Lesson 3.

1 Evaluation and Management

 Place of Service

Factors Type of Service

Patient Status
Place of Service

u Office
u Emergency Room
u Nursing Home
u Hospital
 Consultation

Office Visit
Type of
Service Admission

Newborn care
 u New patient
u Established patient
Patient Status u Outpatient
u Inpatient
Lesson 3.2
 Endotracheal : tube inserted into nose or mouth

Epidural : injection of anesthetic agent into spaces of vertebrae

Spinal : injection of local anesthetic into subarachnoid space

Methods around spinal cord

General : state of unconsciousness by drug or combination of

drugs administered intramuscularly, rectally, intravenously or by
inhalation

Regional : Nerve block –forms wall of anesthesia around the site

 u Atomically
u Type of procedure
u Last four Subsections
Divisions u Radiological
u Excision and debridement
u Obstetrics
u Other Procedures
Levels of Sedation
Documentation Needed

u Pre-anesthesia record completed by the anesthesia provider

u • Anesthesia report completed by the anesthesia provider
u • Post-anesthesia record completed by the anesthesia provider and the post
anesthesia care unit (PACU) team
u • Surgeon’s operative report
 Pre-operative and post-operative visit

• General or regional anesthesia and patient care

What’s
Included ? • Administration of fluids and/or blood

• Usual monitoring services (eg, ECG, temperature,

blood pressure, oximetry, capnography, and mass
spectrometry
 B : Base Units

Formula T : Time Units

B+T+M x
Conversion M: modifying units

Factor ASA Crosswalk: American Society of Anesthesiologist

produces comprehensive list of CPT codes that link
to anesthesia codes
Base Unit

u Each anesthesia code (procedure codes 00100-01999) is assigned a base unit

value by the American Society of Anesthesiologists (ASA) and used for the
purpose of establishing fee schedule allowances.

u Anesthesia services are paid on the basis of a relative value system, which
include both base and actual time units. Base units take into account the
complexity, risk, and skill required to perform the service.

u For the most current list of base unit values for each anesthesia procedure
code can be found on the Anesthesiologist Center page on the CMS website at:
[Link]
Example of base unit conversion

CODE 2018
BASE
UNIT
00100 5
00102 6
00103 5
00104 4
00120 5
00124 4
00126 4
00140 5
00142 4
00144 6
00145 6
00147 4
00148 4
Time Unit

u Anesthesia time is defined as the period during which an anesthesia

practitioner is present with the patient. It starts when the anesthesia
practitioner begins to prepare the patient for anesthesia services in the
operating room or an equivalent area and ends when the anesthesia
practitioner is no longer furnishing anesthesia services to the patient, that is,
when the patient may be placed safely under postoperative care.

u Anesthesia time is a continuous time period from the start of anesthesia to

the end of an anesthesia service. In counting anesthesia time for services
furnished, the practitioner can add blocks of time around an interruption in
anesthesia time as long as the anesthesia practitioner is furnishing continuous
anesthesia care within the time periods around the interruption.
u AMA and ASA recommend that 1 unit of time is equal to 15 minutes of
anesthesia time – Time is rounded up to the next unit after 7 ½ minutes is
reached.
u

u • Some carriers, including Medicare, do not follow the above

recommendation. Refer to your local payer contracts and policies for specific
guidance for reporting time.
Conversion from minutes to units

u Minutes Units
1-2 0.1
u 16-17 1.1
3 0.2
u 18 1.2
4-5 0.3
u 19-20 1.3
u 6 0.4
u 21 1.4
7-8 0.5
u 22-23 1.5
Modifying units

u Qualifying Circumstances : age of patient , emergency situations

u Example : +99100 Anesthesia for patient less than 1 year old or older than 70

u Physical status modifier examples

u P1 Normal health patient value 0
u P2 Patient with mild systemic disease value 0
u P3 A patient with severe systemic disease value 1
Other relevant modifiers
Conversion Factor

u The anesthesia conversion factors for each calendar year are listed by
payment locality and are effective for the date the service was provided. The
participating physician anesthesia conversion factor is listed first, the non-
participating physician anesthesia conversion factor is second, and the non-
medically directed conversion factor is listed in the third column.
u
The anesthesia conversion factors can be found at:
[Link]
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Code Range

Spine and Spinal Cord 00600-00670

Upper Abdomen 00700-00797
Lower Abdomen 00800-00882
Perineum 00902-00952
Pelvis (except hip) 01112-01173
Upper Leg (except knee) 01200-01274
Knee and Popliteal Area 01320-01444
 u 00600 cervical spine, cord surgery
00604 cervical spine and cord surgery
in sitting position
00620 thoracic spine, cord surgery
00625 thoracic spine, cord surgery
transthoracic w/o 1 lung vent
CPT Broken 00626 thoracic spine, cord surgery
transthoracic w/ 1 lung vent
Down 00630 lumbar spine, cord surgery
00632 removal of nerves
00635 lumbar puncture
00640 spine manipulation or closed
procedures on spine
00670 extensive spine, cord surgery
10 Steps to Coding

u 1. Determine the appropriate CPT® code(s) for the surgical procedure(s)

performed.
u 2. Crosswalk the CPT® code(s) to the appropriate ASA code.
u 3. Determine the appropriate number of base units.
u 4. Determine the appropriate number of time units.
u 5. Assign the appropriate modifier to identify the anesthesia provider
u 6. Assign the appropriate modifier to identify MAC services, when
appropriate.
u 7. Assign the appropriate physical status modifier
10 steps to coding (continued)

u 8. If applicable, assign the appropriate qualifying circumstance code(s).

u 9. Determine the appropriate CPT® code(s) for any additional services or
procedures performed.
u [Link] the total units for the anesthesia services
 Base units plus time units (insertion through delivery),
subject to a reasonable cap

