnoses1. Preoperative diagnoses2. 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.

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There are other sources of documentation that could influencethe coding of the operation or procedure. These documents areas follows:■ Progress notes■ Physician orders■ Pathology reports■ Discharge summary■ History and physicals■ Emergency department reports■ Ventilator management forms■ Anesthesiology forms■ Recovery room course and information■ Complications■ Ambulance services■ Consultant’s reports

Surgical and Postoperative Codes

ICD-9-CM CodesICD-9-CM categories 996–999 contain the majority of the codesused when reporting surgical and postoperative complications.When coding an inpatient service, the condition leading to theadmission to the hospital is the primary code used for billing.For outpatient services, the diagnosis code that reflects the mostcurrent reason for this episode of care would be primary.The principal diagnosis is defined as the reason the patient wasadmitted to the hospital.

Surgical ModifiersSurgical modifiers used other than those listed in the GlobalSurgery section of this tab are:■ Modifier –22■ Modifier –51■ Modifier –52■ Modifier –54■ Modifier –56■ Modifier –99

SURGANES

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Elective Surgery NoticeWhen nonparticipating providers submit a Medicare claimfor an elective surgery, the patient must be presented with anelective surgery notice, which identifies the charges and theirliability. This notice must be presented to the patient wheneverthe procedure charge is $500 or more.Requirements for procedure to be considered elective:■ If the surgery is postponed, there will be no damage to the

patient’s health.■ There is no urgency for this surgery.■ This surgery can be scheduled in advance.Physicians who do not participate in Medicare must provide theirelective surgery patients with a fee disclosure form. This formmust contain the following:■ The estimated charge (can’t be higher than the limiting charge)■ The estimated Medicare allowable charge■ The difference between the two charges■ The patient’s coinsurance amount

The Patient’s Out-of-Pocket ExpensesThe charge to the patient must not exceed 115% of the Medicareallowable amount. An example of this estimation calculation canbe seen in the following table:

Description Fee

Charge for the procedureMedicare allowable amountMedicare 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)

$1,000.00$550.00$550.00

$450.00

$110.00

(Continued text on following page)

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Description Fee

Patient’s portion of the bill ifMedicare deductible was met

(450 � 110 � 560)If the patient’s Medicare

deductible has not been met(560 � 100 � 660)

Integumentary System Coding

Considerations when billing for procedures involving the skin:■ Location

■ Where is it?■ Method

■ Was it incised, excised, shaved?■ Structures

■ Did it involve only skin or did it also involve muscle?■ Depth

■ Was it deeper than the subcutaneous tissue?■ Type

■ Was it complete, partial?■ Size

■ Report using centimeters■ Number

■ How many lesions?

Incision and Drainage

Considerations when billing for incision and drainage of anabscess or cyst:■ Site

■ Arm, face, etc.■ Depth

■ Skin, soft tissue■ Method

■ Incision, puncture

SURGANES

$560.00

$660.00

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SURGANES

Removal of Foreign Bodies

Considerations when billing for removal of foreign bodies:■ Site

■ Face, leg, hand, eye■ Depth

■ Muscle, subcutaneous tissue■ Complexity

■ Superficial, complicated

Repairs

Repair codes are used to suture lacerations from injury orprocedures. If suturing is required as a result of a procedure,the reimbursement is included in that procedure code andCANNOT be billed for separately.

Types of Repairs

Simple

Interme-diate

Complex

Considerations for repairs:■ Location

■ Foot, hand, face■ Size

■ Reported in centimeters■ Structure

■ Skin, subcutaneous tissue, muscle

Closure of a partial or full thickness wound to theskin and subcutaneous tissues. No involvementof deep structures.

Closure of wounds/lacerations involving repair ofone or more deeper layers of subcutaneous tissueand nonmuscle fascia along with the skin.

Closure of layered wound that requires additionalwork, such as scar revision, débridement,retention sutures, etc.

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Steps for Coding Wound Repairs1. 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, listthe more complicated as the primary procedure and the lesscomplicated as the secondary procedure, using modifier –51.

3. Decontamination and/or débridement is considered a sepa-rate procedure only when gross contamination requiresprolonged cleansing, when appreciable amounts of tissueare removed, or when débridement is carried out separatelywithout immediate primary closure.

4. If the wound repair involves nerves, blood vessels and/ortendons, choose codes from appropriate subsection of theSurgery section (nervous, cardiovascular, etc.) for repair ofthese structures.

Burns

Considerations for local treatment of burns:■ Anesthesia

■ With or without■ Depth

■ Depth of burn■ Location

■ Hand, face■ Percent

■ Percent of body surface■ Size

■ Small, medium

Rule of NinesAn approximation of the area of skin burnt. It divides the bodyinto units of surface area that are divisible by nine—with theexception of the perineum. In an adult, the following are therespective percentages of the total body surface area:

SURGANES

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Adults:■ Head and neck total for front and back: 9%■ Each upper limb total for front and back: 9%■ Thorax and abdomen front: 18%■ Thorax and abdomen back: 18%■ Perineum: 1%■ Each lower limb total for front and back: 18%The Rule of Nines is relatively accurate for adults but not forchildren due to the relative disproportion of body part surfacearea.Children:■ Head and neck total for front and back: 18%■ Each upper limb total for front and back: 9%■ Thorax and abdomen front: 18%■ Thorax and abdomen back: 18%■ Perineum: 1%■ Each lower limb total for front and back: 13.5%

Fracture Coding

Fracture codes include evaluation and management (E&M)services:■ E&M service the day of the fracture treatment■ Treatment of the fracture, i.e., pinning, open, closed■ Placement and removal of initial cast or splint■ Follow-up care providedSubsequent casts can be billed for separately.Dislocations are reported by two factors:1. The method in which they were stabilized2. The type of manipulation used

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Endoscopy Coding

There are two types of endoscopy:1. Diagnostic2. Therapeutic

Diagnostic Minor Therapeutic Major Therapeutic

Procedures Procedures Procedures

Diagnosticendoscopy

Biopsy of the samelesion in the samearea

Brushing or washingto collect aspecimen

Miscellaneous Facts

■ Use two codes when reporting the replacement of apacemaker battery:■ Code for the removal of the pulse generator■ Code the insertion of the new pulse generator

■ Replacement of the pacemaker within the first 2 weeks isincluded in the original code and cannot be billed forseparately

■ Surgical endoscopy includes diagnostic endoscopy■ When a C-section has been performed, the physician who

performed the procedure is responsible for the postpartumcare

SURGANES

Biopsy of differentlesion in adifferent area

Removal of foreignbody

DilationRemoval of stent

Removal of tumor,polyp, or lesionusing hot biopsy,or snare

Ablation of tumor,polyp, or lesionby othertechnique

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■ All sleep studies include tracing, interpretation, and report■ Surgical arthroscopy includes diagnostic arthroscopy;

therefore, this can never be billed for separately■ An E&M service can be billed the same day as PT if the

service is separately identifiable. The modifier –25 mustbe attached to the E&M service

■ There are three approaches to hysterectomies:■ Abdominal■ Vaginal■ Laparoscopic, vaginal

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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), andinterventional radiology

2. Diagnostic ultrasound3. Radiation oncology4. Diagnostic and therapeutic nuclear medicineAll procedures in the CPT book are listed by anatomical site andbody system. These procedures are presented by type of serviceand body site. Radiation oncology is presented according to thefollowing outline:■ Treatment planning■ Medical radiation physics■ Treatment delivery■ Treatment managementRadiology procedures are many times denied due to lackingmedical necessity. Accurate diagnosis coding is instrumental inthe reimbursement process for radiology codes. It is the order-ing physician or physician extender’s responsibility to providethe diagnosis when ordering a radiology procedure. A physicianextender is an individual whose professional level is between anurse and a physician. Examples of physician extenders arenurse practitioners and physician assistants.Unless the radiology service is being performed in a free-standing facility where the equipment is also owned, mostradiology coding includes only the professional component. In ahospital setting, the equipment is owned by the hospital, but theinterpretation is performed by the radiologist and is billed usinga modifier –26, or –PC for professional component.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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RAD PATH

Component Description Modifier

Technical

Professional

Global

A written report is considered part of the interpretation; therefore,it cannot be billed separately.

With ContrastThis phrase is used when a study is requested with the use of acontrast material for enhancement of the image. This phrase canbe found with the following codes:■ Computerized tomography (CT scan)■ Computerized tomography angiography (CTA)■ Magnetic resonance imaging (MRI)■ Magnetic resonance angiography (MRA)Contrast material is administered via an intravenous line (within avein), intra-articular (within a joint), or intrathecally (within asheath: through the theca of the spinal cord.)CT and MRI scans are listed in the CPT book either with or with-out contrast. The following table shows some of these codes.

CPT Code Description

70450

7046074150

74160

The placement of the IV line for the administration of contrast isconsidered part of the procedure and cannot be billed for separately.

Includes equipment, supplies, personnel(technician), costs to perform theprocedure

Physician’s interpretation, report; alsoincludes costs of physician educationand malpractice insurance

One physician provides both technicaland professional components of theprocedure

�TC

�26

None

Computed tomography (CT scan) head, orbrain; without contrast material

With contrast material

Computed tomography (CT scan) abdomen;without contrast material

With contrast material

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Positron Emission Tomography (PET scan)A PET scan is a diagnostic tool that is most often used to detectcancer and to examine the effects of cancer therapy by biochem-ical changes.PET scans can be used in the following areas:

■ Brain■ Heart■ Cancerous tumors

Emergency Department X-rays■ Medicare will only pay for one interpretation of an x-ray

procedure. This interpretation fee is generally reimbursed tothe radiologist for a formal written report and not the emer-gency department physician for their review of the film. Mostother carriers follow the Medicare guidelines and will notreimburse for an emergency department review.

ConsultationsX-ray consultations performed on x-rays made elsewhere mustcontain a written report. To bill for this consultation, CPT code76140 should be used.

Key Elements to Help in Radiology Coding and Billing

The following lists include components that are found within thespecific procedures that need consideration when considering acode. For example, a chest x-ray is a diagnostic procedure. A chestx-ray may be a single view, frontal, code 71010, a two view, frontaland lateral, code 71020, or a complete, four or more views, code71030. It is important to read the codes carefully before assigning acode to a service or procedure. Does this diagnostic procedurehave more than one view? Is it a complete or limited study? Is itwith contrast, or without? All of these questions must be answeredto properly code a diagnostic procedure.

Diagnostic Procedures1. Number of views2. Complete or limited study3. With or without contrast

122

RAD PATH

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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RAD PATH

Ultrasound Procedures1. Complete or limited2. Unilateral or bilateral3. With or without duplex scanNuclear Medicine Procedures1. Type of radionuclide2. Amount of radionuclide3. Limited, multiple, or whole body area4. Single or multiple determinations5. With or without flow6. Qualitative or quantitativeComputerized Tomography (CT)1. With or without contrast media (type and amount)2. Multiplanar scanning and/or reconstructionMagnetic 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 Description Billing Notes

�22

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Unusual proce-dural service

■ Used rarely in radiology, andwhen used, requires additionaldocumentation to support use

■ Not recognized by mostcarriers

■ Used with CT scans whenadditional views or slices areneeded

■ DO NOT OVER USE

(Continued text on following page)

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Modifier Description Billing Notes

�26

�32

�51

�52

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Professional com-ponent

Mandated service

Multiple proce-dures

Reduced service

■ Used when the physicianprovides an interpretationof the study; this interpre-tation requires a separatewritten and signed report;simple verbiage, such as WNLwithin normal limits (WNL) orfx radius-normal, does notmeet the requirements

■ Used when the service ismandated

■ Used rarely in radiology;sometimes used by Workers’Compensation

■ Use this modifier when morethan one procedure isperformed by the samephysician on the same date,on the same patient

■ Use this modifier whena procedure is partiallyreduced or eliminated atthe physician’s direction

■ Used when a postreductionfilm of fracture care is taken;use the comprehensive x-raycode to identify the fracture;once the fracture has beenreduced, use the compre-hensive x-ray code again withmodifier –52 to indicate that areduced level of service wasprovided

(Continued text on following page)

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Modifier Description Billing Notes

�53

�58

�59

�62

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Discontinuedservice

Staged or relatedprocedure orservice by thesame physicianduring thepostoperativeperiod

Distinct proce-dural service

Two surgeons

■ Used when the physicianchooses to terminate theprocedure

■ Would be used when the x-rayprocedure is discontinuedbecause the patient is at risk

■ Use a diagnosis code that isappropriate, such as, procedurenot carried out because ofcontraindication (V64.1),procedure not carried outbecause of patient’s election(V64.2), procedure not carriedout for another reason (V64.3)

■ Applying this code to thesecond related procedure dur-ing a postoperative period willresult in a denial of the claim

■ Cannot be used in conjunctionwith codes whose descriptionsstate that the code representsone or more services

■ This modifier indicates that theprocedure was distinct orseparate from the otherprocedure performed on thesame day

■ Used when the skills of twodifferent physicians from twodifferent specialties are neededto perform a procedure on apatient during the sameoperation

(Continued text on following page)

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Modifier Description Billing Notes

�66

�76

�77

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Surgical team

Repeat proce-dure by samephysician

Repeat proce-dure byanother phy-sician

■ Cannot be used by two physi-cians of the same specialty

■ Used when a complex procedurerequires the services ofphysicians from differentspecialties and other highlyskilled individuals

■ May be used in instances of mul-tiple traumas, heart transplants,separation of conjoined twins

■ Some carriers will not allowradiology to use this modi-fier; each modifier is carrier-specific, so it is best to alwayscheck with the individual carriersbefore using modifiers

■ It is used to identify that theprocedure had to be performedagain and that this was not aduplicate billing; without thismodifier in this circumstance, theclaim will be denied as duplicate

■ Use of this modifier is rare as asecond interpretation and reportare unusual in radiology

■ Add this modifier to the secondservice

■ Sometimes used when a phy-sician wants a better look usinga darker density, so patient mustreturn for second procedure withdarker density

(Continued text on following page)

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Modifier Description Billing Notes

�78

�79

�99

Diagnostic Radiology

MinimumIn the radiology section of the CPT book, the word “minimum”becomes a key factor in billing. This word indicates that there isno ceiling beyond what is mentioned for that particular code.See the following table for an example of this wording.

CPT Code Description

73630

If an x-ray of a left foot contained 4 views, the same code73630 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 code73510.

Return to operating forrelated procedureduring the post-operative period

Unrelated procedureor service by thesame physicianduring the postop-erative period

Multiple modifiers

■ Used when a subsequentprocedure is related to thefirst and requires the useof an operating room

■ Used when an unrelatedprocedure is performed bythe same physician duringthe postoperative periodof the original procedure

■ Used to report that mul-tiple modifiers are beingreported in this claim

Radiologic examination, foot, complete, minimumthree views

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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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 twoviews is code 73540.

Transcatheter ServicesTranscatheter supervision and interpretation codes include thefollowing services:■ Contrast, angiography/venography, roadmapping, fluoro-

scopic guidance for the intervention■ Measurement of the vessel■ Angiography/venography completion, except for procedures

through existing catheters for follow-up studies■ Diagnostic angiography/venography performed during a

transcatheter therapeutic radiological and interpretive serviceis separately reportable, unless otherwise specified

Diagnostic Ultrasound

Terminology

Term Definition

A-mode

M-mode

B scan

Real-timescan

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Signifies a one-dimensional ultrasonicmeasurement procedure

Signifies a one-dimensional ultrasonic recordamplitude and velocity of moving echo-producingstructures

Signifies a two-dimensional ultrasonic scanningprocedure with a two-dimensional display

Signifies a two-dimensional ultrasonic scan-ning procedure with display of both two-dimensional structure and motion with time

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Doppler evaluation of vascular structures is separately report-able, unless color flow is used only for anatomic structureidentification.A complete ultrasound examination of the abdomen consistsof B-mode scans of:■ Liver■ Gallbladder■ Common bile duct■ Pancreas■ Spleen■ Kidneys■ Upper abdominal aorta■ Inferior vena cava■ Any abnormality found in the abdomenA complete ultrasound examination of the retroperitoneumconsists of B-mode scans of the:■ Kidneys■ Abdominal aorta■ Common iliac artery origins■ Inferior vena cava■ Any abnormality found in the retroperitoneum

Radiation Oncology

Items Included in Radiation Oncology

1.2.3.4.5.6.7.8.9.

Initial consultationClinical treatment planningSimulationMedical radiation physicsDosimetryTreatment devicesSpecial servicesClinical treatment management proceduresNormal follow-up care for 3 months following

completion of radiation

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Simple

Intermediate

Complex

Simple

Intermediate

Planning requires a single treatment area ofinterest encompassed in a single port orsimple parallel opposed ports with simpleor no blocking

Planning requires three or more convergingports, two separate treatment areas,multiple blocks, or special time doseconstraints

Planning requires highly complex blocking,custom shielding blocks, tangential ports,special wedges or compensators, three ormore separate treatment areas, rotatingor special beam considerations, com-bination of therapeutic modalities

Simulation of a single treatment area witheither a single port or parallel opposedports; blocking is simple or may not exist

Simulation of three or more convergingports, two separate treatment areas,multiple blocks

(Continued text on following page)

Clinical Treatment PlanningTreatment planning for radiation oncology is a highly specializedservice, which includes the following:1. Interpretation of special testing2. Tumor localization3. Treatment volume determination4. Treatment time/dosage determination5. Choice of treatment modality6. Determination of number and size of treatment ports7. Selection of appropriate treatment devices

Treatment Planning Definitions

1.

2.

3.

Therapeutic Radiology Simulation Definitions

1.

2.

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Therapeutic Radiology Simulation Definitions

3.

4.

Proton Beam Definitions

1.

2.

3.

Complex

Three-dimensional

Simple

Intermediate

Complex

Simulation of tangential portals, three ormore treatment areas, rotation or arctherapy, complex blocking, customshielding blocks, brachytherapy sourceverification, hyperthermia probe veri-fication, or any use of contrast materials

Three-dimensional reconstruction oftumor volume and surroundingreconstruction of tumor volume andsurrounding critical normal tissuestructures from direct CT and or MRIscans in preparation for noncoplanar orcoplanar therapy; the simulation usesdocumented three-dimensional beam’seye view volume dose displays ofmultiple or moving beams

Proton treatment delivery to a single treat-ment area using a single nontangentialor oblique port, custom block with com-pensation and without compensation

Proton treatment delivery to one or moretreatment areas using two or more portsor one or more tangential or obliqueports, with custom blocks and compen-sators.

Proton treatment delivery to one or moretreatment areas using two or more portsper treatment area with matching orpatching fields and/or multiple isocen-ters, with custom blocks and compen-sators.

(Continued text on following page)

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External (superficial, deep)InterstitialIntracavity

77600, 7760577610, 7761577620

SimpleIntermediateComplex

Application of 1–4 sourcesApplication of 5–10 sourcesApplication of more than 10 sources

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Hyperthermia

Types of Hyperthermia CPT Codes

1.2.3.

Physics planning and interstitial insertion of temperature sensors, andthe use of external or interstitial heat-generating sources are included inthe above codes. Consultations may be billed separately with the aboveprocedures.

Clinical Brachytherapy

Brachytherapy Applications

1.2.3.

Interventional Radiology Procedures

Interventional procedures are most often performed by the samephysician, but may be performed by two physicians. Forexample, a liver biopsy may be performed by a surgeon and aradiologist. The surgeon’s responsibility would be the placementof the needle and the tissue sampling. The radiologist would beresponsible for performing the x-rays, dye injections, and filminterpretations.

Nuclear MedicineDiagnosticNuclear medicine codes do not include radium or other radioele-ments and should be reported separately. Nuclear medicineprocedures may be performed independently or during thecourse of care.

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Front to back

Two projections are included in thisexamination: front to back and side

Usually a radiopaque material that isplaced into the body to enable a systemor body structure to be visualized;common terms include nonionic andlow 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, nuclearmedicine, duplex Doppler, CT, and MRI

Oblique view of the object is being x-rayed

Back to front

Immediate imaging, usually in movement

(Continued text on following page)

TherapeuticThe administration codes for oral and intravenous administra-tion are inclusive of the mode of administration. When reportingintra-arterial, intracavitary, and intra-articular administration,also use the following codes when appropriate:■ Appropriate injection and or procedure codes■ Imaging guidance■ Radiological supervision and interpretation codes

Basic Radiology Definitions

Term Definition

Anteroposterior (AP)

Anteroposterior andlateral

Contrast material

Decubitus (DEC)

Frontal

Lateral (LAT)

Modality

Oblique (OBL)

Posteroanterior (PA)

Real-time

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Tube to provide support in a body cavity orlumen

The removal of an overlying structure to bettervisualize the structure in question; this isdone in a series by imposing one x-ray ontop of another

A specialized type of x-ray imaging thatprovides slices through a body structure toobliterate overlying structures; commonlyperformed for studies on the kidneys or thetemporomandibular joint (TMJ)

Basic Radiology Definitions (continued)

Term Definition

Stent

Subtraction

Tomogram

Laboratory

Laboratory and pathology studies cover the followingareas:■ Organ panels■ Urinalysis■ Chemistry■ Hematology■ Blood banking■ Drug testing■ Cytopathology■ Surgical pathologyOrgan panels consist of various components that are generallyordered together. An example can be seen in the following basicmetabolic panel:

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*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Test CPT Code

Calcium 82310Carbon dioxide 82374Chloride 82435Creatinine 82565Glucose 82947Potassium 84132Sodium 84295Urea nitrogen 84520

The above tests, as with other panels, are components of thebasic metabolic panel and would be billed using CPT code80048. Billing all of the above codes individually would beunbundling (complete description of this term can be found inTab 5) and, therefore, would be considered a matter of fraud andabuse. If only two of the above tests are ordered, only the twoindividual codes would be billed.Other organ panels are:

Panel CPT Code

General health panel 80050Electrolyte panel 80051Comprehensive metabolic panel 80053Obstetric panel 80055Lipid panel 80061Renal function panel 80069Acute hepatitis panel 80074Hepatic function panel 80076

In addition to the widely ordered panels above, other commontests are:

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81000

81001

81002

81003

82465

84478

82947

82948

82951

82952

82962

84152

84443

84702

85004

85025

85027

85610

85730

87086

87184

Test CPT Code

Urinalysis, by dip stick, non-automated, withmicroscopy

Urinalysis, by dip stick, automated, withmicroscopy

Urinalysis, by dip stick, non-automated, withoutmicroscopy

Urinalysis, by dip stick, automated, withoutmicroscopy

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, withautomated 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, perplate (12 fewer discs)

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Surgical pathology, gross examSurgical pathology, gross and

microscopic exam■ Appendix■ Skin, plastic repair■ Vas deferens, sterilizationSurgical pathology, gross and

microscopic exam■ Carpal tunnel tissue■ Gallbladder■ TonsilsSurgical pathology, gross and

microscopic exam■ Colon biopsy■ Joint resection■ Stomach biopsySurgical pathology, gross and

microscopic exam■ Breast, mastectomy – partial/simple■ Cervix, conization■ Liver biopsy – needle/wedgeSurgical pathology, gross and

microscopic exam■ Colon, total resection■ Prostate, radical resection■ Soft tissue tumor, extensive resection

8830088302

88304

88305

88307

88309

Surgical Pathology

Surgical pathology codes include accession, examination, andreport. There are six levels of surgical pathology codes.

Level Definition and Examples of Level CPT Code

III

III

IV

V

VI

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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36415

G0001

36416

Unusual proce-dural service

Professionalcomponent

■ Used rarely in radiology, andwhen used, requires additionaldocumentation to support theiruse

■ Not recognized by most carriers■ Used with CT scans when

additional views or slices areneeded

■ DO NOT OVER USE■ Used when the physician

provides an interpretation of thestudy; this interpretation requiresa separate written and signedreport; simple verbiage, such aswithin normal limits (WNL) or fxradius-normal, does not meet therequirements

(Continued text on following page)

Collection of Specimen

Description CPT Code

1. Venipuncture, routine collection of venousblood

2. Venipuncture, routine collection of venousblood, Medicare patient

3. Collection of capillary blood specimen(heel, finger, ear)

Modifiers

Modifiers used in pathology coding are �22, �26, �32, �52,�53, �59, �90, �91.

Modifier Description Billing Notes

�22

�26

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Mandated service

Reduced service

Discontinuedservice

■ Used when the service ismandated

■ Used rarely in radiology;sometimes used by Workers’Compensation

■ Use this modifier when aprocedure is partially reducedor eliminated at thephysician’s direction

■ Used when a postreductionfilm of fracture care is taken;use the comprehensive x-raycode to identify the fracture;once the fracture has beenreduced, use thecomprehensive x-ray codeagain with modifier –52 toindicate that a reduced levelof service was provided

■ Used when the physicianchooses to terminate theprocedure

■ Would be used when an x-rayprocedure is discontinuedbecause the patient is at risk

■ Use a diagnosis code that isappropriate, such as,procedure not carried outbecause of contraindication(V64.1), procedure not carriedout because of patient’selection (V64.2), procedurenot carried out for anotherreason (V64.3)

(Continued text on following page)

Modifier Description Billing Notes

�32

�52

�53

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Distinctproceduralservice

Reference(outside)laboratory

Repeat clinicaldiagnosticlaboratorytest

■ This modifier indicates thatthe procedure was distinct orseparate from the otherprocedure performed on thesame day

■ Used when laboratoryprocedures are performed bysomeone other than thereporting physician

■ Used when it is necessary toreport the same test on thesame day to obtain multipletest results

■ Cannot be used for confir-mation of results

■ Cannot be used when there isa problem with the specimenor equipment

Modifier Description Billing Notes

�59

�90

�91

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Unbundling

The process of coding integral services separately from a procedureis called unbundling. If the component is considered part of thebundled service, it cannot be coded separately. For example, CPTcode 93000 is a code for Electrocardiogram, routine ECG, with at least12 leads, with interpretation and report. If codes 93005 (ECG tracingonly, without interpretation and report) and 93010 (ECG withinterpretation and report only) were billed together, it would beconsidered unbundling, as both elements are found in the all-inclusive CPT code of 93000.

Add-On Codes

There are codes that are performed in addition to the main CPT code.Add-On Code Facts:■ These codes are called Add-on codes.■ They are not reported with the modifier –51 for multiple

procedures as other CPT codes would be.■ They cannot be billed by themselves.■ Add-on codes are identified by wording that designates it is an

Add-on code.

Examples:Primary Add-On

Code Description Code Description

96409

92607

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Chemotherapy adminis-tration, intravenous;push technique

Evaluation for prescriptionfor speech-generatingaugmentative and alter-native communicationdevice, face-to-face withthe patient; first hour

Infusion technique,1 to 8 hours, eachadditional hour (listseparately in addi-tion to code for pri-mary procedure)

Each additional 30minutes (list separa-tely in addition tocode for primaryprocedure)

96415

92608

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There are instances where more than one add-on code is used. See the following table.

Add-On Second Add-

Primary Code Code Description On Code Description

Any outpatientevaluation andmanagementcode (e.g.,99201–99205,99211–99215,99241–99245)

*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.

MED

9935599354 Prolonged physician servicein the office or otheroutpatient setting requir-ing direct (face-to-face)patient contact beyondthe usual service (e.g.,prolonged care and treat-ment of an acute asth-matic patient in anoutpatient setting); firsthour (list separately inaddition to code for officeor other outpatientEvaluation and Manage-ment code)

Each additional 30minutes (list sepa-rately in additionto code for primaryprocedure)

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Multiple Procedure/Services

Certain procedures can be reported separately without the riskof unbundling. For example, a patient hospitalized for a mentalcondition can receive interactive psychotherapy in conjunctionwith an Evaluation and Management code. Both the psychother-apy code and the Evaluation and Management codes would bebilled for that date of service.

Separate Procedures

Any code that is designated as a “separate procedure” cannot bebilled in addition to the code for the comprehensive procedureas it is considered to be a part of the comprehensive procedure.If a code listed as “separate procedure” is coded independent ofany other procedure, it can then be billed.

Injections

Injections of immune globulins require the CPT code for theactual immune globulin serum and a CPT code for the adminis-tration of the injection. Immune globulin codes range from90281–90399 for the serum. They should be reported with theappropriate delivery code. These codes range from 90780 to90784. A description of codes 90780 and 90781 can be found inthe following section. Vaccines and toxoids are reported usingcodes 90476–90748. Descriptions of codes 90782–90784 follow.

CPT Code Description

90772

9077390774

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Therapeutic, prophylactic, or diagnostic injection(specify material injected); subcutaneous orintramuscular

■ Intra-arterial■ Intravenous

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Immunization administration codes for vaccines are reportedusing the following administration codes.

CPT Code Description

90465

90466

90467

90468

90471

90472

90473

90474

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Immunization administration under 8 years old(includes percutaneous, intradermal, subcuta-neous, or intramuscular), when the physiciancounsels the patients; first injection (single orcombination vaccine/toxoid), per day

■ Each additional injection (single or combinationvaccine/toxoid) per day; list separately inaddition to code for primary procedure

Immunization administration under 8 years old(includes intranasal or oral routes of adminis-tration) when the physician counsels the patient;first administration (single or combinationvaccine/toxoid), per day

■ Each additional administration (single orcombination vaccine/toxoid) per day; listseparately in addition to code for primaryprocedure

Immunization administration (includes percuta-neous, intradermal, subcutaneous, or intramus-cular), one vaccine (single or combinationvaccine/toxoid)

■ Each additional vaccine (single or combinationvaccine/toxoid); list separately in addition tocode for primary procedure.

Immunization administration by intranasal or oralroute; one vaccine (single or combinationvaccine/toxoid)

■ Each additional vaccine (single or combinationvaccine/toxoid); list separately in addition tocode for primary procedure

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Common Vaccines and Toxoids

CPT Code Description

90632

90645

90648

90656

90660

90665

90700

90702

90703

90704

90705

90707

90712

90713

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Hepatitis A vaccine, adult dosage, for intramus-cular use

Hemophilus influenza b vaccine (Hib), HbOCconjugate (4-dose schedule), for intramuscularuse

Hemophilus influenza b vaccine (Hib), PRP-Tconjugate (4-dose schedule), for intramus-cular use

Influenza virus vaccine, split virus, preservativefree, for children 6–35 months of age, forintramuscular use

Influenza virus vaccine, live, for intranasal use

Lyme disease vaccine, adult dosage, forintramuscular use

Diphtheria, tetanus toxoids, and acellularpertussis vaccine (DtaP), for use in individualsyounger than 7 years, for intramuscular use

Diphtheria, tetanus toxoids (DT) absorbed for usein individuals younger than 7 years, forintramuscular 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, livefor subcutaneous use

Poliovirus vaccine, (any type) (OPV), live, for oraluse

Poliovirus vaccine, inactivated, (IPV), forsubcutaneous or intramuscular use

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Intravenous infusion, hydration; initial

Each additional hour up to 8 hours (listseparately in addition to the code forthe primary procedure).