• Base units plus one unit per hour for neuraxial analgesia
Anesthesia management plus direct contact time (insertion,
management of adverse effects, delivery, removal)

for
• Incremental time-based fees (eg, 0<2 hrs, 26 hrs, >6 hrs)
Obstetrics
• Single fee
Vaginal converted to C-Section

u – Only anesthesia scenario in which each of the services reported require base
and time units to be calculated
u • Vaginal labor and delivery: 01967 – Time: Anesthesia start time through
decision for C-Section
u • Cesarean delivery following labor analgesia: +01968 – Time: Decision for
C-Section through anesthesia end time
 u Second- or third-degree burns treated
during anesthesia and surgery
u • Based on total body surface area
Burn Excisions (TBSA)
u – 01951: less than 4% total body
or surface area
u – 01951: 4% to 9% total body surface
Debridement area or part thereof
u – +01953: each additional 9% total
body surface area or part thereof
u
 u 86-year-old woman with severe hypertension
has a 5 cm malignant lesion removed from left
knee . Total time of anesthesia was 60 minutes
Open Book and the insurance carrier indicates that a unit is
15 minutes . Record indicates anesthesiologist
discovery documented P3 status

u What codes would you use and how many units ?

 u Base Units : 3
u Time units : 4
u Modifiers : age 1 plus physical status 1=2
u Total : 9 units

Rational
u Coding :
00400-P3 Anesthesia for procedure of
integumentary system of knee for a patient
with severe systemic disease
u 99100 Anesthesia for 86-year-old
New or Established
 u Medical Record should be complete and
legible
u Date of encounter, reason , history ,
physical and review of systems
u Past and present diagnosis should be
available

Medical Record u Reason and results of labs, X-rays and

other tests
Documentation u Documented response to treatment
u Treatments and medications listed in
the medical chart
u Provider must date and sign encounter
notes
u Documentation should support ICD and
CPT codes billed to insurance
 History
E/M Key u

u Examination
Components u Medical Decision Making
Elements of History

Chief Complaint History of present Review of Systems Past, Family, and/

(CC) illness (HPI) (ROS) or Social History
(PFSH)
 Location

Quality

Severity
History of Duration
Present Timing
Illness Context

Modifying Factors

Associated signs and symptoms

 Constitutional

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Review of
Respiratory

Gastrointestinal

Systems Genitourinary

Musculoskeletal

Neurologic

Psychiatric

Endocrine
 Past History –Allergies, medications,
prior hospitalizations or operations

Past, Family Family History – parents' history,

health status of other family members
and Social
Social History- Occupation, sexual
history, smoking/ drinking
 u Problem Focused
u Expanded problem focused
HPI Levels u Detailed
u Comprehensive
 u Problem focused
u Expanded problem focused
Examination u Detailed
u Comprehensive
Documentation
Guidelines
u CMS developed standards for E/M
u CMS regulates rules for Medicare and
Medicaid beneficiaries
u 1995
u 1997
1997 vs 1995
 Management Options

Medical
Decision Data to be reviewed

Making
Risk
Medical Decision Making (MDM)
Number of Diagnosis/ Options
Amount of Data to be Reviewed
Risk
Split /Shared Services
Consultation Codes
 R- Request
Consulation
Requirements
R- Render

R- Reply
Request

u First, let’s review some basic criteria about requests for consults. The
following items can help you make sure you’re meeting the criteria for a
consult:
u Who is initiating or requesting the consultation? Your documentation needs to
refer to a provider’s name (an individual physician, not a medical group) and
a unique physician identification number (UPIN).
u A “consult” initiated by a patient, family member or third-party payer (in
other words, a consult not requested by a physician) should not be billed
using initial inpatient consultation codes.
Render

u The medical record needs to contain documentation of the consultant’s opinion,

advice and (if applicable) any services that may have been ordered or performed.
CPT guidelines state that a consultant can initiate diagnostic and/or therapeutic
services to help formulate an opinion. CPT instructs that only one initial inpatient
consultation should be billed per hospital admission.
u If the transfer of care will be given to the consultant to treat the problem after an
opinion is rendered, each visit after the consult should be reported as a
subsequent hospital visit (CPT 99231-99233). If not, care remains with the
referring physician for treatment and follow-up.
u If the consultant can’t complete an opinion on the initial consult day, or if the
referring physician requests the consultant to return later to provide additional
advice, use follow-up inpatient consultation codes (99261-99263). You must
thoroughly document additional consult days. Also make sure you describe
modifications to management options or advise of a new plan for patient care.
 u When consultants reply back to the
referring physician, they must provide
treatment recommendations or an
Reply opinion. In the inpatient setting, this is
commonly done through the shared
medical record of the hospital.
 u A transfer of care occurs when one
physician turns over responsibility for
the comprehensive care of a patient to
another physician. The transfer may be
initiated by either the patient or by the
patient’s physician, and it may be
Transfer of either permanent or for a limited
period of time until the patient’s
Care condition improves or resolves or based
on the patient wishes. When initiated
by the patient’s physician, the
transferring physician should explicitly
inform the patient of the transfer and
assist the patient with timely transfer
of care consistent with local practice.
 u A referral is a request from one physician to another to
assume responsibility for management of one or more of
a patient’s specified problems. This may be for a
specified period of time, until the problem(s) is
resolved, or on an ongoing basis. This represents a
temporary or partial transfer of care to another
Referral physician for a particular condition. It is the
responsibility of the physician accepting the referral to
maintain appropriate and timely communication with
the referring physician and to seek approval from the
referring physician for treating or referring the patient
for any other condition that is not part of the original
referral.
Audit form
Critical Care Definition
From CMS Manual
Critical Care Codes
Time based follows CPT Rules
Inpatient Care
Subsequent Care
Subsequent
Care
Conciderations
Inpatient
Audit
Concerns
Inpatient Setting and Time
What's included ?
Auditing Records

u Should be 3-4 times per year for each provider

u Keeps us compliant to ensure correct billing
u If errors found, required to send correct and refund any overpayments
u Provider and staff training opportunity
Patient # 1
Exam
MDM & Medical Necessity
Audit Findings
Overall Findings 99221
Telehealth VS Telemedicine
Barriers
Medicare definition of payment
Originating POS
Private Insurance Coverage laws per
Aetna
 u A new patient is seen at the office for an
earache(otalgia). The history and examination
are problem focused and the MDM complexity
was straightforward . The diagnosis was acute
Open Book mastoiditis .

Discovery u CPT Code __________

u ICD 10 Code __________
u ICD 11 Code __________
 u CPT 99201 - New patient with exam and history
problem focused .MDM was straightforward

Rational u ICD 10 – H07.009 (Acute mastoiditis without

complications, unspecified ear)
u ICD 11 –AB11 + XK6G (unspecified laterality)
Lesson 3.3
Modifiers
 • Provide more information

• Clarify

• Expand upon
Purpose of • Enhance Specificity
the modifier • Identify separation

Impacts Payment

• …they add to…or CHANGE the story

Types of Modifiers

u Informational Modifiers
u Payment impacting modifiers
u Status of patient modifier
u Type of service – Both CPT® modifiers and HCPCS Level II modifiers •
u Many commercial payers do not require HCPCS Level II modifiers •
u All modifiers have a vital role in accurate coding.
u •NOT all payers recognize modifiers
 u Modifier RT, LT:
u To identify that procedures were done
on separate sides‟ of the body
u – ONLY appropriate on procedures and
Anatomical services, NOT diagnosis codes or E/M
codes

Modifiers u – Some payers would also rather see an

RT, LT, and not the 50 for bilateral,
must know what the payers want
u – Lesion removed from right arm,
excision taken from left arm, modifier
RT and LT
Surgical Modifiers

u 58 Staged or related procedure in the post-op period by the same physician

Patient had a lumpectomy and after pathology, it was determined that
mastectomy needed to be performed. Mastectomy, more extensive and
related to the initial surgery, modifier 58, identifies that it is staged/related
in the post-op period.
u 78 Return to the OR for a related procedure during the post-op period Patient
had open heart surgery, during hospitalization, began bleeding and had to be
taken BACK to the OR for more surgery. It was NOT „STAGED,‟ it is NOT more
extensive than initial surgery, modifier 78 identifies a return to the OR.
u 79 Return to the OR for an unrelated procedure during the postop period
Patient had surgery to repair a fractured hip. During recovery, he slipped and
fell fracturing his wrist and had to have an ORIF performed, modifier 79 must
be utilized.
 54 Surgical Care ONLY – To identify that a
provider ONLY did the surgery, that someone else
will be billing the post-op care (OPHTH-
OPTOMETRY for „comanaged cataract patients)

Splitting the
Global 55– Post-op Management ONLY – Physicians can
SHARE the post-op care as well – Reported with
procedure code, original date of surgery, NOT
Surgical the date the patient was seen

Package
56– Pre-op Management ONLY
Multiple/Bilateral Procedures

u Modifier 51 – Modifier ONLY recognizes that it is a multiple procedure

u – Is NOT a pricing modifier, although many payers reduce reimbursement for
multiple procedures. 100% paid for the highest physician fee schedule amount and
50% of the fee schedule for each additional procedure.
u • MANY payers do not require this modifier; Medicare no longer requires it. In some
areas, claims will be denied if the modifier is utilized.

u Modifier 50 – Bilateral modifier, to indicate that the EXACT same procedure

was performed on both sides of the body.
u – Only appropriate for those areas, where you have „two‟ – Bilateral knee
replacement – Also, NOT a pricing modifier
u • Expected reimbursement is 150% but this is based on multiple procedure reduction rules
• Some payers would rather have RT and LT on separate line items
 u Modifier 53 – Discontinued procedure,
when a procedure HAD to be stopped,
due to the condition of the patient.
u Still bill the code of the procedure that
was being attempted

Additional
Work or u Modifier 22
Discontinue u – When a procedure/service took more
work, more time, or was unusual from
what was expected – May charge more,
when modifier is used
u – May not be reimbursed more by payers
u – Will expect documentation
Reduced Services

u Modifier 52
u – Reduced services
u – If for some reason, the entire service was not provided, but only a portion of it, this
modifier may be used
u – Physician should determine how much of the procedure/service was done, and how much
the fee should be reduced
u – NOT TO BE USED JUST TO REDUCE THE FEE
u Example: If a pure tone audiometry, air, CPT® 92552 is performed only on the left ear,
modifier 52 should be appended (92552-52). This procedure is a bilateral procedure and
was reduced because it was only performed on one ear.
Repeats

u Modifier 91 – FOR use on REPEAT LAB TESTS, ONLY. – If the exact same test is
done, on the same date, because they want to compare data, this is
appropriate.
u Modifier 76 – Repeat procedure by same doctor, same date. – Chest X-ray done
at 10 am, 1 pm, and 3 pm. – Modifiers needed on the 1 pm and 3 pm service.
u Modifier 77 – Repeat procedure by different doctor, same date. – Works just
like the 76 modifier but identifies that it is a different physician.
Payment Impact and Use of “Repeat
Modifiers‟
u • Patient presents to the office and two nebulizer treatments are given to try to
get the pulse oximetry measurement to be satisfactory, due to a severe asthma
attack – The second nebulizer would be reported with a modifier 76
u • An inpatient has two EKGs during the same hospital day, as first shows
abnormalities; and separate Cardiologists read the two tracings; 93010 would be
reported by the first and 93010-77 would be reported for the second cardiologists
reading
u • A blood glucose was taken in the morning and was repeated every 4 hours
throughout the day; to insure that the glucose levels were stabilizing – Each repeat
lab would be submitted with modifier 91
u • Why? Impact without?
u • It is important to identify to the payer that these are „repeat‟ services, so
that each service is separately reimbursable
u • Failure to utilize the modifiers can result in claims being denied as duplicate
procedure
 80 Surgical assistant services may be identified by
adding modifier 80 to the usual procedure
number(s).

81 Minimum surgical assistant services are identified

by adding modifier 81 to the usual procedure
number.
Assists 82 The unavailability of a qualified resident surgeon
is a prerequisite for use of modifier 82 appended to
the usual procedure code number(s)