Up to1 hour

2–8 hours

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Therapeutic, Diagnostic Infusions(Excludes Chemotherapy)

CPT codes 90780 and 90781 are used to report prolonged intra-venous injections. They are not used for billing of the followingservices:■ Intradermal■ Subcutaneous■ Intramuscular■ Routine intravenous (IV)Choose the appropriate code based on time.

CPT Code Description Time

90760

90761

Psychiatry

Billing codes for psychiatry services include:90801–90802 Psychiatric diagnostic interview examinationsOffice or Outpatient90804–90809 Insight oriented, behavior modifying and/or

supportive psychotherapy90810–90815 Interactive psychotherapy

Inpatient Hospital, Partial Hospital, or Residential Care Facility90816–90822 Insight oriented, behavior modifying and/or

supportive psychotherapy90823–90829 Interactive psychotherapy90845–90857 Other psychotherapy90862–90899 Other psychiatric services or procedures

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Guide to coding psychiatric services:■ Psychiatric diagnostic interviews must include history, mental

status, and a disposition■ Interactive psychiatric diagnostic interviews are generally

provided to children; they use physical aids and nonverbalcommunication to overcome barriers between the patient andthe clinician due to language skills that have either been lost,or have not yet developed

■ Psychiatric therapeutic services are found in two categories:■ Interactive psychotherapy■ Insight oriented, behavior modifying and/or supportive

psychotherapy■ Some patients receive psychotherapy only, while others

receive Evaluation and Management services (see Tab 2)in addition

■ Psychotherapy codes are chosen based on the typeof psychotherapy, the place of service, face-to-facetime spent with the patient, and whether or not anEvaluation and Management code is performed onthe same day.

■ Medicare will not accept psychiatric therapy codes90804–90829 billed on the same day as an Evaluationand Management code.

Physical Medicine and Rehabilitation

Important facts:■ Medicare patients and many other carriers require a written

plan of care before the patient begins physical therapy.■ Some codes are time-based codes and therefore require the

documentation of time to be billable.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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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

■ Traction, mechanical

■ Electrical stimulation (unattended)

■ Whirlpool

■ Infrared

■ Ultraviolet

Application of a modality to one or more areas;electrical stimulation (manual), each 15 minutes

■ Iontophoresis, each 15 minutes

■ Ultrasound, each 15 minutes

Therapeutic procedure, one or more areas, each15 minutes; therapeutic exercises to developstrength and endurance, range of motion andflexibility

■ Gait training (includes stair climbing)

■ Massage, including effleurage, pétrissage, and/tapotement (stroking, compression, percussion

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manualtraction), one or more regions, each 15 minutes

Therapeutic procedure(s), group (2 or moreindividuals)

Some examples of commonly used physical therapy codes are:

CPT Code Description

97001

97002

97003

97004

97010

97012

97014

97022

97026

97028

97032

97033

97035

97110

97116

97124

97140

97150

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Gastroenterology

Gastroenterology is the study of the stomach and intestine anddiseases associated with them. Following is a select list of themost commonly used codes for these services. A completelisting can be found in the Medicine section of the CPT bookunder subsection Gastroenterology.

CPT Code Description

91000

9101091105

Gastroenterology Surgical Codes

There are many other gastroenterology codes listed in thesurgery section of the CPT book. Some of the most commonlyused codes are:

Important definitions:■ Sigmoidoscopy: the examination of the entire rectum,

sigmoid colon, and may include examination of a portion ofthe descending colon.

■ Colonoscopy: the examination of the entire colon, from therectum to the cecum, and may include the examination of theterminal ileum.

Note: There is sometimes confusion between the two proceduresand codes explained above. It is important to read the proce-dural report carefully to establish the completeness of theexamination.

Esophageal intubation and collection of washingsfor cytology, including preparation of specimens(separate procedure)

Esophageal motilityGastric intubation, and aspiration or lavage for

treatment (for ingested poisons)

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Upper gastrointestinal endoscopy includingesophagus, stomach, and either the duodenumand/or jejunum as appropriate; diagnostic, withor without collection of specimens by brushingor washing (separate procedure)

■ With biopsy, single or multiple■ With injection sclerosis of esophageal and/or

gastric varices■ With directed placement of percutaneous

gastrostomy tubeEndoscopic retrograde cholangiopancreatography

(ERCP)■ With biopsy, single or multiple■ With sphincterotomy/papillotomy■ With endoscopic retrograde removal of calculus

from biliary and/or pancreatic ductsSigmoidoscopy, flexible; diagnostic, with or without

collection of specimen(s) by brushing or washing(separate procedure)

■ With biopsy, single or multiple■ With removal of tumor(s), polyp(s), or other

lesion(s) by hot biopsy forceps or bipolar cautery■ With removal of tumor(s) polyp(s), or other

lesion(s) by snare techniqueColonoscopy■ With biopsy, single or multiple■ With control of bleeding (e.g., injection, bipolar

cautery, unipolar cautery, laser, heater probe,stapler, plasma coagulator)

■ With ablation of tumor(s), polyp(s), or otherlesion(s) not amenable to removal by hot biopsyforceps, bipolar cautery, or snare technique

(Continued text on following page)

CPT Code Description

43235

4323943243

43246

43260

432614326243264

45330

4533145333

45338

453784538045382

45383

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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CPT Code Description

45384

45385

Ophthalmology

Ophthalmology is the study of the eye, its anatomy, physiology,and pathology. Following is a select list of the most commonlyused codes for these services. A complete listing can be foundin the Medicine section of the CPT book under subsectionOphthalmology.Three types of ophthalmology services:

Type Description

Interme-diate

Compre-hensive

Special

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

■ With removal of tumor(s), polyp(s), or otherlesion(s) by hot biopsy forceps or bipolar cautery

■ With removal of tumor(s), polyp(s), or otherlesion(s) by snare technique

Evaluation of a new or existing condition complicat-ed with a new diagnostic or management problemnot necessarily relating to the primary diagnosis,including history, general medical observation,external ocular and adnexal examination and otherdiagnostic procedures as indicated; may includethe use of mydriasis for ophthalmoscopy

Evaluation of the complete visual system; consists ofa single service entity but need not be performedat one session; includes history, general medicalobservation, external and ophthalmoscopicexaminations, gross visual fields, and basicsensorimotor examination; it often includes, asindicated, biomicroscopy, examination withcycloplegia or mydriasis and tonometry; includesinitiation of diagnostic and treatment programs

Services in which a special evaluation of part of thevisual system is made, which goes beyond theservices included under the general ophthalmo-logical services

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Ophthalmological service: medical examinationand evaluation with initiation of diagnostic andtreatment program; intermediate, new patient

■ Comprehensive, new patient, one or more visitsOphthalmological service: medical examination

and evaluation with initiation or continuation ofdiagnostic and treatment program; intermediate,established patient

■ Comprehensive, established patient, one ormore visits

Biofeedback training by any modalityBiofeedback training, perineal muscles, anorectal

or urethral sphincter, including EMG and/ormanometry

Special services that are separately billable are:■ Fluorescein angioscopy■ Quantitative visual field examination■ Refraction or extended color vision examination (Nagel’s

anomaloscope)

CPT Code Description

92002

9200492012

92014

Codes used for office visits can be either the Ophthalmology codes orthe Evaluation and Management codes. It is the physician’s choice.

Biofeedback

There are two codes used to report biofeedback services. Thesecodes may require pre-authorization by the carrier.

CPT Code Description

9090190911

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Dialysis

End-Stage Renal Disease (ESRD)

ESRD services are outpatient codes and are reported with thefollowing codes:

CPT Code Description

90918–9092190922–90925

Guide to Reporting ESRD■ The various levels are age-specific.■ These codes are not billable with hospitalization codes.■ Codes 90918–90921 are used to report consecutive services.■ Codes 90922–90925 are used to report services that are not

performed consecutively during the month.■ Each month is considered to be 30 days.■ Procedures for other medical problems and complications

unrelated to ESRD are not included in the monthly ESRD serviceand are reported separately.

Hemodialysis

Hemodialysis codes are inpatient codes used to report hemodialysisprocedures in addition to Evaluation and Management codes for thesame day. These services are reported with the following codes:

CPT Code Description

9093590937

90940

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

ESRD-related services per full month

ESRD-related services (less than a full month),per day

Hemodialysis procedure with single physician evaluationHemodialysis procedure requiring repeated evaluations

with or without substantial revision of the dialysisprescription

Hemodialysis access flow study to determine bloodflow in grafts and arteriovenous fistulae by anindicator method

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Dialysis procedure other than hemodialysis(e.g., peritoneal dialysis, hemofiltration, or othercontinuous renal replacement therapies), withsingle physician evaluation

Dialysis procedure other than hemodialysis (e.g.,peritoneal dialysis, hemofiltration, or othercontinuous renal replacement therapies) requir-ing repeated physician evaluations, with or with-out substantial revision of dialysis prescription

Hemoperfusion, e.g., with activated charcoal orresin

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Miscellaneous Dialysis Procedures

There are dialysis procedures other than hemodialysis. Thesecodes are reported using CPT codes 90945 and 90947.

CPT Code Description

90945

90947

90997

Dialysis Training

Dialysis training is reported using CPT codes 90989–90993. Code90989 is used to report the completion of the dialysis-trainingcourse. 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 codesfor these services. A complete listing can be found in theMedicine section of the CPT book under subsection SpecialOtorhinolaryngologic Services.Diagnostic procedures are reported as part of the office visit codeand cannot be billed for separately. This includes such tests asotoscopy, rhinoscopy, and tuning fork test, and whispered voice.

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CPT Code Description

92506

92507

Audiologic Function TestsCommonly Used Codes

CPT Code Description

9255192552925539256792568925909259192592925939259492595

Cardiovascular Services

Cardiology is the study of the heart and its functions. Follow-ing is a select list of most commonly used cardiology codes.A complete listing can be found in the Medicine section of theCPT book under subsection Cardiovascular.Important Definitions■ Echocardiography: Echocardiography includes obtaining

ultrasonic signals from the heart and great arteries, withtwo-dimensional image and/or Doppler ultrasonic signaldocumentation, and interpretation and report.

Evaluation of speech, language, voice,communication, and or auditory processing

Treatment of speech, language, voice, communication,and/or auditory processing disorder; individual

Screening test, pure tone, air onlyPure tone audiometry (threshold); air only■ Air and boneTympanometry (impedence testing)Acoustic reflex testing; thresholdHearing aid exam and selection; monaural■ BinauralHearing aid check■ BinauralElectroacoustic eval for hearing aid, monaural■ Binaural

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Cardiopulmonary resuscitation (CPR) (cardiac arrest)

Percutaneous transluminal coronary balloonangioplasty; single vessel

Electrocardiogram, routine ECG, with at least12 leads; with interpretation and report

■ Tracing only, without interpretation and report

■ Interpretation and report only

Cardiovascular stress test using maximal or sub-maximal treadmill or bicycle, continuous electro-cardiographic monitoring, and/or pharmacologicalstress; with physician supervision, with interpre-tation and report

Rhythm ECG, one to three leads; with interpretationand report

Electrocardiographic monitoring for 24 hours bycontinuous original ECG waveform recording andstorage, with visual superimposition scanning;includes recording, scanning analysis with report,physician review and interpretation

Echocardiography, transthoracic, real-time withimage documentation (2D) with or withoutM-mode recording; complete

(Continued text on following page)

■ Cardiac catheterization: Cardiac catheterization is a diagnosticmedical procedure that includes introduction, positioning andrepositioning of catheter(s), when necessary, recording ofintracardiac and intravascular pressure, obtaining bloodsamples for measurement of blood gases or dilution curvesand cardiac output measurements (Fick or other method,with or without rest and exercise and/or studies) with orwithout electrode catheter placement, final evaluation andreport of procedure.

CPT Code Description

92950

92982

93000

93005

93010

93015

93040

93224

93307

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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CPT Code Description

93320

93325

93350

9350193510

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 pulmonarycodes. A complete listing can be found in the Medicine sectionof the CPT book under subsection Pulmonary.

CPT Code Description

94010

94060

94150*Current Procedural Terminology © 2006 American Medical Association,

All Rights Reserved.

Doppler echocardiography, pulsed wave and/orcontinuous wave with spectral display (listseparately in addition to codes forechocardiographic imaging); complete

Doppler echocardiography color flow velocitymapping (list separately in addition to codesfor echocardiography)

Echocardiography, transthoracic, real-time withimage documentation (2D) with or without M-mode recording; during rest and cardiovascularstress test using treadmill, bicycle exercise and/or pharmacologically induced stress, withinterpretation and report

Right heart catheterizationLeft heart catheterization

Spirometry, including graphic record, total and timedvital capacity, expiratory flow rate measurement(s),with or without maximal voluntary ventilation

Bronchospasm evaluation: Spirometry as in 94010,before and after bronchodilator (aerosol orparenteral)

Vital capacity, total (separate procedure)

(Continued text on following page)

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Ventilation assist and management, initiation ofpressure volume preset ventilators for assistedor controlled breathing, first day

■ Subsequent daysContinuous positive airway pressure ventilation

(CPAP), initiation, and managementDemonstration and/or evaluation of patient

utilization of an aerosol generator, nebulizer,metered dose inhaler, or IPPB device

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

CPT Code Description

94656

9465794660

94664

Allergy and Clinical Immunology

Allergy sensitivity testing is the performance and evaluation ofselective cutaneous and mucous membrane tests in correlationwith the history, physical examination, and other observationsof the patient. Immunology is the parenteral administration ofallergenic extracts as antigens at periodic intervals, usually onan increasing dosage scale to a dosage that is maintained asmaintenance therapy. A complete listing of codes can be foundin the Medicine section of the CPT book under subsectionAllergy and Clinical Immunology.

Important Billing and Coding Facts■ Professional services (Evaluation and Management codes) are

included in CPT codes 95115–95199, which are the allergenimmunotherapy codes

■ Evaluation and Management codes can only be used if thereis a separate and identifiable service being performed on thesame date. Use modifier –25 with the Evaluation andManagement code should this occur

■ Codes 95115 and 95117 do not include the extract itself, onlyadministration of the allergy injection

■ Codes 95120 through 95134 include both the administration ofthe injection and the extract. These are referred to as completeservice codes, as they also include the preparation, antigen,supplies, and observation of the patient after injection

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■ Code number of allergens correctly; for example:■ 95130: Single stinging insect venom■ 95131: Two stinging insect venoms■ 95132: Three stinging insect venoms

Neurology and Neuromuscular Procedures

Neurology is the study of the nervous system. Following is a selectlist of most commonly used neurology codes. A complete listingcan be found in the Medicine section of the CPT book underNeurology and Neuromuscular Procedures.