AS Physician assistant, nurse practitioner, or clinical

nurse specialist services for assistant at surgery
Medicare Modifiers

u GA Waiver of liability statement issued as required by payer policy, individual

case
u Should be used only when a properly executed ABN is completed for the service
u GZ Item or service expected to be denied as not reasonable and necessary
u Utilized for those services in which an ABN should have been obtained, the service
is expected to be denied, but an ABN was not garnered
u GY Item or service statutorily excluded, does not meet the definition of any
Medicare benefit or for non-Medicare insurers, is not a contract benefit
E/M Modifiers

u Modifier 25 – Very common modifier

u – For use on an E/M code ONLY
u – Identifies that the E/M service is separate and significant from any other service
provided on that date
u – Documentation MUST support
u • DO NOT have to have a different diagnosis
u • DO HAVE to show that it was separate and significant
Some examples of when Not to Use the
Modifier 25
u Do not use a 25 modifier when billing for services performed during a
postoperative period if related to the previous surgery.
u Do not append modifier 25 if there is only an E/M service performed during
the office visit (no procedure done).
u Do not use a modifier 25 on any E/M on the day a “Major” (90 day global)
procedure is being performed.
u Do not append modifier 25 to an E/M service when a minimal procedure is
performed on the same day unless the level of service can be supported as
significant, separately identifiable. All procedures have “inherent” E/M
service included. See example #2.
u Patient came in for a scheduled procedure only
 u Modifier 24
u For use on an E/M service, when it is
provided during the „global surgical
package,‟ but is unrelated

u Modifier 57
E/M Modifiers u For use when an E/M service is within
24 - 48 hours of a MAJOR SURGICAL
procedure, but was the visit when it
was determined that surgery was
necessary
Modifier 59

u Modifier 59 –
u Modifier of LAST RESORT
u – Only use if an anatomical modifier can not clearly identify that it was separate
and significant
u – NOT just to be attached to bypass an edit
u – Must be DISTINCT AND SEPARATE (separate incision, separate excision, separate
time of day, etc)
u – MUST be supported by chart documentation
 u Different Session
u Different Procedure or surgery
59 Powerful u Different site or organ

Meaning u Separate incision / excision

u Separate lesion
u Separate injury or area of injury
 XE occurred during separate
encounter

XS Separate organ

X Modifiers
XP different practitioner

XU Unusual Non overlapping service

 u John undergoes an appendectomy on May 8th
and then a cholecystectomy on June 10th by
Code Review the same physician .
u What modifier would the physician add to the
cholecystectomy code?
 u 79 modifier
Rational u Unrelated Procedure by same physician during
Post operative period
Lesson 3.4 Surgery
 Broken down into subsections

Surgical package
Introduction
to Surgery Follow up care

Unlisted Procedures
Subsections

Fine Needle Aspiration 10021 – 10022

Integumentary System 10030 – 19499
Musculoskeletal System 20005 – 29999
Respiratory System 30000 – 32999
Cardiovascular System 33010 – 37799
Hemic and Lymphatic Systems 38100 – 38999
Mediastinum and Diaphragm 39000 – 39599
Digestive System 40490 – 49999
Urinary System 50010 – 53899
Male Genital System 54000 – 55899
Things to consider before coding

u Approach
u Laterality
u Previous Surgeries
u Co-surgeon or assist ?
u Diagnosis
u Gender
u Age
u Anesthesia
u Desired result
 Find Find Problem

Diagnostic Confirm Confirm Problem

Procedures

Check Check Status of the Problem

 Fix Fix problem

Therapeutic Remove Remove problem

Procedures
Go Go around problem
around
Steps to dissect operative Report

u Identify / verify date/ time of procedure

u How many surgeons and who are they ?
u Identify DX
u Review procedures performed
u Read body of op note
u Are there any known complications?
u Are their any other notes that need to be reviewed?
u Are their any quarries that need to be sent ?
u Assign DX and CPT code
Surgical Package

u By their very nature, the services to any patient are variable. The CPT codes that represent a
readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a
variety of services. In defining the specific services "included" in a given CPT surgical code,
the following services related to the surgery when furnished by the physician or other
qualified health care professional who performs the surgery are included in addition to the
operation per se:
u Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the
day before and/or day of surgery (including history and physical)
u Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
u Immediate postoperative care, including dictating operative notes, talking with the family
and other physicians or other qualified health care professionals
u Writing orders
u Evaluating the patient in the post anesthesia recovery area
u Typical postoperative follow-up care
Separate Procedure

u Some of the procedures or services listed in the CPT codebook that are commonly
carried out as an integral component of a total service or procedure have been
identified by the inclusion of the term "separate procedure." The codes designated
as "separate procedure" should not be reported in addition to the code for the
total procedure or service of which it is considered an integral component.
u However, when a procedure or service that is designated as a "separate procedure"
is carried out independently or considered to be unrelated or distinct from other
procedures/services provided at that time, it may be reported by itself, or in
addition to other procedures/services by appending modifier 59 to the specific
"separate procedure" code to indicate that the procedure is not considered to be a
component of another procedure, but is a distinct, independent procedure. This
may represent a different session, different procedure or surgery, different site or
organ system, separate incision/excision, separate lesion, or separate injury (or
area of injury in extensive injuries).
Unlisted Service or Procedure

u A service or procedure may be provided that is not listed in this edition of the CPT
codebook. When reporting such a service, the appropriate "Unlisted Procedure"
code may be used to indicate the service, identifying it by "Special Report" as
discussed in the section below. The "Unlisted Procedures" and accompanying codes
for Surgery are as follows:
u 21899 Unlisted procedure, neck or thorax
u 22899 Unlisted procedure, spine
u 22999 Unlisted procedure, abdomen, musculoskeletal system
u 23929 Unlisted procedure, shoulder
u 24999 Unlisted procedure, humerus or elbow
u 25999 Unlisted procedure, forearm or wrist
u 26989 Unlisted procedure, hands or fingers
u 27299 Unlisted procedure, pelvis or hip joint
 Day of surgery admission (before
care)

What is
included into Post operative care (after care)

surgery ?
Intraoperative (during surgery )
 u endoscopies and some minor
procedures
0 Day post u Most likely done in the office

operative u No pre-operative period

No post-operative days
package u

u Visit on day of procedure is generally

not payable as a separate service
 u Other minor procedures
u No pre-operative period
10-day post u Visit on day of the procedure is generally not payable as
a separate service
operative u Total global period is 11 days. Count the day of the
period surgery and the 10 days immediately following the day
of the surgery.
 u Major procedures
u Mostly done hospital or ASC