Important Billing and Coding Facts■ Hyperventilation and/or phonic stimulation is included in codes

95812–95822 and cannot be billed separately■ EEG codes are time-based codes and must be chosen correctly

based on time of monitoring■ Electromyography and nerve conduction tests are based on the

number of extremities tested

CPT Codes Description

95812

9581395816

9581995860

95861

95863

95864

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Electroencephalogram (EEG) extended monitoring;41–60 minutes

■ Greater than 1 hour

Electroencephalogram (EEG) including recordingawake and drowsy

■ Including awake and asleep

Needle electromyography; one extremity with orwithout related paraspinal areas

■ Two extremities with or without related paraspinalareas

■ Three extremities with or without related paraspinalareas

■ Four extremities with or without related paraspinal

(Continued text on following page)

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CPT Codes Description

95900

9590395904

Chemotherapy

Chemotherapy is the treatment of various diseases by usingchemical agents. Following is a select list of the most commonlyused Chemotherapy codes. A complete listing can be found inthe Medicine section of the CPT book under Chemotherapy.

Important Facts■ Evaluation and Management codes can be billed with

Chemotherapy procedures when warranted■ Preparation of the chemotherapy is included in the

administration code■ When chemotherapy is delivered by different techniques, each

code should be billed separately by method of delivery

CPT Code Description

96401

9640296409

96413

96415

96420

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Nerve conduction, amplitude and latency, velocitystudy, each nerve; motor, without F-wave study

■ Motor, with F-wave study■ Sensory

Chemotherapy administration, subcutaneous orintramuscular, nonhormonal antineoplastic

■ Hormonal antineoplasticChemotherapy administration, intravenous; push

technique, single or initial substance/drug■ Intravenous infusion technique, up to 1 hour,

single or initial substance/drug■ Intravenous infusion technique, 1 to 8 hours,

(list separately in addition to code for primaryprocedure)

Chemotherapy administration, intra-arterial pushtechnique

(Continued text on following page)

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CPT Code Description

96422

96423

96521

96522

Moderate Sedation (Conscious)

Moderate (conscious) sedation is a drug-induced depression ofconsciousness during which patients respond purposefully toverbal commands, either alone or accompanied by light tactilestimulation. No interventions are required to maintain a patentairway, and spontaneous ventilation is adequate. Cardiovascularfunction is usually maintained.

Important Facts■ Pre- and postsedation evaluations are included in these codes

and cannot be billed for separately■ Does not include maximum allowable concentration (MAC)

anesthesia or minimal or deep sedationThe following services cannot be billed for separately:■ Assessment of the patient■ Establishment of IV access and fluids to maintain patency,

when performed■ Administration of agent(s)■ Maintenance of sedation■ Monitoring of oxygen saturation, heart rate, and blood

pressure■ Recovery (not included in intra-service time)

■ Infusion technique, up to 1 hour

■ Infusion technique, each additional hour upto 8 hours, each additional (list separatelyin addition to code for primary procedure)

Refilling and maintenance of portable pump

Refilling and maintenance of implantable pumpor reservoir for drug delivery, systemic (e.g.,intravenous, intra-arterial)

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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CPT Code Description

99143

99144

99145

99148

99149

99150

162

MED

Moderate sedation services (other than 00100–01999), provided by the same physicianperforming the diagnostic or therapeutic serv-ice that the sedation support, requiring thepresence of an independent trained observerto assist in the monitoring of the patient’s levelof consciousness and physiological status;under 5 years of age, first 30 minutes intra-service time.

■ Age 5 years or older, first 30 minutes intra-service time

■ Each additional 15 minutes intra-service time(list separately in addition to code for primaryservice)

Moderate sedation services (other than 00100–01999), provided by the physician other than thehealth-care professional performing thediagnostic or therapeutic service that thesedation supports; under 5 years of age, first 30minutes intra-service time

■ Age 5 years or older, first 30 minutes intra-service time

■ Each additional 15 minutes intra-service time(list separately in addition to code for primaryservice)

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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ICD-9-CM

(ICD-9-CM)

The International Classification of Diseases, 9th edition, ClinicalModifications (ICD-9-CM) is the coding system used to report thediagnosis or condition of the patient. This system takes a descrip-tion of the patient’s condition, illness, or injury and translates itinto numerical and alphanumerical format. The ICD-9-CM manualis published in the Spring and Fall of each year. To ensure thatthe codes billed are accurate, it is necessary to purchase a newmanual each year. These codes provide the medical necessity forthe service or procedure that was performed.

Dx Codes � Medical Necessity � Reimbursement

Three Volumes of ICD-9-CM

Volume 1

Volume 2

Volume 3

Volume One

A listing of the chapters found in Volume of the ICD-9-CMmanual can be found in the following:

Chapter Title Diagnosis Codes

123

4

This volume consists of the most specific informa-tion about the conditions, diseases, and injuries

This volume contains an alphabetic listing ofVolume 1

This volume contains information that is reservedfor hospital use

Infectious and Parasitic DiseasesNeoplasmsEndocrine, Nutritional and Metabolic

Diseases, and Immunity DisordersDiseases of the Blood and Blood-

Forming Organs

Codes 001–139Codes 140–239Codes 240–279

Codes 280–289

(Continued text on following page)

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Chapter Title Diagnosis Codes

56

789

10

11

12

13

1415

16

17

Supplemental Chapters Diagnosis Codes

V Codes: Supplemental Classification ofFactors of Influencing Health Status andContact with Health Services

E Codes: Supplemental Classification ofExternal Causes of Injury and Poisoning

ICD-9-CM

Mental DisordersDiseases of the Nervous System

and Sense OrgansDisease of the Circulatory SystemDiseases of the Respiratory SystemDiseases of the Digestive SystemDiseases of the Genitourinary

SystemComplications of Pregnancy, Child-

birth, and the Puerperium (theperiod of confinement after labor)

Diseases of the Skin andSubcutaneous Tissue

Diseases of the MusculoskeletalSystem and Connective Tissue

Congenital AnomaliesCertain Conditions Originating in

the Perinatal Period (periodshortly before and after birth)

Symptoms, Signs, and Ill-DefinedConditions

Injury and Poisoning

Codes 290–319Codes 320–389

Codes 390–459Codes 460–519Codes 520–579Codes 580–629

Codes 630–677

Codes 680–709

Codes 710–739

Codes 740–759Codes 760–779

Codes 780–799

Codes 800–999

Codes V01–V83

Codes E800–E999

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ICD-9-CM

Appendices Title

ABC

D

E

Volume Two

Three Sections

123

Easy Diagnosis Coding

Steps Rules

1

2

3

4

5

6

Morphology of Neoplasms (M Codes)Glossary of Mental DisordersClassification of Drugs by American Hospital

Formulary Service List Number and Their ICD-9-CM Equivalents

Classification of Industrial Accidents According toAgency

Three-Digit Categories

Index to Diseases and InjuriesTable of Drugs and ChemicalsAlphabetic Index to External Causes of Injuries and Poisonings

Determine the main term that best describes the condi-tion or symptom of the patient

Use Volume 2 of the ICD-9-CM book to look up that mainterm; this Volume is alphabetized

Read any cross-references such as “see also” and go tothat category

Read all subterms and explanations; refer to indentedterms under the main term to obtain further clarification

Check the code listed in Volume 2 against the tabularlisting in Volume 1

Review all instructions and notes in Volume 1 to be surethe code selected is accurate

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Coding Conventions

Convention Definition/Example

Typeface

Italicized type

[Bracketed]

(Parentheses)

Colons:

Braces

ICD-9-CM

Bold type indicates main terms and codes inVolume 1.

EXAMPLE: CONVULSIONSBrain 780.39Febrile 780.31

This type indicates categories that cannot bereported as a primary diagnosis code. Thistype is also used for identification ofexclusion notes.

Example: 250 Diabetes MellitusExcludes gestational diabetes (648.8)

These are used to enclose synonyms, alterna-tive terminology, or explanatory phrases.

Example: 482.2 Pneumonia due to Hemophilusinfluenza [H. influenza]

These are used to enclose supplementarywords that may be present in thedescription.

Example: 198.4 Other parts of nervous systemMeninges (cerebral) (spinal)

These are used in the tabular listing after anincomplete term that needs a modifier tomake it assignable.

Example: 021.1 Enteric tularemiaTuleremia: cryptogenic intestinalThese enclose a series of terms, each of which

is modified by the statement appearing tothe right of the brace.

Example: 560.2 VolvulusKnotting StrangulationTorsionTwist

of intestine,bowel or colon}

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ICD-9-CM

ICD-10

The following list contains changes that exist between the 9threvision 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 andregulations for mortality and morbidity coding. Volume III is thealphabetic index, which provides the index to all the codes listedin Volume I. The ICD-10 contains more descriptions.

ICD-9-CM ICD-10

Old Title: International Classifi-cation of Diseases, 9th Revi-sion, Clinical Modifications

Contains a chapter titledDiseases of the NervousSystem and Sense Organs

Contains a chapter titledMental Disorders

Supplement: Classification ofFactors Influencing HealthStatus and Contact withHealth Services (V codes)

Supplement: Classification ofExternal Causes of Injuryand Poisoning (E codes)

Contains codes that require4 and 5 digits

Many other changes were made to the descriptions found throughoutthe 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.

New Title: International Statis-tical Classification of Diseasesand Related Health Problems

Splits out the chapter to thefollowing chapters:

■ Diseases of the NervousSystem

■ Diseases of the Eye andAdnexa

■ Diseases of the Ear andMastoid Process

Renames this chapter Mental andBehavioral Disorders

Becomes a chapter and is nolonger considered a supple-ment to the code book

Becomes a chapter and is nolonger considered a supple-ment to the code book

Contains codes that requiremore than 5 digits

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V Codes

V codes describe circumstances surrounding a patient’s healthstatus and identify reasons for medical treatment other than fora disease process or injury.

Three Categories of V Codes

123

V codes can be used as primary codes in certain instances. Forexamples, see the following table:

Scenario Code

Patient presents for removal of castPatient presents for preoperative clearancePatient presents for chemotherapy

Problem-Oriented

A problem-oriented V code identifies a factor that may affectthe patient, but that is not an injury or an illness. Examples ofproblem-oriented V codes are:■ V76.11: Special screening mammogram for high-risk patients■ V46.13: Encounter for weaning from a respirator

Service-Oriented

A service-oriented V code identifies that a service was an exami-nation, therapy, ancillary service, or aftercare. It will identify apatient that is not currently sick, but who is looking for medicalservices for another reason. Examples of service-oriented Vcodes are:■ V67.2: Follow-up examination following cancer chemotherapy■ V58.32: Removal of sutures

ICD-9-CM

Problem-OrientedService-OrientedFact-Oriented

V54.8V72.8V58.1

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ICD-9-CM

Fact-Oriented

A fact oriented V code simply states a fact. Examples of fact-oriented V codes are:■ V27.2: Outcome of delivery; twins, both live born■ V02.6: Viral hepatitis

E Codes

E codes are used to establish medical necessity, identify causesof injury and poisoning, and identify medications.

123

45

6

Examples of E codes are:■ E884.0: Fall from playground equipment■ E917.0: Struck accidentally by object or persons in sports■ E901.0: Excessive cold

Late Effect Codes

Two Types of Late Effects Codes■ General■ Injury-relatedLate effect codes should be the primary diagnosis when it isthe primary reason for the visit. To use late effect codes, codefirst the condition of the late effect and code the late effectcode second.

Can never be primary codesDo not affect the amount of reimbursementCan speed up the reimbursement process by providing

additional information to the insurance payorChild abuse takes precedent over all other E codesCataclysmic events take priority over all other E codes

except for abuseTransportation accidents take priority over all other E

codes except cataclysmic events and abuse

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For example:■ 012.22: Isolated tracheal tuberculosis, bacterial examination

unknown■ 137.0: Late effects of respiratory tuberculosis

General Late Effect Codes

These codes describe a residual condition produced after theacute phase of an illness (usually 1 year or more). Examples ofthese codes are:■ 137.0: Late effects of tuberculosis■ 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” inwhich the cause is classified elsewhere. These late effect codescan be used at any time after the acute injury. Examples of thesecodes are:■ 906.3: Late effect of contusion■ 908.0: Late effect of internal injury to chest

Examples of Late Effects With the Cause

Cause Late Effect

Fracture

Cardiovascular accident

Third-degree burn

Polio

Laceration

Breast implants

ICD-9-CM

Malunion

Hemiplegia

Deep scarring

Contractures

Keloids

Ruptured implant

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ICD-9-CM

Truncated Diagnosis Code

A truncated diagnosis code is one that has not reported with therequired 4th or 5th digit.There are fewer than 100 codes that are three-digit codes, allothers require additional digits for billing. It is the responsibilityof the provider to assign the diagnosis codes.Example: Abdominal Pain 789.0_ (requires a 5th digit)0 Unspecified site1 Right upper quadrant2 Left upper quadrant3 Right lower quadrant4 Left lower quadrant5 Periumbilical6 Epigastric7 Generalized8 Other specified site

Multiple Diagnosis Codes

■ All diagnosis codes must be prioritized in order of significanceand linked to the appropriate procedure or service.

■ When coding both surgical and medical problems on the samepatient, list the surgical problem first. When the severity of themedical problem supersedes the importance of the surgicalproblem, the medical problem is then listed first.

■ A maximum of four diagnosis codes can be submitted perclaim.

Nonspecific/Unspecified Codes

Codes that are referred to as nonspecific or unspecified arenot the most specific codes possible for the reporting of thediagnosis or condition of the patient. In Volume 1, thesecodes are listed as

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NOS (not otherwise specified) and in Volume 2, they are listed asNEC (not elsewhere classified).An example of these codes would be:■ 420.90: Acute pericarditis, unspecified NOS■ 682.9: Cellulitis, NOS■ 599.0: Infection, genitourinary tract NEC

Signs and Symptom Codes

When a definitive diagnosis code is not available, use a sign orsymptom code.Example: Suspected pneumonia, but not sure until x-ray. Diag-noses used for this visit would be the symptoms of the patient.■ Wheeze■ Shortness of breath■ CoughExample: Possible fracture of wrist, but not sure until x-ray. Diag-noses used for this visit would be the symptoms of the patient.■ Swelling■ Pain in wrist

ICD-9-CM Guidelines for Coding and Reporting

■ Identify each service, procedure, or supply with a diagnosiscode

■ Chronic diseases should be reported if appropriate■ Always use the code with the highest degree of specificity;

add 4th and 5th digits when appropriate■ Properly link all diagnosis codes to the CPT code■ Do not code using “rule-out,” “suspected,” “probable,”

“questionable,” etc.■ Use signs and symptoms when a definitive diagnosis code is

not available

ICD-9-CM

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ICD-9-CM

■ Code the primary diagnosis code first, followed by thesecondary, tertiary, and so on

■ Do not code a diagnosis code that is no longer applicable■ For surgical procedures, code the diagnosis applicable to the

procedure; if at the time the claim is filed the postoperativediagnosis is different from the preoperative diagnosis, use thepostoperative diagnosis for billing

Principal Versus Primary Diagnosis Code

■ Principal diagnosis: reported on inpatient hospital claims(facility, Part A Medicare); reported on UB-92 forms; the princi-pal diagnosis is the condition determined after the study thatresulted in the patient’s admission to the hospital

■ Primary diagnosis: reported by the physician (professional,Part B Medicare); reported on HCFA 1500 claim forms; theprimary diagnosis is the most significant condition for whichservices and/or procedures were provided

Hypertension/Hypertensive Table

The hypertension table is a complete listing of hypertensioncodes and conditions associated with hypertension. The tableconsists of three columns:1. Malignant2. Benign3. UnspecifiedMalignant hypertension is a form with vascular damage anda diastolic blood pressure reading of 130mm HG or greater.Benign is a form of mild or controlled hypertension with nodamage to the patient’s vascular system or organs.Unspecified hypertension is where there is no notation ofbenign or malignant status found in the patient’s medicalrecord.

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Neoplasm Table

Neoplasms are new growths in which cell reproduction is out ofcontrol. It is important to know whether the tumor is malignantor benign. Malignant is when the growth is cancerous, invasive,or capable of spreading to other parts of the body. Benign iswhen the growth is noncancerous, nonmalignant, noninvasive.The Neoplasm Table is arranged by anatomical site and containsfour classifications:

Type of Neoplasm Description

Malignant■ Primary

■ Secondary

■ Ca in Situ

Benign

Uncertainbehavior

ICD-9-CM

■ Primary malignant growth is the originaltumor site. All malignant tumors areconsidered primary unless otherwisenoted as metastatic or secondary.

■ Secondary malignant growth is wherethe tumor has metastasized (spread) to asecondary site, either adjacent to theprimary site or to a remote region of thebody.

■ Ca in Situ is a malignant tumor that islocalized, circumscribed, encapsulated,and noninvasive (has not spread to othertissues or organs).

■ A benign growth is a noninvasive,nonspreading, nonmalignant tumor.

■ Uncertain behavior is a type of growthin which it is not possible to predictsubsequent morphology or behavior fromthe submitted specimen. In order toassign a code from this column, thepathology report must specifically indicatethe “uncertain behavior” of the neoplasm.

(Continued text on following page)

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ICD-9-CM

Type of Neoplasm Description

Unspecified nature

Hint: If the statement does not classify the neoplasm, refer to the Indexto Diseases entry for the condition documented instead of the table. Thatentry will contain a code that can be cross-checked in the table.

Primary Malignancies

Primary malignancies are coded if the note in the medical recordstates:■ Metastatic from a site■ Spread from a site■ Primary neoplasm of a site■ A malignancy for which no specific classification is

documented■ A recurrent tumorExample: Carcinoma of the cervical lymph nodes, Metastaticfrom the breast.Primary: breastSecondary: cervical lymph nodes

Secondary Malignancies

Secondary malignancies are Metastatic and indicate that aprimary cancer spread to another part of the body.Example: Metastatic carcinoma from breast to lungAssign two codes:1. Primary malignant neoplasm of the breast: 174.92. Secondary neoplasm of the lung: 197.0

■ Unspecified nature is a type ofgrowth in which a neoplasm is identi-fied, but there is no further indicationof the histology or nature of the tumorreflected in the documented diagnosis.Assign a code from this column whenthe neoplasm was destroyed orremoved and a tissue biopsy wasperformed and results are pending.

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The following table lists secondary sites for malignancies:

123456789

101112

Re-excision

A re-excision is when a pathologist recommends that thesurgeon perform a second excision to widen the margins of theoriginal tumor site. The pathology report may not specify amalignancy at this time, but the patient is still under treatmentfor the original neoplasm.

M Codes

M codes are morphology of neoplasm codes. They are used toreport the type of neoplasm. They are used by the hospital toreport neoplasms to the cancer registry.An example of these codes would be:■ M8041/3: Small cell carcinoma NOS■ M8000/0: Neoplasm, benign

ICD-9-CM

BoneBrainDiaphragmHeartLiverLymph NodesMediastinumMeningesPeritoneumPleuraRetroperitoneumSpinal Cord

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ICD-9-CM

Table of Drugs and Chemicals

The table of drugs and chemicals lists drugs and chemicals thathave caused a poisoning or adverse effect. It is divided into sixexternal cause codes:

External Cause Description Codes

1

2

3

4

5

6

Poisoning

Accident

Therapeuticuse

Suicideattempt

Assault

Undetermined

These codes are assignedaccording to the classifica-tion of the drug or chemicalinvolved in the poisoning

These codes are used for acci-dental overdoing, wrongsubstance given or taken,drug inadvertently taken, oraccidents in the use of drugsand chemical substancesduring a medical or surgicalprocedure

These codes are used for theexternal effect caused bycorrect substance properlyadministered in therapeuticor prophylactic dosages

These codes are used to reportself-inflicted poisonings

These codes represent apoisoning inflicted byanother person whointended to kill or injure thepatient

These codes are used if therecord does not statewhether the poisoning wasintentional or accidental

960–989

E850–E869

E930–E952

E950–E952

E961–E962

E980–E982

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Fracture Coding

When coding fractures, if the note does not state whether or notthe fracture is open or closed, assume that it is closed and codeit appropriately. When dealing with multiple injuries, list them indescending order of severity.

Types of Fractures

Types of Closed

Fractures Description

Comminuted

LinearSpiral

DepressedSimple

Impact/Compression

Complex

Stress

Double

Greenstick

ICD-9-CM

Has more than two fragments of bone thatare broken off; it is unstable and containsmany bone fragments and tissue damage

The fracture runs along the length of the boneThe bone is broken as a result of a twisting

motion and is sometimes confused with anoblique fracture

Skull fracture with the bone forced inwardFracture does not break the skin and

has little, if any tissue damageThe vertebral column is compressed and then

breaks under the pressureFracture that severely damages the soft tissue

around the fracture siteA fracture caused by repeated stress to the

boneMultiple fractures of the same bone occurring

at the same timeBendlike fracture found mostly on children;

the bone is not broken through.

(Continued text on following page)

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ICD-9-CM

Types of Fractures (Continued)

Types of Closed

Fractures Description

Impacted

Fragmented

Oblique

Fissure

ClosedInfectedCompound/OpenPathological

Miscellaneous Commonly Used Codes

Codes Description

278.02305.1333.94338.1338.2519.11528.3

The bones are broken and the ends aresmashed together in a head-on fashion

A fracture where the trauma leaves manybroken bones inside the patient

Fracture forms an oblique break in the bone;very rare

Also known as a hairline fracture; minimaltrauma to the bone and tissues; it is anincomplete fracture, as it is not all the waythrough the bone

There is a fracture with no broken skinA fracture where the area has become infectedA fracture that breaks the skinFracture is caused by some type of disease

process

OverweightTobacco use disorderRestless leg syndrome (RLS)Acute painChronic painAcute bronchospasmCellulitis and abscess

(Continued text on following page)

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Miscellaneous Commonly Used Codes (Cont’d)

Codes Description

649.5784.91781.2783.2

795.81V58.32V72.11

180

ICD-9-CM

Spotting complicating pregnancyPostnasal dripAbnormality of gaitAbnormal loss of weight and

underweightElevated CEA (carcinoembryonic antigen)Encounter for removal of suturesEncounter for hearing examination

following failed hearing screening

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MODHCPCS

Modifiers

Modifiers are two- to five-digit numeric or alphanumericcharacters that can be reported with CPT codes. They provideadditional information regarding the code to which they areattached. These codes indicate that the CPT code has beenaltered 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 performed2. When a service or procedure has been reduced3. When a service or procedure has been increased4. When unusual circumstances surround the service or

procedure5. The service or procedure was performed multiple times6. The procedure was bilateral7. The procedure can be reported either as a technical or

professional service8. When an adjunctive service was performed9. When the service or procedure was performed by more than

one physician10. When the service or procedure was performed in more than

one location11. For anesthesia: when the physical status of the patient needs

to be reported for the administration of anesthesiaSome modifiers are informational only and do not affectreimbursement of the claim.These informational modifiers canaffect whether or not the claim will be paid or denied. Others,however, can affect reimbursement.

Types of Modifiers

Abbreviation Modifier Use With: Code Range

E

A

S

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Evaluation and Management CodesAnesthesia CodesSurgery Codes

99201–9949900100–0199910021–69990

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Abbreviation Modifier Use With: Code Range

R

P

M

Evaluation and Management (E&M)

Code Modifiers

The modifiers used with E&M codes are �21, �24, �25, �32,�52, �57.

Effect on Accepted by

Modifier �21 Description Payment Medicare

Prolonged E&MService

Explanation

This modifier is used to identify face-to-face time with a patientthat is prolonged or greater than normal. Can only be used onthe highest level of E&M service within each category. CPTcodes that can be used with the �21 modifier are 99205, 99215,99220, 99223, 99233, 99236, 99381–99387, and 99391–99397.

Effect on Accepted by

Modifier �24 Description Payment Medicare

Unrelated E&Mservice by samephysician duringthe postop period

Explanation

It may be necessary to indicate that the E&M service performedduring a postoperative period was not related to the procedureperformed. CPT codes that can be used with the �24 modifierare 99201–99499 and 92002–92014.

MODHCPCS

Radiology CodesPathology & Laboratory CodesMedicine Codes

70010–7999980048–8935690281–99602

No effect

Failure to usemodifiermay causeclaim denials

Yes

Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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MODHCPCS

Effect on Accepted by

Modifier �25 Description Payment Medicare

Significant sepa-rately identifiableE&M service bythe same physi-cian on the sameday of procedure

ExplanationIt may be necessary to perform a separate service, above andbeyond the procedure performed. Should also be used withPreventive Medicine services when patient also presents with acomplaint that requires further treatment or testing. CPT codesthat can be used with the �25 modifier are 92002–92014 and99201–99499.

Effect on Accepted by

Modifier �32 Description Payment Medicare

Mandated service

ExplanationIt may be necessary to provide an E&M service at the request ofa third-party carrier, government, or peer review organization.Use this modifier to identify mandated consultations. Commonlyused with Workers’ Compensation cases. CPT codes that can beused with the �32 modifier are 99201–99499, 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �52 Description Payment Medicare

Reduced service

ExplanationIt may be necessary to report a reduced E&M service, when acomplete service is not performed. This is not commonly usedwith E&M services, however, can be used with PreventiveMedicine services. CPT codes that can be used with the �52

Failure to usemodifiermay causeclaim denials

Yes

No effect Yes

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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modifier are 99201–99499, 00100–01999, 10040–69979, 70010–79999, 80049–89399, and 90700–99199. Codes 99201–99499cannot use this modifier on Medicare claims.

Effect on Accepted by

Modifier �57 Description Payment Medicare

Decision for surgery

Explanation

It may be necessary to report an E&M service that resulted in adecision to perform surgery. This service would be performedthe day prior to and/or day of the surgery. CPT codes that can beused with the �57 modifier are 92002–92014 and 99201–99499.

Anesthesia Modifiers

The modifiers used with anesthesia codes are �22, �23, �32,�47, �51, �53, �59.

Effect on Accepted by

Modifier �22 Description Payment Medicare

Unusual proce-dural service

Explanation

It may be necessary to report a procedure that is greater thanthat normally required. Overuse of this modifier may trigger anaudit. Appropriate documentation must accompany the claim toestablish the medical necessity for the unusual service. CPTcodes that can be used with the modifier �22 are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �23 Description Payment Medicare

Unusual anesthesia

*Current Procedural Terminology © 2006 American Medical Associa-tion, All Rights Reserved.

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

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MODHCPCS

Explanation

It may be necessary to report a procedure that usually requiresno anesthesia or local anesthesia, or requires general anes-thesia. This modifier is used only by anesthesia. CPT codesthat can be used with the modifier �23 are 00100–01999.

Effect on Accepted by

Modifier �32 Description Payment Medicare

Mandated service

Explanation

It may be necessary to provide an E&M service at the request ofa third-party carrier, government, or peer review organization.Use this modifier to identify mandated consultations. Commonlyused with Workers’ Compensation cases. CPT codes that can beused with the �32 modifier are 99201–99499, 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �47 Description Payment Medicare

Anesthesia by surgeonExplanation

Is used when regional or general anesthesia is provided by thesurgeon without an anesthesiologist or CRNA involvement. Doesnot include local anesthesia.

Effect on Accepted by

Modifier �51 Description Payment Medicare

Multiple procedures

Explanation

Is used when multiple procedures, other than E&M services,are performed at the same session by the same provider. Theadditional procedure is identified by the addition of the �51modifier. This modifier is not used for the billing of trigger pointinjections. CPT codes that can be used with the �51 modifier are00100–01999, 10040–69979, 70010–79999, and 90700–99198.

Yes Yes

No effect Yes

No effect No

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �53 Description Payment Medicare

Discontinuedprocedure

Explanation

Is used when procedures are terminated after they are started,or after anesthesia is started due to extenuating circumstancesor a threat to the patient’s health. Cannot be used for electivecancellation of a procedure. CPT codes that can be used with the�53 modifier are 00100–01999, 10040–69979, 70010–79999,80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �59 Description Payment Medicare

Distinct proceduralservice

Explanation

Is used when procedures not usually performed together areperformed, are distinct, and medically necessary. CPT codesthat can be used with the �59 modifier are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

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.

Effect on Accepted by

Modifier �22 Description Payment Medicare

Unusual proceduralservice

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

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MODHCPCS

Explanation

It may be necessary to report a procedure that is greater thanthat normally required. Overuse of this modifier may trigger anaudit. Appropriate documentation must accompany the claimto establish the medical necessity for the unusual service. CPTcodes that can be used with the modifier �22 are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �26 Description Payment Medicare

Professionalcomponent

Explanation

It may be necessary to report only a physician’s interpretation ofa test. CPT codes that can be used with the modifier �26 are10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �32 Description Payment Medicare

Mandated serviceExplanation

It may be necessary to provide an E&M service at the requestof a third-party carrier, government, or peer review organization.Use this modifier to identify mandated consultations. Commonlyused with Workers’ Compensation cases. CPT codes that canbe used with the �32 modifier are 99201–99499, 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �47 Description Payment Medicare

Anesthesia by surgeonExplanation

Is used when regional or general anesthesia is provided by thesurgeon without an anesthesiologist or CRNA involvement. Doesnot include local anesthesia.

Yes Yes

No effect Yes

No effect Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �50 Description Payment Medicare

Bilateral procedureExplanation

It is used to report bilateral procedures performed at the sameoperative session. Add the �50 modifier to the second proce-dure. Do not use with codes that are performed bilaterally. CPTcodes that can be used with the �50 modifier are 10040–69979,70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �51 Description Payment Medicare

Multiple proceduresExplanation

Is used when multiple procedures, other than E&M services,are performed at the same session by the same provider. Theadditional procedure is identified by the addition of the �51modifier. This modifier is not used for the billing of trigger pointinjections. CPT codes that can be used with the �51 modifier are00100–01999, 10040–69979, 70010–79999, and 90700–99198.

Effect on Accepted by

Modifier �52 Description Payment Medicare

Reduced serviceExplanation

It may be necessary to report a reduced E&M service whena complete service is not performed. This is not commonlyused with E&M services, however, can be used with Preven-tive Medicine services. CPT codes that can be used with the�52 modifier are 99201–99499, 00100–01999, 10040–69979,70010–79999, 80049–89399, and 90700–99199. Codes99201–99499 cannot use this modifier on Medicare claims.

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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MODHCPCS

Effect on Accepted by

Modifier �53 Description Payment Medicare

Discontinuedprocedure

ExplanationIs used when procedures are terminated after they are started, orafter anesthesia is started due to extenuating circumstances or athreat to the patient’s health. Cannot be used for elective cancel-lation of a procedure. CPT codes that can be used with the �53modifier are 00100–01999, 10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �54 Description Payment Medicare

Surgical care only

ExplanationIt is used to report a procedure when a surgeon performs theprocedure, but another physician performs the postoperativecare. CPT codes that can be used with the �54 modifier are10040–69990 and 90281–99199.