90-day Post- u One day pre-operative included

u Day of the procedure is generally not payable as a
operative separate service

Period u Total global period is 92 days. Count 1 day before the

day of the surgery, the day of surgery, and the 90 days
immediately following the day of surgery.
What services are included in the global
surgery payment?
u • Pre-operative visits after the decision is made to operate. For major procedures, this includes
preoperative visits the day before the day of surgery. For minor procedures, this includes pre-
operative visits the day of surgery.
u • Intra-operative services that are normally a usual and necessary part of a surgical procedure
u • All additional medical or surgical services required of the surgeon during the post-operative period
of the surgery because of complications, which do not require additional trips to the operating room
u • Follow-up visits during the post-operative period of the surgery that are related to recovery from
the surgery
u • Post-surgical pain management by the surgeon
u • Supplies, except for those identified as exclusions
u • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack,
removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion,
irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and
rectal tubes; and changes and removal of tracheostomy tubes
What services are not included in the
global surgery payment?
u • Initial consultation or evaluation of the problem by the surgeon to
determine the need for major surgeries. This is billed separately using the
modifier “-57” (Decision for Surgery). This visit may be billed separately only
for major surgical procedures.
u Services of other physicians related to the surgery, except where the surgeon
and the other physician(s) agree on the transfer of care. This agreement may
be in the form of a letter or an annotation in the discharge summary, hospital
record, or ASC record
u Visits unrelated to the diagnosis for which the surgical procedure is
performed, unless the visits occur due to complications of the surgery
u Clearly distinct surgical procedures that occur during the post-operative
period which are not re-operations or treatment for complications
u Treatment for post-operative complications requiring a return trip to the
Operating Room (OR). An OR, for this purpose, is defined as a place of
service specifically equipped and staffed for the sole purpose of performing
procedures. The term includes a cardiac catheterization suite, a laser suite,
and an endoscopy suite. It does not include a patient’s room, a minor
treatment room, a recovery room, or an intensive care unit (unless the
patient’s condition was so critical there would be insufficient time for
transportation to an OR).
u Diagnostic tests and procedures, including diagnostic radiological procedures
Physicians Who Furnish the Entire Global
Package
u Physicians who furnish the surgery and furnish all of the usual pre-and post-
operative care may bill for the global package by entering the appropriate
CPT code for the surgical procedure only. Separate billing is not allowed for
visits or other services that are included in the global package.
u When different physicians in a group practice participate in the care of the
patient, the group practice bills for the entire global package if the physicians
reassign benefits to the group. The physician who performs the surgery is
reported as the performing physician.
Physicians Who Furnish Part of a Global
Surgical Package
u More than one physician may furnish services included in the global surgical package. It is
possible that the physician who performs the surgical procedure does not furnish the follow-
up care. Payment for the postoperative, post-discharge care is split among two or more
physicians where the physicians agree on the transfer of care.
u When more than one physician furnishes services that are included in the global surgical
package, the sum of the amount approved for all physicians may not exceed what would have
been paid if a single physician provided all services, except where stated policies allow for
higher payment. For instance, when the surgeon furnishes only the surgery and a physician
other than the surgeon furnishes pre-operative and post-operative inpatient care, the
resulting combined payment may not exceed the global allowed amount.
u The surgeon and the physician furnishing the post-operative care must keep a copy of the
written transfer agreement in the beneficiary’s medical record. Where a transfer of care does
not occur, the services of another physician may either be paid separately or denied for
medical necessity reasons, depending on the circumstances of the case. Split global-care
billing does not apply to procedure codes with a 0-day postoperative period.
Multiple Surgeries

u Multiple surgeries are separate procedures performed by a single physician or

physicians in the same group practice on the same patient at the same
operative session or on the same day for which separate payment may be
allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate
in performing multiple surgeries on the same patient on the same day
u Multiple surgeries are distinguished from procedures that are components of
or incidental to a primary procedure. These intra-operative services,
incidental surgeries, or components of more major surgeries are not
separately billable.
u There may be instances in which two or more physicians each perform
distinctly different, unrelated surgeries on the same patient on the same day
(for example, in some multiple trauma cases). When this occurs, the payment
adjustment rules for multiple surgeries may not be appropriate.
Return to the OR for a Related Procedure
during the Post-Operative Period

u When treatment for complications requires a return trip to the operating

room, physicians bill the CPT code that describes the procedure(s) performed
during the return trip. If no such code exists, the physician should use the
unspecified procedure code in the correct series, which is, 47999 or 64999.
The procedure code for the original surgery is not used except when the
identical procedure is repeated.
u In addition to the CPT code, physicians report modifier “-78” (Unplanned
return to the operating or procedure room by the same physician following
initial procedure for a related procedure during the post-operative period).
u The physician may also need to indicate that another procedure was
performed during the post-operative period of the initial procedure. When
this subsequent procedure is related to the first procedure, and requires the
use of the operating room, this circumstance may be reported by adding the
modifier “-78” to the related procedure
Critical Care

u Critical care services furnished during a global surgical period for a seriously
injured or burned patient are not considered related to a surgical procedure
and may be paid separately under the following circumstances.
u Pre-operative and post-operative critical care may be paid in addition to a
global fee if: •
u The patient is critically ill and requires the constant attendance of the physician;
and
The critical care is above and beyond, and, in most instances, unrelated to the
specific anatomic injury or general surgical procedure performed.
 Induction and Removal

Incision and Drainage

Taking a
deeper look Debridement
at skin codes Excision

Destruction
Pressure Ulcers

u There are two methods for surgical treatment of bedsores: excision and
debridement. When coding a claim for surgical treatment of bedsores, your
first task is to determine which method was used by answering the question,
“Did the surgeon close the surgical wound?”
u If the surgeon documents immediate or subsequent closure of the surgical
wound, he or she performed an excision (15920-15958). This will occur only if
the wound shows no signs of infection.
u If the surgeon did not close the surgical wound, he or she performed a
debridement (11042-11047). An initial debridement may be followed by
subsequent debridement(s), and/or the wound will be allowed to heal by
secondary intent.
 Ulcer location (coccygeal, sacral,
ischial, or trochanteric)

Three Facts
If the surgeon also removed infected
to Code bone under the ulcer (ostectomy)
Excision
Method of closure (e.g., primary suture,
skin flap, or muscle/myocutaneous flap
or skin graft)
Coding Examples
 u When reporting debridement of a bedsore, code
selection depends on the depth of debridement and
Debridement total area debrided:

by u Depth to subcutaneous tissue (to the depth of blood

vessels and nerves): 11042 (first 20 sq cm) and +11045

Documented u
(each additional 20 sq cm, or part thereof)
Depth to muscle: 11043 (first 20 sq cm) and +11046 (each
Depth and additional 20 sq cm, or part thereof)
u Depth to bone: 11044 (first 20 sq cm) and +11047 (each
Area additional 20 sq cm, or part thereof)
Burns

u To determine a CPT® code for burn treatment, the medical record must document
the degree of the burn and the percentage of body area affected. For second-
degree burns, it’s important to document information on what is done during the
visit because burn coding can be used for a dressing change or debridement.
u 16000 Initial treatment, first degree burn, when no more than local
treatment is required
u 16020 Dressings and/or debridement of partial-thickness burns, initial
or subsequent; small (less than 5% total body surface area)
u 16025 Dressings and/or debridement of partial-thickness burns, initial
or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% of total
body surface area)
u 16030 Dressings and/or debridement of partial-thickness burns, initial
or subsequent; large (eg, more than 1 extremity, or greater than 10% of total body
surface area)
Deeper into burns

u CPT® code 16000 is for initial treatment only, whereas codes 16020, 16025, and
16030 are for initial and subsequent visits. CPT® does not specify a maximum
number of subsequent visits; however, a specific health plan may have a maximum
number.
u Note that 16020, 16025, and 16030 state “dressing and/or debridement.” It is
appropriate to report these codes when patients are coming in specifically for
dressing changes and the application of a burn product, such as Silvadene cream
(silver sulfadiazine).
u Burn treatment codes can be used in addition to an office visit; however, the
office visit must be medically necessary and modifier 25 Significant, separately
identifiable evaluation and management service by the same physician on the
same day of the procedure or other service must be appended to the office visit.
A separate, medically necessary office visit might occur, for instance, to prescribe
medications such as antibiotics and pain medication.
 u A wheelchair-bound patient presents to the office after
dropping a pot of boiling water onto her lap. Exam
reveals second-degree burns on both upper legs—
anterior and posterior—and on the genital area. Areas
Burn Example are dressed with Silvadene cream and bandages. Patient
is told to return in three days for possible debridement,
along with dressing change. Patient is prescribed
medication for pain management.
Rational

u To calculate the percentage of area burned, total both upper legs for 18
percent (9 percent for the upper portion of each leg) and add an additional 1
percent for the genital area. A total of 19 percent of body area is affected.
u CPT® code 16030 is appropriate in this example because these are partial
thickness burns covering more than one extremity or 10 percent of body area.
Depending on the provider’s documentation, an evaluation and management
(E/M) code in the 9920x-9921x series is also appropriate when appended with
modifier 25.
Mohs Surgery

u Mohs surgery is a precise surgical technique used to treat skin cancer. During
Mohs surgery, thin layers of cancer-containing skin are progressively removed
and examined until only cancer-free tissue remains. Mohs surgery is also
known as Mohs micrographic surgery.
u The goal of Mohs surgery is to remove as much of the skin cancer as possible,
while doing minimal damage to surrounding healthy tissue. Mohs surgery is
usually done on an outpatient basis using a local anesthetic.
u Mohs surgery is an improvement to standard surgery (local excision), which
involves removing the visible cancer and a small margin of surrounding
healthy tissue all at once. Mohs surgery allows surgeons to verify that all
cancer cells have been removed at the time of surgery. This increases the
chance of a cure and reduces the need for additional treatments or additional
surgery.
Coding Mohs Surgery

u Step 1:
Confirm the Surgeon and Pathologist Are the Same
u Mohs requires that a single physician act as both surgeon (excising tissue) and pathologist
(immediately examining excised tissue to determine clear margins). Per CPT®, “if either of
these responsibilities is delegated to another physician or qualified health care professional
who reports the services separately, the … [Mohs] codes should not be reported.”
u Step 2: Identify Location
u CPT® categorizes Mohs procedures by location:
u For lesions of the head, neck, hands, feet, and genitalia, or any location with surgery directly
involving muscle, cartilage, bone, tendon, major nerves, or vessels, look to code 17311 and
add-on code 17312.
u For lesions of the trunk, arms, and legs, select code 17313 and add-on code 17314.
u Regardless of location, you might also need to report add-on code 17315, as explained in the
Mohs Code Definitions
u Step 3:
How Many Stages?
How Many Blocks?
u Things become more complicated at this step. It helps greatly if you understand what the
surgeon/pathologist does in the procedure room.
u To spare as much healthy tissue as possible (while still eradicating cancerous cells), the
physician removes tissue in stages. The first stage is to excise the lesion. The specimen is
divided into smaller portions, called blocks.
u Per CPT®, “a tissue block … is defined as an individual tissue piece embedded in a mounting
medium for sectioning.” The location of each block within the stage is carefully mapped, and
each block is examined for cancer cells.
u Where the surgeon sees a clear margin (no malignant tissue), no further excision is necessary
beyond that block. Where the physician finds malignancy, a further stage is required to
remove additional material (this is the second stage, which is again divided into blocks). The
process continues until no further cancer cells are identified.
u Bottom line: Each time the surgeon excises material counts as a stage. Each slide resulting
from an individual stage counts as a block.
u Step 4:
Separately Consider
Each Lesion Treated
u If the surgeon/pathologist uses the Mohs technique on multiple lesions during
the same session, code for each lesion separately.
u Step 5: Put It All Together
 u The patient presents with a squamous cell carcinoma of
the nose. After prepping the patient and site, the
physician removes the carcinoma (first stage) and
divides the stages into six tissue blocks for examination.
Mohs Coding Upon microscopic examination, the physician finds
there are positive margins. He removes the positive
Example margin with another excision (second stage), which is
divided into three tissue blocks for examination. Upon
microscopic examination, the physician finds the
margins are negative.
 CPT®: 17311 (first stage)

Rational +17312 (second stage)

+17315 (six blocks)

 Where is the site of the fracture?

Was treatment open or closed?

Fractures Was manipulation performed?

Was skin or skeletal traction involved?