Effect on Accepted by

Modifier �55 Description Payment Medicare

Postoperativecare only

ExplanationIt is used to report a procedure when a physician performs thepostoperative care only and another surgeon performs theprocedure. CPT codes that can be used with the �55 modifierare 10040–69990 and 90281–99199.

Effect on Accepted by

Modifier �56 Description Payment Medicare

Preoperaativecare only

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Yes Yes

Yes Yes

Yes Yes

Yes No

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Explanation

It is used to report when one physician performs the preoper-ative care and the other physician performs the procedure. CPTcodes that can be used with the �56 modifier are 10040–69979.

Effect on Accepted by

Modifier �58 Description Payment Medicare

Staged or related proce-dure or service bysame physician duringthe postoperative period

Explanation

It is used to report when the same physician performs a stagedor related procedure during the postoperative period. CPT codesthat can be used with the �58 modifier are 10040–69990,70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �59 Description Payment Medicare

Distinct procedural service

Explanation

Is used when procedures not usually performed together areperformed, are distinct, and medically necessary. CPT codesthat can be used with the �59 modifier are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �62 Description Payment Medicare

Two surgeons

Explanation

Is used when two surgeons work together as primary surgeonsif the procedure is so complex that it requires two surgeons tomanage. Each surgeon is of a different specialty. CPT codes thatcan be used with the �62 modifier are 10040–69979,70010–79999, 90281–99199.

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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MODHCPCS

Effect on Accepted by

Modifier �66 Description Payment Medicare

Surg teamExplanation

Is used when procedures that are extremely complex areperformed under a surgical team concept. CPT codes that can beused with the �66 modifier are 10040–69979 and 70010–79999.

Effect on Accepted by

Modifier �76 Description Payment Medicare

Repeat procedureby same physician

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, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �77 Description Payment Medicare

Repeat procedure byanother physician

Explanation

Is used when a procedure is repeated by a different physician, ata separate time on the same day. CPT codes that can be usedwith the �77 modifier are 10040–69979, 70010–79999 and90281–99199.

Effect on Accepted by

Modifier �78 Description Payment Medicare

Return to operatingroom for relatedprocedure duringthe postoperativeperiod

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Yes Yes

Yes Yes

Yes Yes

Yes Yes

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ExplanationIs used when a patient needs to return to the operating room totreat complications of the original surgery. CPT codes that can beused with the �78 modifier are 10040–69979, 70010–79999, and90281–99199.

Effect on Accepted by

Modifier �79 Description Payment Medicare

Unrelated procedureor service by thesame physicianduring the postop-erative period

ExplanationIs used when an unrelated procedure is performed by the samephysician during the postoperative period of the originalprocedure. CPT codes that can be used with the �79 modifierare 10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �80 Description Payment Medicare

Assistant surgeon

ExplanationIs used to identify the services of an assistant surgeon necessaryfor a procedure. CPT codes that can be used with the �80modifier are 10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �81 Description Payment Medicare

Minimum assistantsurgeon

ExplanationIs used when the services of additional surgeons (second orthird assistant) are required for a procedure. CPT codes that canbe used with the �81 modifier are 10040–69979, 70010–79999,and 90281–99199.

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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MODHCPCS

Effect on Accepted by

Modifier �82 Description Payment Medicare

Assistant surgeon,when a qualifiedresident isunavailable

ExplanationIs used when a surgical assist is necessary for a procedure, butthere is no resident available. CPT codes that can be used withthe �82 modifier are 10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �99 Description Payment Medicare

Multiple modifiers

ExplanationIs used to report that there are multiple modifiers being used forthis claim. CPT codes that can be used with the �99 modifier are10040–69979, 70010–79999, and 90281–99199.

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.

Effect on Accepted by

Modifier �22 Description Payment Medicare

Unusual proceduralservice

ExplanationIt may be necessary to report a procedure that is greater thanthat normally required. Overuse of this modifier may trigger anaudit. Appropriate documentation must accompany the claimto establish the medical necessity for the unusual service. CPTcodes that can be used with the modifier �22 are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Yes Yes

Yes Yes

No effect Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �26 Description Payment Medicare

Professional component

ExplanationIt may be necessary to report only a physician’s interpretationof a test. CPT codes that can be used with the modifier �26 are10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �32 Description Payment Medicare

Mandated service

ExplanationIt may be necessary to provide an E&M service at the request ofa third-party carrier, government, or peer review organization.Use this modifier to identify mandated consultations. Commonlyused with Workers’ Compensation cases. CPT codes that can beused with the �32 modifier are 99201–99499, 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �50 Description Payment Medicare

Bilateral procedure

ExplanationIt is used to report bilateral procedures performed at the sameoperative session. Add the �50 modifier to the second pro-cedure. Do not use with codes that are performed bilaterally.CPT codes that can be used with the �50 modifier are10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �51 Description Payment Medicare

Multiple procedures

ExplanationIs used when multiple procedures, other than E&M services,are performed at the same session by the same provider. The

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

No effect Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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MODHCPCS

additional procedure is identified by the addition of the �51modifier. This modifier is not used for the billing of trigger pointinjections. CPT codes that can be used with the �51 modifier are00100–01999, 10040–69979, 70010–79999, and 90700–99198.

Effect on Accepted by

Modifier �52 Description Payment Medicare

Reduced serviceExplanation

It may be necessary to report a reduced E&M service, when acomplete service is not performed. This is not commonly usedwith E&M services, however, can be used with PreventiveMedicine services. CPT codes that can be used with the �52modifier are 99201–99499, 00100–01999, 10040–69979, 70010–79999, 80049–89399, and 90700–99199. Codes 99201–99499cannot use this modifier on Medicare claims.

Effect on Accepted by

Modifier �53 Description Payment Medicare

Discontinuedprocedure

Explanation

Is used when procedures are terminated after they are started,or after anesthesia is started due to extenuating circumstancesor a threat to the patient’s health. Cannot be used for electivecancellation of a procedure. CPT codes that can be used withthe �53 modifier are 00100–01999, 10040–69979, 70010–79999,80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �58 Description Payment Medicare

Staged or related pro-cedure or serviceby same physicianduring the posto-perative period

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

Yes Yes

Yes Yes

Yes Yes

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Explanation

It is used to report when the same physician performs a stagedor related procedure during the postoperative period. CPT codesthat can be used with the �58 modifier are 10040–69990,70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �59 Description Payment Medicare

Distinct proceduralservice

Explanation

Is used when procedures not usually performed together areperformed, are distinct, and medically necessary. CPT codesthat can be used with the �59 modifier are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �62 Description Payment Medicare

Two surgeons

Explanation

Is used when two surgeons work together as primary surgeonsif the procedure is so complex that it requires two surgeons tomanage. Each surgeon is of a different specialty. CPT codes thatcan be used with the �62 modifier are 10040–69979,70010–79999, 90281–99199.

Effect on Accepted by

Modifier �76 Description Payment Medicare

Repeat procedureby same physician

Explanation

Is used when the same physician repeats the exact sameservice. CPT codes that can be used with the �76 modifierare 10040–69979, 70010–79999, and 90281–99199.

MODHCPCS

Yes Yes

Yes Yes

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �77 Description Payment Medicare

Repeat procedure byanother physician

Explanation

Is used when a procedure is repeated by a different physician,at a separate time on the same day. CPT codes that can beused with the �77 modifier are 10040–69979, 70010–79999,and 90281–99199.

Effect on Accepted by

Modifier �78 Description Payment Medicare

Return to operatingroom for a relatedprocedure duringthe postoperativeperiod

Explanation

Is used when a patient needs to return to the operating room totreat complications of the original surgery. CPT codes that canbe used with the �78 modifier are 10040–69979, 70010–79999,and 90281–99199.

Effect on Accepted by

Modifier �79 Description Payment Medicare

Unrelated procedureor service by samephysician during thepostoperative period

Explanation

Is used when an unrelated procedure is performed by the samephysician during the postoperative period of the original pro-cedure. CPT codes that can be used with the �79 modifier are10040–69979, 70010–79999, and 90281–99199.

Yes Yes

Yes Yes

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �80 Description Payment Medicare

Assistant surgeon

Explanation

Is used to identify the services of an assistant surgeon necessaryfor a procedure. CPT codes that can be used with the �80modifier are 10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �99 Description Payment Medicare

Multiple modifiers

Explanation

Is used to report that there are multiple modifiers being used forthis claim. CPT codes that can be used with the �99 modifier are10040–69979, 70010–79999, and 90281–99199.

Pathology and Laboratory Modifiers

The modifiers used with pathology and laboratory codes are�22, �26,�32, �52, �53, �59, �90, �91.

Effect on Accepted by

Modifier �22 Description Payment Medicare

Unusual proceduralservice

Explanation

It may be necessary to report a procedure that is greater thanthat normally required. Overuse of this modifier may trigger anaudit. Appropriate documentation must accompany the claimto establish the medical necessity for the unusual service. CPTcodes that can be used with the modifier �22 are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

MODHCPCS

Yes Yes

Yes Yes

No effect Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �26 Description Payment Medicare

Professionalcomponent

Explanation

It may be necessary to report only a physician’s interpretationof a test. CPT codes that can be used with the modifier �26 are10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �32 Description Payment Medicare

Mandated service No effect Yes

Explanation

It may be necessary to provide an E&M service at the request ofa third-party carrier, government, or peer review organization.Use this modifier to identify mandated consultations. Commonlyused with Workers’ Compensation cases. CPT codes that can beused with the �32 modifier are 99201–99499, 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �52 Description Payment Medicare

Reduced service Yes Yes

Explanation

It may be necessary to report a reduced E&M service whena complete service is not performed. This is not commonlyused with E&M services, however, can be used with PreventiveMedicine services. CPT codes that can be used with the �52modifier are 99201–99499, 00100–01999, 10040–69979,70010–79999, 80049–89399, and 90700–99199. Codes99201–99499 cannot use this modifier on Medicare claims.

Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �53 Description Payment Medicare

Discontinued procedure Yes YesExplanation

Is used when procedures are terminated after they are started, orafter anesthesia is started due to extenuating circumstances, ora threat to the patient’s health. Cannot be used for electivecancellation of a procedure. CPT codes that can be used with the�53 modifier are 00100–01999, 10040–69979, 70010–79999,80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �59 Description Payment Medicare

Distinct procedural Yes Yesservice

Explanation

Is used when procedures not usually performed together areperformed, are distinct, and medically necessary. CPT codes thatcan be used with the �59 modifier are 00100–01999, 10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �90 Description Payment Medicare

Reference (outside) No effect Nolaboratory

Explanation

Is used when laboratory tests are performed by a laboratoryother than the reporting physician. Any laboratory or pathologyCPT code could be used with the �90 modifier.

Effect on Accepted by

Modifier �91 Description Payment Medicare

Repeat clinical Yes Yesdiagnosticlaboratory test

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

MODHCPCS

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MODHCPCS

ExplanationIs used when laboratory tests are performed on specimens fromthe 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 andrequires multiple glucose tests on the same day. Failure to usethis modifier may result in claim denial as they may be viewedas duplicate claims. Any laboratory or pathology CPT code couldbe 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.

Effect on Accepted by

Modifier �22 Description Payment Medicare

Unusual proce- Yes Yesdural service

ExplanationIt may be necessary to report a procedure that is greater thanthat normally required. Overuse of this modifier may trigger anaudit. Appropriate documentation must accompany the claimto establish the medical necessity for the unusual service. CPTcodes that can be used with the modifier �22 are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �26 Description Payment Medicare

Professional component Yes Yes

ExplanationIt may be necessary to report only a physician’s interpretation of a test. CPT codes that can be used with the modifier �26 are10040–69979, 70010–79999, 80049–89399, and 90700–99199.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �32 Description Payment Medicare

Mandated service No effect YesExplanation

It may be necessary to provide an E&M service at the request ofa third-party carrier, government, or peer review organization.Use this modifier to identify mandated consultations. Commonlyused with Workers’ Compensation cases. CPT codes that canbe used with the �32 modifier are 99201–99499, 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �50 Description Payment Medicare

Bilateral procedure Yes Yes

Explanation

It is used to report bilateral procedures performed at the sameoperative session. Add the �50 modifier to the secondprocedure. Do not use with codes that are performed bilaterally.CPT codes that can be used with the �50 modifier are10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �51 Description Payment Medicare

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. Theadditional procedure is identified by the addition of the �51modifier. This modifier is not used for the billing of trigger pointinjections. CPT codes that can be used with the �51 modifier are00100–01999, 10040–69979, 70010–79999, and 90700–99198.

Effect on Accepted by

Modifier �52 Description Payment Medicare

Reduced service Yes Yes

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

MODHCPCS

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MODHCPCS

Explanation

It may be necessary to report a reduced E&M service when acomplete service is not performed. This is not commonly usedwith E&M services, however, can be used with PreventiveMedicine services. CPT codes that can be used with the �52modifier are 99201–99499, 00100–01999, 10040–69979,70010–79999, 80049–89399, and 90700–99199. Codes99201–99499 cannot use this modifier on Medicare claims.

Effect on Accepted by

Modifier �53 Description Payment Medicare

Discontinued Yes Yesprocedure

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 patient’s health. Cannot be used for electivecancellation of a procedure. CPT codes that can be used with the�53 modifier are 00100–01999, 10040–69979, 70010–79999,80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �55 Description Payment Medicare

Postoperative Yes Yescare only

Explanation

It is used to report a procedure when a physician performs thepostoperative care only and another surgeon performs theprocedure. CPT codes that can be used with the �55 modifierare 10040–69990 and 90281–99199.

Effect on Accepted by

Modifier �56 Description Payment Medicare

Preoperative Yes Nocare only

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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ExplanationIt is used to report when one physician performs the preopera-tive care and the other physician performs the procedure. CPTcodes that can be used with the �56 modifier are 10040–69979.

Effect on Accepted by

Modifier �58 Description Payment Medicare

Staged or related Yes Yesprocedure or serviceby same physicianduring the post-operative period.

ExplanationIt is used to report when the same physician performs a stagedor related procedure during the postoperative period. CPT codesthat can be used with the �58 modifier are 10040–69990,70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �59 Description Payment Medicare

Distinct procedural Yes Yesservice

ExplanationIs used when procedures not usually performed together areperformed, are distinct, and medically necessary. CPT codes thatcan be used with the �59 modifier are 00100–01999,10040–69979, 70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �76 Description Payment Medicare

Repeat procedure Yes Yesby same physician

ExplanationIs used when the same physician repeats the exact same service.CPT codes that can be used with the �76 modifier are10040–69979, 70010–79999, and 90281–99199.

MODHCPCS

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �77 Description Payment Medicare

Repeat procedure Yes Yesby another physician

Explanation

Is used when a procedure is repeated by a different physicianat a separate time on the same day. CPT codes that can beused with the �77 modifier are 10040–69979, 70010–79999,and 90281–99199.

Effect on Accepted by

Modifier �78 Description Payment Medicare

Return to operating Yes Yesroom for related procedure during postoperative period

Explanation

Is used when a patient needs to return to the operating room totreat complications of the original surgery. CPT codes that canbe used with the �78 modifier are 10040–69979, 70010–79999,and 90281–99199.

Effect on Accepted by

Modifier �79 Description Payment Medicare

Unrelated procedure Yes Yesor service by same physician during the postoperative period

Explanation

Is used when an unrelated procedure is performed by the samephysician during the postoperative period of the originalprocedure. CPT codes that can be used with the �79 modifierare 10040–69979, 70010–79999, and 90281–99199.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �99 Description Payment Medicare

Multiple modifiers No effect YesExplanation

Is used to report that there are multiple modifiers being used forthis claim. CPT codes that can be used with the �99 modifier are10040–69979, 70010–79999, and 90281–99199.