Was there any debridement or bone grafting

required?
 Closed treatment without
manipulation, ex. 27500

Closed Closed treatment with

manipulation, ex. 27502 –
Treatment
Closed treatment with or without
traction, ex. 27502
 Surgically opened and the fracture
visualized, and internal fixation may
be used, such as a plate/screw-type
implant, ex. 27507; or
Open
Treatment The fractured bone is opened remote
from the fracture site in order to
insert an intramedullary nail across
the fracture site, ex. 27506
 u fracture care that is neither open nor
closed. The fracture fragments are not
Percutaneous visualized, but fixation is placed across
the fracture site under fluoroscopy or
skeletal other X-ray imaging, ex. 27509.
The type of fracture does not dictate
fixation u
the type of fracture care.
 Treatment choice of most orthopedic surgical
procedures

Incisions smaller

Arthroscopy Decreased risk of infection

Quicker recovery time

Diagnostic arthroscopy always included

 29881 - Arthroscopy, knee, surgical; with
meniscectomy (medial OR lateral, including any
A deeper meniscal shaving) including
debridement/shaving of articular cartilage
(chondroplasty), same or separate compartment
look
Arthroscopy 29888 Arthroscopically aided anterior cruciate

knee codes
ligament repair/ augmentation or
reconstruction
u 29871 - ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE

29873 - ARTHROSCOPY KNEE LATERAL RELEASE

29874 - ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY

29875 - ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX

29876 - ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS

Knee Compartments

u * Medial: medial femoral condyle, medial tibial plateau, and medial meniscus

* Lateral: lateral femoral condyle, lateral tibial plateau, and lateral meniscus

* Patellofemoral: patella, patellofemoral joint, trochlear notch of the femur,

and synovial plicae The ACL is the knee’s major stabilizing ligament. It is in
the center of the knee joint and runs from the femur to the tibia through the
center of the knee. The ACL prevents the femur from sliding backwards on
the tibia. Together with the posterior cruciate ligament, the ACL stabilizes
the knee in a rotational fashion.
Heart Surgery Codes
 Approach

Cardiovascular
Location
Coding
•Coronary
•Noncoronary
Cardiac Catheterization

u Cardiac catheterization is performed to diagnose coronary artery disease,

valvular heart disease, angina (chest pain), congestive heart failure, and
certain congenital (present at birth) heart conditions. Ensure your providers
are correctly reimbursed for these diagnostic techniques by understanding
what these procedures involve and the requirements for coding them
Understanding the details

u During cardiac catheterization, a small, flexible tube called a catheter is

placed into a blood vessel in the patient’s arm, groin (upper thigh), or neck,
and advanced through the aorta into the heart. The tip of the catheter can be
placed in various parts of the heart, or advanced to the coronary arteries.
This is followed by an injection of contrast dye through the catheter into the
arteries. This test, coronary angiography, allows the physician to locate
blockages in the coronary arteries.
u The dye can show whether a waxy substance called plaque has built up inside
the coronary arteries. Fatty deposits may develop in childhood and continue
to thicken and enlarge throughout life. Atherosclerosis (a buildup of plaque in
the inner lining of an artery, causing it to narrow or become blocked) is the
most common form of coronary artery disease.
Coding options

u 93451 Right heart catheterization including measurement(s) of oxygen

saturation and cardiac output, when performed
u the catheter is advanced through the inferior or superior vena cava into the right
atrium, then into the right ventricle, pulmonary artery, and pulmonary capillary
wedge positions for pressure measures.
u 93452 Left heart catheterization including intraprocedural injection(s) for left
ventriculography, imaging supervision and interpretation, when performed
u Documentation should indicate crossing of the aortic valve, and that the pressures
are from inside the left heart chamber
u 93459 Catheter placement in coronary artery(s) for coronary angiography,
including intraprocedural injection(s) for coronary angiography, imaging
supervision and interpretation; with left heart catheterization including
intraprocedural injection(s) for left ventriculography, when performed,
catheter placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) with bypass graft angiography
u 93461 Catheter placement in coronary artery(s) for coronary angiography,
including intraprocedural injection(s) for coronary angiography, imaging
supervision and interpretation; with right and left heart catheterization
including intraprocedural injection(s) for left ventriculography, when
performed, catheter placement(s) in bypass graft(s) (internal mammary, free
arterial, venous grafts) with bypass graft angiograph
Add on codes

u Suparavalvular aortography +93567 Injection procedure during cardiac

catheterization including imaging supervision, interpretation, and report; for
supravalvular aortography (List separately in addition to code for primary
procedure) describes positioning a catheter in the aortic root and injecting
contrast. The resulting angiograms show the aortic valve, the aortic root, and
the ascending aorta.
u Pulmonary angiography +93568 Injection procedure during cardiac
catheterization including imaging supervision, interpretation, and report; for
pulmonary angiography (List separately in addition to code for primary
procedure) describes passing a catheter through the right atrium into the
right ventricle, and then into the main pulmonary artery or one of its
branches. Report this add-on code in addition to 93451, 93453, 93456, 93457,
93460, 93461, and CHD heart catheterization codes.
 Devices inserted into the body to
electrically shock the heart into
regular rhythm
Pacemaker When pacemaker is inserted ,a
/implantable pocket is made, and a generator and
lead(s)are placed inside the chest .
defibrillator
Sometimes only components of
pacemaker are replaced
 u Is this initial placement, replacement ,
upgrade or repair
u What is the approach ?
Things you u Epicardial : open chest cavity

need to know u Transvenous : accessing subclavian or

jugular vein
u Where the electrode (lead) is placed
u Atrium, ventricle or both
How the codes come into play

u 1. The subclavian vein is accessed.

u 2. Under fluoroscopy, the pacing lead(s) are inserted into the right atrium
(33206) or right ventricle (33207) for a single chamber system, or into the
right atrium and right ventricle for a dual chamber system (33208).
u 3. Lead measurement tests, including pacing and sensing thresholds and lead
impedances, are performed.
u 4. The pacemaker pulse generator (included in 33206, 33207, and 33208) is
connected to the lead(s) that are in place and a pulse generator pocket is
formed.
u 5. Additional testing of the lead(s) is completed.
u 6. The lead(s) and device are secured, and the pulse generator pocket is
closed
 Method
Vascular
Coding
Territory