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.

Effect on Accepted by

Modifier�25 Description Payment Medicare

Significant separately Yes, failure Yesidentifiable E&M to use modi-service by the same fier may physician on the same cause claim day of procedure denials

Explanation

It may be necessary to perform a separate service, above andbeyond the procedure performed. Should also be used withPreventive Medicine services when patient also presents with acomplaint that requires further treatment or testing. CPT codesthat can be used with the �25 modifier are 92002–92014 and99201–99499.

Effect on Accepted by

Modifier �27 Description Payment Medicare

Multiple outpatient Yes Yeshospital E&M ser-vices on same date

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

MODHCPCS

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MODHCPCS

Explanation

This modifier is to be used for facility billing only. It is used toreport the utilization of hospital resources related to separateand distinct E&M services performed in multiple outpatienthospital settings on the same date.

Effect on Accepted by

Modifier �50 Description Payment Medicare

Bilateral procedure Yes YesExplanation

It is used to report bilateral procedures performed at the sameoperative session. Add the �50 modifier to the second proce-dure. Do not use with codes that are performed bilaterally. CPTcodes that can be used with the �50 modifier are 10040–69979,70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �52 Description Payment Medicare

Reduced service Yes YesExplanation

It may be necessary to report a reduced E&M service when acomplete service is not performed. This is not commonly usedwith E&M services, however, can be used with PreventiveMedicine services. CPT codes that can be used with the �52modifier are 99201–99499, 00100–01999, 10040–69979,70010–79999, 80049–89399, and 90700–99199. Codes99201–99499 cannot use this modifier on Medicare claims.

Effect on Accepted by

Modifier �58 Description Payment Medicare

Staged or related pro- Yes Yescedure or serviceby same physicianduring the post-operative period

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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ExplanationIt is used to report when the same physician performs a stagedor related procedure during the postoperative period. CPT codesthat can be used with the �58 modifier are 10040–69990,70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �59 Description Payment Medicare

Distinct procedural service Yes Yes

ExplanationIs used when procedures not usually performed together areperformed, are distinct, and medically necessary. CPT codes thatcan be used with the �59 modifier are 00100–01999, 10040–69979,70010–79999, 80049–89399, and 90700–99199.

Effect on Accepted by

Modifier �73 Description Payment Medicare

Discontinued outpatient Yes Yeshospital/ambulatorysurgery center (ASC)prior to the adminis-tration of anesthesia

ExplanationIs used when there are extenuating circumstances that maythreaten the well-being of the patient and cause the physician tocancel or postpone the procedure. The cancellation of the proce-dure must take place before the administration of anesthesia,however, may take place after the administration of surgicalprep sedation.

Effect on Accepted by

Modifier �74 Description Payment Medicare

Discontinued outpatient Yes Yeshospital/ambulatorysurgery center (ASC)after administrationof anesthesia

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

MODHCPCS

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MODHCPCS

Explanation

Is used when there are extenuating circumstances that maythreaten the well-being of the patient and cause the physicianto cancel or postpone the procedure after administration ofanesthesia.

Effect on Accepted by

Modifier �76 Description Payment Medicare

Repeat procedure Yes Yesby same physician

Explanation

Is used when the same physician repeats the exact same service.CPT codes that can be used with the �76 modifier are10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �77 Description Payment Medicare

Repeat procedure Yes Yesby another physician

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 usedwith the �77 modifier are 10040–69979, 70010–79999, and90281–99199.

Effect on Accepted by

Modifier �78 Description Payment Medicare

Return to operating Yes Yesroom for a related pro-cedure during thepostoperative period

Explanation

Is used when a patient needs to return to the operating room totreat complications of the original surgery. CPT codes that canbe used with the �78 modifier are 10040–69979, 70010–79999,and 90281–99199.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �79 Description Payment Medicare

Unrelated procedure Yes Yesor service by thesame physicianduring the post-operative period

Explanation

Is used when an unrelated procedure is performed by the samephysician during the postoperative period of the originalprocedure. CPT codes that can be used with the �79 modifierare 10040–69979, 70010–79999, and 90281–99199.

Effect on Accepted by

Modifier �91 Description Payment Medicare

Repeat clinical Yes Yesdiagnostic labo-ratory test

Explanation

Is used when laboratory tests are performed on specimens fromthe same patient source more than one time on the same day.This code is not used when a test is rerun to confirm results. Thismodifier may be used on a patient who has diabetes andrequires multiple glucose tests on the same day. Failure to usethis modifier may result in claim denial as they may be viewedas duplicate claims. Any laboratory or pathology CPT code couldbe used with the �91 modifier.

Teaching Physician Modifiers

The following two modifiers are used in a teaching physiciansetting when a resident is involved in the service. Thesemodifiers have no effect on payment and are only used to trackthe medical education funds.

MODHCPCS

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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Effect on Accepted by

Modifier �GC Description Payment Medicare

The service has been No effect Yesperformed in partby a resident underthe direction of ateaching physician

Explanation

When a teaching physician’s services are billed using thismodifier, the physician is certifying that he/she was present forthe key portion of the services and was immediately availableduring the other portions of the service.

Effect on Accepted by

Modifier �GE Description Payment Medicare

The service has No effect Yesbeen performed bya resident withoutthe presence of ateaching physician

Explanation

This modifier is used when services are provided under theprimary care exemption. The primary care exemption mustbe obtained prior to following the guidelines for use of thismodifier. Once all criteria have been met, residents may pro-vide services to patients without the presence of the teachingphysician.

*Current Procedural Terminology © 2006 American Medical Association,All Rights Reserved.

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TOOLS

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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TOOLS

Important Hospital Numbers:

Main Number: Laboratory:X-ray:PT: EKG/EEG: Outpatient Scheduling: Emergency room: Admissions:Billing office: Medical records:Medical staff office:

Office manager’s home number:

Office manager’s cell:

Other important numbers: 1. 2.3.4.5.6.78.9.

Frequently Called Offices

Dr. Address:

Phone:Fax:

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TOOLS

Doctor’s Office (O)

Patient’s Home (H)

Inpatient Hospital (IH)

Dr. Address:

Phone:Fax:

Dr. Address:

Phone:Fax:

Dr. Address:

Phone:Fax:

Dr. Address:

Phone:Fax:

Place of Service Codes

Code Place of Service

11

12

21

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TOOLS

Place of Service Codes

Code Place of Service

222324252631323334354142505152535455566061626571728199

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 FacilityAmbulance – landAmbulance – air, waterFederally Qualified Health Center (FQHC)Inpatient Psychiatric Facility (OL)Psychiatric Facility Partial HospitalizationCommunity Mental Health Care (CMHC)Immediate Care Facility mentally retarded (STF)Residential Substance Abuse Treatment Facility (RTC)Psychiatric Residential Treatment Center (RTC)Mass Immunization CenterComprehensive 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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TOOLS

State Medicare Carriers

State Medicare Carrier

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Blue Cross/Blue Shield of AlabamaPO Box 830139, Birmingham, AL 35283–0139Phone: 205–988–2100 Fax: 205–981–4841Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Arkansas Blue Cross/Blue Shield, A Mutual

Insurance Company601 Gaines StLittle Rock, AR 72201Phone: 501–378–2000 Fax: 501–378–2804National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Trailblazer Health Enterprises, LLCPO Box 660156Dallas, TX 75266Phone: 972–766–6900 Fax: 972–766–1765

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State Medicare Carriers

State Medicare Carrier

Delaware

District ofColumbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Trailblazer Health Enterprises, LLCPO Box 660156Dallas, TX 75266Phone: 972–766–6900 Fax: 972–766–1765Trailblazer Health Enterprises, LLCPO Box 660156Dallas, TX 75266Phone: 972–766–6900 Fax: 972–766–1765Blue Cross/Blue Shield of Florida, Inc.532 Riverside AveJacksonville, FL 32202Phone: 904–791–6111 Fax: 904–905–6020Blue Cross/Blue Shield of AlabamaPO Box 830139, Birmingham, AL 35283–0139Phone: 205–988–2100 Fax: 205–981–4841Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Connecticut General Life Insurance

CompanyHartford, CT 06152Phone: 615–782–4576 Fax: 615–244–6242National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182AdminaStar Federal, Inc.8115 Knue RoadIndianapolis, IN 46250Phone: 317–841–4400 Fax: 317–841–4691

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State Medicare Carriers

State Medicare Carrier

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

TOOLS

Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Blue Cross/Blue Shield of Kansas, Inc.1133 Topeka AveTopeka, KS 66629Phone: 785–291–7000 Fax: 785–291–7098AdminaStar Federal, Inc.8115 Knue RoadIndianapolis, IN 46250Phone: 317–841–4400 Fax: 317–841–4691Arkansas Blue Cross/Blue Shield, A Mutual

Insurance Company601 Gaines StLittle Rock, AR 72201Phone: 501–378–2000 Fax 501–378–2804National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182Trailblazer Health Enterprises, LLCPO Box 660156Dallas, TX 75266Phone: 972–766–6900 Fax: 972–766–1765National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182

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State Medicare Carriers

State Medicare Carrier

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182Wisconsin Physicians Insurance CorporationPO Box 8190Madison, WI 53708Phone: 608–221–4711 Fax: 608–223–3614Wisconsin Physicians Insurance CorporationPO Box 8190Madison, WI 53708Phone: 608–221–4711 Fax: 608–223–3614Blue Cross/Blue Shield of Kansas, Inc.1133 Topeka AveTopeka, KS 66629Phone: 785–291–7000 Fax: 785–291–7098Blue Cross/Blue Shield of Montana, Inc.PO Box 4310, 340 N. Last Chance GulchHelena, MT 59604Phone: 406–444–8350 Fax: 406–442–9968Blue Cross/Blue Shield of Kansas, Inc.1133 Topeka AveTopeka, KS 66629Phone: 785–291–7000 Fax: 785–291–7098Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182

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State Medicare Carriers

State Medicare Carrier

New Jersey

New Mexico

New YorkCounties of Bronx,

Columbia,Delaware,Duchess,Greene, Kings,Nassau, New York,Orange, Putnam,Richmond,Rockland, Suffolk,Sullivan, Ulster,Westchester

Queens

Other partsof the state

Medicare Carriers

TOOLS

Highmark, IncC/O HGS AdministratorsPO Box 8900065Camp Hill, PA 17089Phone: 717–763–3151 Fax: 717–975–7045Arkansas Blue Cross/Blue Shield,

A Mutual Insurance Company601 Gaines StLittle Rock, AR 72201Phone: 501–378–2000 Fax: 501–378–2804

Empire Medicare ServicesPO Box 2280Peekskill, NY 10566Phone: 866–837–0241 Fax: 866–709–1905

Group Health Incorporated88 West End AvenueNew York, NY 10023Phone: 212–721–1300 Fax: 212–721–0580Healthnow New York, Inc.Upstate Medicare Division Operations33 Lewis Road, PO Box 80Binghampton, NY 13905Phone: 716–887–6900 Fax: 607–779–6395

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State Medicare Carriers

State Medicare CarrierQueens

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

Connecticut General Life InsuranceCompany

Hartford, CT 06152Phone: 615–782–4576 Fax: 615–244–6242Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Nationwide Mutual Insurance CompanyPO Box 16788Columbus, OH 43216Phone: 614–249–7111 Fax: 614–249–3732Arkansas Blue Cross/Blue Shield,

A Mutual Insurance Company601 Gaines StLittle Rock, AR 72201Phone: 501–378–2000 Fax: 501–378–2804Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Highmark, IncC/O HGS AdministratorsPO Box 8900065Camp Hill, PA 17089Phone: 717–763–3151 Fax: 717–975–7045Blue Cross/Blue Shield of Rhode Island444 Westminster StreetProvidence, RI 02903Phone: 401–459–1000 Fax: 401–459–1709

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State Medicare Carriers

State Medicare Carrier

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

TOOLS

PGBA17 Technology CircleColumbia, SCPhone: 803–735–1034 Fax: 803–935–0081Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002Connecticut General Life Insurance

CompanyHartford, CT 06152Phone: 615–782–4576 Fax: 615–244–6242Trailblazer Health Enterprises, LLCPO Box 660156Dallas, TX 75266Phone: 972–766–6900 Fax: 972–766–1765Regence Blue Cross/Blue Shield of Utah2890 E. Cottonwood ParkwaySalt Lake City, UT 84121Phone: 801–333–2000 Fax: 801–333–6510National Heritage Insurance Company402 Otterson DriveChico, CA 95928Phone: 530–896–7400 Fax: 530–896–7182Trailblazer Health Enterprises, LLCPO Box 660156Dallas, TX 75266Phone: 972–766–6900 Fax: 972–766–1765

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State Medicare Carriers

State Medicare Carrier

Washington

West Virginia

Wisconsin

Wyoming

Puerto Rico

Virgin Islands

Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002

Nationwide Mutual Insurance CompanyPO Box 16788Columbus, OH 43216Phone: 614–249–7111 Fax: 614–249–3732

Wisconsin Physicians Insurance CorporationPO Box 8190Madison, WI 53708Phone: 608–221–4711 Fax: 608–223–3614

Noridian Mutual Insurance Company4305 13th Ave SWFargo, ND 58103Phone: 701–282–1100 Fax: 701–282–1002

Triple-S, IncPO Box 71391San Juan, PR 00936Phone: 787–749–4080 Fax: 787–749–4092

Triple-S, IncPO Box 71391San Juan, PR 00936Phone: 787–749–4080 Fax: 787–749–4092

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www.ahcpr.gov

www.cms.gov

www.access.gpo.gov/nara/cfr

www.dhhs.gov

www.fda.gov/medbullwww.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.htmlwww.aapcnatl.org

www.ache.org

Websites

Organization/Association Website

Agency for HealthcarePolicy and Research

Center for Medicare andMedicaid Services

Code of FederalRegulations

Department of Healthand Human Services

FDA Medical BulletinGovernment Printing

OfficeJoint Commission on

Accreditation ofHealthcareOrganizations

Local Carrier Info-Medicare

National Committeefor Quality Assurance

Office of InspectorGeneral Workplan

Office of InspectorGeneral Compli-ance Plans

Social Security OnlineAmerican Academy of

Professional CodersAmerican College of

Healthcare Executives

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Websites

Organization/Association Website

American HealthManagement Informa-tion Association

Healthcare FinancialManagementAssociation

Medical GroupManagementAssociation

Center for HealthcareInformationManagement

Health HippoHuman Anatomy

Medical Abbreviations

United States Units of Measure

Apothecaries’ Fluid Measure60 minims � 1 fluid dram8 fluid drams � 1 fluid ounce16 fluid ounces � 1 pint2 pints � 1 quart4 quarts � 1 gallonAvoirdupois Weight27 11/32 grains � 1 dram16 drams � 1 ounce16 ounces � 1 poundTroy Weight24 grains � 1 pennyweight20 pennyweights � 1 ounce12 ounces � 1 pound

www.ahima.org

www.hfma.org

www.mgma.com

www.chim.org

Hippo.findlaw.com/hippol.htmlwww.mnsu.edu/emuseum/biology/

humananatomy/index.shtmlwww.pharma-lexicon.com/

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Metric Units of Measure

Linear Measure10 millimeters � 1 centimeter10 centimeters � 1 decimeter10 decimeters � 1 meterWeight10 milligrams � 1 centigram10 centigrams � 1 decigram10 decigrams � 1 gram

U.S. and Metric Equivalents

Linear MeasureU.S. Unit Metric Unit1 inch � 2.54 centimeters1 foot � 0.3048 meters0.03937 inch � 1 millimeterLiquid MeasureU.S. Unit Metric Unit1 fluid ounce � 29.573 millimeters1 quart � 0.94635 liter1 gallon � 3.7854 liter0.033814 fluid ounce � 1 milliliter1.0567 quarts � 1 liter0.26417 � 1 literWeightsU.S. Units Metric Unit1 grain � 0.064799 gram1 avoirdupois ounce � 28.350 grams1 troy ounce � 31.103 grams1 avoirdupois pound � 0.453359 kilogram1 troy pound � 0.3732415.432 grains � 1 gram0.032151 troy ounce � 1 gram2.2046 avoirdupois � 1 kilogram

TOOLS

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AAbdomen, ultrasound examination of,

129ABN (Advance beneficiary notice), 53–54Add-on codes, 141–142Adults, treatment of burns in, 117Advance beneficiary notice (ABN), 53–54Allergy and clinical immunology, 158–159Ambulatory service centers (ASC)/hospi-

tal outpatient modifiers, 206–210A-mode, in diagnostic ultrasound, 128Anesthesia

conscious sedation, 107facts, 103HCPCS modifiers, 105medically directed services, 105moderate (conscious) sedation, 105modifiers, 184–186monitored care, 104physical status modifiers, 105–106

Annual nursing facility assessment, 89Arthroscopy, surgical, 119Assistant surgeon, 106Audiologic function tests, 157

BB scan, in diagnostic ultrasound, 128Bankruptcy, 40Benefits, explanation of, 30Benign growth, 174Benign hypertension, 173Bilateral surgeries, 107Biofeedback, 152Body areas examination, 72Brachytherapy, clinical, 132Bronchospasm, acute, 179Burns, 116–117

CCa in Situ, 174Carcinoembryonic antigen (CEA),

elevated, 180Cardiac catheterization, 156Cardiovascular services, 155–157

CC (Chief complaint), 65, 71Cellulitis and abscess, 179Checks

personal, verification of, 33returned, 33–34

Chemotherapy, 160–161Chief complaint (CC), 65, 71Children, treatment of burns in, 117Claim(s)

clean, 43denial of, 31–32, 60unpaid, 35, 36

Claims submission issuesexplanation of benefits, 30problems with, 29

Clean claim, 43Clinical brachytherapy, 132Clinical treatment planning, 130–132CMS 1500 form

completion instructions, 13–22in Medicare, 52place of service codes, 22–29

Codes/coding. See also Specific topicsadd-on, 141–142conventions, 166E, 169easy diagnosis, 165late effect, 169–170M, 176miscellaneous commonly used,

179–180nonspecific/unspecified, 171–172place of service, 22–29, 214–215principal vs. primary diagnosis, 173signs and symptoms, 172V, 168–169

Collectionsabbreviations, 38–40bankruptcy, 40billing for relatives, 41overpayments, 41statute of limitations by state, 36–38

Colonoscopy, 149Computerized tomography (CT), 123

Index

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Concurrent care, 101Consultations

documenting, 102inpatient, 83outpatient, 82three Rs of, 102types of, 101x-ray, 122

Continuing intensive care, 94Cosurgeon, 106CPT (HCPCS Level I)

codes, 41CPT book sections, 42symbols, 42

Critical care servicesbilling codes examples, 97–98codes, 97conditions for providing, 97inpatient neonatal and pediatric, 99preoperative and postoperative, 108time spent for providing, 97

C-section, 118

DDenial of claims, 31–32, 60Diagnostic radiology, 127–128Diagnostic ultrasound

clinical brachytherapy, 132clinical treatment planning, 130hyperthermia, 132proton beam definitions, 131radiation oncology, 129terminology, 128–129therapeutic radiology simulation defi-

nitions, 130–131Dialysis

end-stage renal disease (ESRD), 153hemodialysis, 153miscellaneous procedures, 154training, 154

Discharge servicesdecision matrix for, 89hospital discharge day, 82

Documentationof consultations, 102medical record, 62–63operative report, 109

patient visit, 12–13SNOCAMP, 101–102SOAP, 100

Domiciliary careestablished patient, 93new patients, 92

Drugs and chemicals table, 177

EE codes, 169Easy diagnosis coding, 165Echocardiography, 156–157Elective surgery notice, 113Electroencephalogram (EEG), 159Electrocardiogram, 156Electromyography, 159E&M services. See Evaluation and

Management (E&M) servicesEmergency(ies)

after hours codes, 87room services, 86X-rays, 122

Endocardiography, 157Endoscopy, surgical, 118End-stage renal disease (ESRD), 153EOB. See Explanation of benefits

(EOB)ESRD. See End-stage renal disease

(ESRD)Established patient(s)

domiciliary care, 92, 93home services, 91office, 7–8, 79preventive medicine services, 95

Evaluation and Management(E&M) services

billing, 119code modifiers, 182–184codes, 60, 61components of, 63examination in, 72–74history in, 64–68list of services, 61–62time in, 63–64

Examination, in E&M servicesbody areas, 721995 guidelines, 72

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1997 guidelines, 73–74organ systems, 73

Explanation of benefits (EOB), 30External causes effects, 170, 177

FFact-oriented V code, 169Financial hardship, patients with, 34Foreign bodies removal, 115Form(s)

CMS 1500 form, 13–22frequently called offices, 213–214important hospital numbers, 213important numbers, 212patient encounter form, 3patient registration form, 1–3

Fracture(s)coding, 117types of, 178–179

GGait, abnormality of, 180Gastroenterology

important definitions, 149–151surgical codes, 149

General late effect codes, 170Global surgeries, 106–107Guarantor, 59

HHCPCS anesthesia services modifiers,

105Health Maintenance Organization

(HMO), Medicaid plans and, 55–56Hearing examination, 180Hemodialysis, 153History

chief complaint (CC), 65, 71in evaluation and management serv-

ices, 64–68levels and types of, 64past, family, social history, 69–71of present illness, 65–68, 71review of systems, 68–69, 71summary, 71

History of present illness (HPI), 65–68,71

Home servicesestablished patient, 91new patient, 90

Hospital observation or inpatient care,84

Hospital observation services, 85HPI (History of present illness), 65–68,

71Hypertension/hypertensive table, 173Hyperthermia, 132Hyperventilation and/or phonic stimula-

tion, 159Hysterectomies, 119

IICD-10, 167ICD-9-CM

about, 163coding and reporting guidelines,

172–173surgical and postoperative codes,

112three volumes, 163–165vs. ICD-10, 167

Immunization administration codes forvaccines, 144

Incision and drainage, 114Infusions, diagnostic, 146Initial hospital patients, 80Initial nursing facility, 87Injections of immune globulins, 143–146Injuries, late effects of, 170Injury-related late effect codes, 169Inpatient pediatric critical care, 94Inpatient(s). See also Outpatient(s)

consultations, 83extension of days, Medicaid and, 56hospital observation, 84–85neonatal critical care, 94, 99pediatric critical care services, 94,

99prolonged care services, 96

Insurance commissioner, 36Insurance form life cycle

established patient, office, 7–8new patient, office, 4–6patient discharge, 8–11

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Integumentary system coding, 114–117International Classification of Diseases,

9th edition, Clinical Modifications(ICD-9-CM). See ICD-9-CM

Interventional radiology procedures,132–133

LLaboratory

areas of, 134–136modifiers, 198–201

Late effect codesof external causes, 170general, 170types of, 169–170

Locum tenens providers, 43

MM codes, 176Magnetic resonance imaging (MRI), 123Major Medical, 59Malignancies

primary, 175secondary, 174–176

Malignant hypertension, 173Managed care

dos and don’ts of working with, 45quick guide to, 46summary of plans, 44–46

Medicaidbilling summary, 57confirming eligibility, 55extension of inpatient days, 56nurse practitioner billing, 57physician assistant billing, 56preauthorization, 55–56services available, 54

Medical decision-makingcomponents of, 75four levels of, 75–76table of tasks, 76–77

Medical necessityabout, 77after hour codes for emergencies, 87annual nursing facility assessment, 89continuing intensive care, 94discharge services, 82, 89

domiciliary care, 92, 93emergency room services, 86established office patients, 79home services, 90, 91hospital observation or inpatient care,

84–85initial hospital patients, 80inpatient consultation, 83inpatient neonatal critical care, 94inpatient pediatric critical care, 94new office patients, 78outpatient consultation, 82preventive medicine services, 95prolonged care services, 96subsequent hospital patients, 81subsequent nursing facility, 88

Medical record documentation, 62–63Medically directed anesthesia services,

105Medicare

advance beneficiary notice (ABN),53–54

billing summary, 52covered/noncovered services, 51deductibles and co-pays, 46–47emergency department x-rays, 122fee schedule, 50medical supplies and equipment

billing, 51MSP billing guide, 47–48nonparticipating providers billing, 46nurse practitioner billing, 50patient’s out-of pocket expenses,

113–114physical medicine and, 147–148physician assistant billing, 48–49review process, 52–53state carriers, 216–223surgical tray, 108

Medicare secondary payor (MSP), 47billing guide, 47–48physician assistance billing, 48–49

Medicine modifiers, 201–206Minimum (word), in billing, 129Minor surgeries, 107M-mode, in diagnostic ultrasound, 128Modifiers

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about, 181ambulatory service centers/hospital

outpatient, 206–210anesthesia, 184–186anesthesia services, HCPCS, 105evaluation and management services

code, 182–184with global surgery, 107laboratory, 198–201medicine, 201–206pathology, 138–140, 198–201physical status, 103–104radiology, 125–129, 193–198surgery, 112, 186–193teaching physician, 210–211types of, 181–182

MSP. See Medicare secondary payor(MSP)

Multiple diagnosis codes, 171Multiple procedure services, 143Multiple surgeries, 108

NNeonatal critical care

inpatient, decision matrix for, 94inpatient services, 99

Neoplasm table, 174–176Nerve conduction, 161, 162Neurology, 159–160Neuromuscular procedures, 159–160New patient(s)

domiciliary care, 92home services, 90office visit, 4–6, 78

1995 examination guidelines, 721997 examination guidelines, 73–74Nonspecific/unspecified codes, 171–172Nonsufficient funds (NSF), 33NP (Nurse practitioner) billing, 50NSF. See Nonsufficient funds (NSF)Nuclear medicine

diagnostic, 132procedures, 123therapeutic, 133

Numbershospital, 213–214physicians, 212

Nurse practitioner (NP) billingin Medicaid, 57in Medicare, 50

OOffice patients

established, 7–8, 79new, 4–6, 78visit steps, 7–8

Offices, frequently called, 213–214Operative report

components in coding from, 109–112documenting, 109surgical and postoperative codes,

112–114Ophthalmology, 151–152Organ systems examination, 73Organization/association Web sites,

224–225Otorhinolaryngologic services, 154–155Outpatient(s)

ambulatory service centers/hospitalmodifiers, 206–210

consultations, 82prolonged care services, 96

Overpayments, 41

PPacemaker replacement code, 118Pain

acute, 179chronic, 179postoperative, 108

Past, family, social history (PFSH), 69–71Pathology

areas of, 134–136modifiers, 138–140, 198–201surgical, 137–138

Patient(s). See also Establishedpatient(s); Inpatient(s); New patient(s);Outpatient(s)

discharge of, 8–11encounter form, 3initial hospital, 80out-of-pocket expenses, 113–114registration form, 1–3visit documentation, 12–13

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Pediatric critical care services, inpa-tient, 94, 99

PET scan (Positron emission tomogra-phy), 124

PFSH (Past, family, social history), 69–71Physical medicine, 147–148Physical status modifiers, 103–104Physician assistant (PA) billing

Medicaid, 56Medicare Secondary Payor (MSP)

billing, 48–49Tricare, 58

Place of service codes, 22–29, 214–215Poisoning

late effect codes, 172late effects of, 170

Positron emission tomography (PETscan), 122

Postnasal drip, 180Preauthorization, 11Precertification, 11Pregnancy, spotting complicating, 180Preventive medicine services, 95Primary diagnosis code, principal vs.,

173Primary malignancies, 174, 175Principal vs. primary diagnosis code, 173Problem-oriented V code, 168Prolonged care services, 96Prolonged intravenous injections, 146Proton beam definitions, 131Providers

locum tenens, 43nonparticipating in Medicare, 46

Psychiatry, 146–147Pulmonary, 157–158

RRadiation oncology, 129–130Radiology

basic definitions, 133–134billing and coding, 120–127computerized tomography, 123consultations, 122with contrast, 121diagnostic, 127–128diagnostic procedures, 122

diagnostic ultrasound, 128–132emergency department x-rays, 122interventional procedures, 132–133magnetic resonance imaging, 123modifiers, 125–129, 193–198nuclear medicine, 123, 132–133positron emission tomography, 122ultrasound procedures, 123

Real-time scan, in diagnostic ultrasound,128

Re-excision, 176Rehabilitation, 147–148Relatives, billing for, 41Repairs

burns, 116–117coding for wound, 116considerations for, 115types of, 115

Restless leg syndrome (RLS), 179Retroperitoneum, ultrasound examina-

tion of, 129Returned checks, 33–34Review of systems (ROS), 68–69, 71Rule of nines, in burns, 116

SSecondary malignancies, 174, 175–176Sedation, moderate (conscious), 105,

161–162Separate procedures, 143Service-oriented V code, 168Sigmoidoscopy, 149Signs and symptoms codes, 172Sleep studies, 119SNOCAMP documentation, 100–101SOAP documentation, 100State Medicare carriers, 216–223Subsequent hospital patients, 81Subsequent nursing facility, 88Surgery(ies)

bilateral, 107elective notice, 115global, 106–107important definitions, 106integumentary system coding,

114–117minor, 107

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modifiers, 112, 186–193multiple, 108patient’s out-of-pocket expenses,

113–114physical status modifiers, 103–104postoperative pain, 108preoperative and postoperative

billing, 108Surgical and postoperative codes,

112–114Surgical arthroscopy, 119Surgical endoscopy, 118Surgical pathology, 137–138Surgical tray, 108Sutures, 180Symbols, CPT, 42

TTeaching physician modifiers,

210–211Team surgery, 106Terminology, diagnostic ultrasound,

128–129Therapeutic diagnostic infusions

(excludes chemotherapy), 146Therapeutic radiology simulation

definitions, 130–131Time, in E&M services, 63–64Tobacco use disorder, 179Toxic effects codes, 170Toxoids, 147Transcatheter services, 128Treatment planning, for radiation

oncology, 130Tricare

definition and plans, 58

physician assistant billing, 58–59workers’ compensation, 59

Truncated diagnosis code, 171

UUltrasound

diagnostic, terminology, 128–129procedures, 123, 125

Unbundling, 141Underweight, abnormal loss of, 180United States

metric equivalents, 226units of measure, 225

Units of measuremetric, 226United States, 225

Unpaid claims, 35, 36Unspecified hypertension, 173

VV codes

fact-oriented, 169problem-oriented, 168service-oriented, 168

Vaccines, common, 147

WWeb sites, organization/association,

224–225Weight, abnormal loss of, 180Workers’ compensation, in

Tricare, 59Wound repairs, coding, 116

XX-rays, 122

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