Hierarchy
Territories
Iliac Artery
Femoral - Popliteal
Guidelines

u • When treating multiple territories in same leg, one primary code is used for
each territory treated.
u • Add-on codes would represent additional vessels within the iliac and
tibial/peroneal areas.
u • When more than 1 stent is placed in the same vessel, the code is reported
once.
u If there is overlap between territories, and treated with a single therapy,
report with a single code.
u When same territories of BOTH legs are treated, use modifier -59 to denote
different legs.
Hierarchy By Vessel & Procedure
 u Moderate (conscious) sedation (99143-
99145)
u All of the work of accessing and
selectively catheterizing the vessel and
traversing the lesion
u Radiological S&I directly related to the
intervention(s) performed
Embolic protection, when performed
What is
u

u Standard closure of arterial puncture

included u
site
Imaging performed to document
completion of the intervention in addition
to the intervention(s) performed
u When performed in an office, all
necessary supplies for the procedure,
including guidewires, catheters, and
angioplasty balloons
Endovascular Aneurysm Repair
What do we Code?
Exposure
AAA Coding
Noninvasive Breast Procedures
Mastectomies and Sentinel Node
Coding for Colon
Pancreatic Cancer Coding
 The appendix is a 3 1/2-inch-long narrow tube of
tissue that projects from the large intestine on
right side of the abdomen

Appendix Appendicitis occurs when the appendix becomes

blocked by stool, a foreign body like food, or
cancer. An infection in the body can make the
appendix to get blocked and swell. The pain due
to appendicitis typically begins around the navel
and then moves to the lower right abdomen
 u The first sign is a dull ache near the
navel or the upper abdomen that
progresses into a sharp pain as it moves
to the lower right abdomen
u Loss of appetite, nausea and/or
symptoms of vomiting

appendicitis u

u
Abdominal swelling
Fever
u Pain during urination
u Inability to pass gas
Approaches to Appendectomy

u Open appendectomy: The traditional approach, open appendectomy involves

removal of the appendix through an incision in the right lower abdominal wall. The
patient is usually administered general anesthesia. Care is taken to prevent
spilling of the pus from the appendix while it is being removed. The incision is
then closed with sutures and leaves a scar. In the event of rupture (peritonitis),
the abdomen will be cleaned of pus using a warm saline solution. A drain is placed
to allow the pus to drain out. The skin is packed with sterile gauze and is left open
so that the pus can drain out completely.
u Laparoscopic approach: In this approach, the surgeon uses a laparoscope to view
the patient’s internal organs on a television screen and perform the operation
through small incisions. This safe and efficient procedure offers clinical
advantages over the open method such as less post-op pain, lower risk of wound
infection, shorter hospital stay, possibly quicker return to bowel function, lower
rate of wound infection, faster return to normal activity and work, and better
aesthetic outcomes. However, in some patients, the laparoscopic method is not
feasible because of the difficulty to visualize or handle the organs effectively. In
such cases, the surgeon may convert the laparoscopic procedure to an open one.
 u 44950 Appendectomy; incidental
during intra-abdominal surgery
44955 Appendectomy; when done for
indicated purpose at time of other
Appendectomy major procedure (not as separate
procedure) (To be listed separately in
– Open addition to code for primary
procedure)
44960 Appendectomy; for ruptured
appendix with abscess or generalized
peritonitis
 u 44970 Laparoscopy, surgical,
Appendectomy appendectomy
44979 Unlisted laparoscopy procedure,
– Laparoscopic appendix
 u 44900 Incision and drainage of an
appendiceal abscess through an open
incision
44901 Drainage of appendiceal abscess
49406 Image-guided fluid collection
Other Codes drainage by catheter (e.g., abscess,
hematoma, seroma, lymphocele, cyst);
peritoneal or retroperitoneal,
percutaneous for a percutaneous
image-guided drainage by catheter of
an appendiceal abscess.
Gastric Surgery Insurance Requirements
Experimental Options
Skin Removal
Arm Procedures
Common Nail Codes
Diagnostic Endoscopy
Endoscopic Sinus Surgury
Endoscopic Coding Tips
Epistaxis (Nose Bleeds)
 u From the right femoral artery approach , the
catheter is placed in the abdominal aorta and is
then threaded into the left external iliac artery
where contrast material is injected, and
angiography is done. The surgeon then pulls
Coding Review back the catheter into the right external iliac
where contrast is injected, and angiography is
completed . The catheter is withdrawn. The
patient is diagnosed with peripheral vascular
disease
u What is the CPT codes in this case ?
 u Angiography , leg artery
u 73716-26
u Catheterization Legs
Rational u 36246-LT
u 36246-59-RT
Lesson 3.5 Radiology
 Diagnostic Radiology

Diagnostic Ultrasound

Radiologic Guidance
Radiology Breast Mammography
Sections Bone/ Joint Studies

Radiation Oncology

Nuclear Medicine
 Fluoroscopy Visualization of internal
organs in motion-real time video images

Magnetic Resonance Imaging(MRI) tube

surrounded by giant circular magnet
Radiology
Terms Tomography two-dimensional image of a
slice or section

Biometry application of a
statistical method to a biologic fact
 u Global : 100% of payment ;
combination of professional and
technical . Provider and equipment
owned by the same provider Code has
no modifier
u Professional : 40 % of payment; services
Guidelines of reading and interpretation of X-ray
by physician . Physician does not work
for provider who owns the equipment
Code has 26 modifier
u Technical :60% of payment ;Services of
technologist and use of equipment ,
film and supplies Code has TC modifier
Steps to Coding

u Be Sure Reports Meet Minimum Requirements

u To meet ACR guidelines, all dictated radiology reports must contain:
u Heading (study name)
u Number of views or sequences (name of views – what was done)
u Clinical indication (reason for exam)
u Body of report (findings)
u Impression or conclusion (synopsis of findings)
u Physician signature
u Diagnostic studies (plain films)
Separate Professional and Technical
Components
u Most radiology procedures include both a technical component and a professional
component. As a basic requirement of radiology coding, the coder must know
whether to report a technical, professional, or “global” service.
u The technical component (TC) of a service includes the provision of all equipment,
supplies, personnel, and costs related to the performance of the exam. To report
only the technical portion of a service, append modifier TC Technical component.
u There is one important exception to this rule. For services performed in a
hospital, it is assumed the hospital is billing for the technical component of each
study so hospitals are exempt from reporting modifier TC.
u The professional component of a service includes the physician work in providing a
dictated report or dictated report and supervision. To report only the physician
work portion of a service, append modifier 26 Professional component. When
applied, modifier 26 should be placed in the first designated modifier field
because it affects how the claim will be paid.
u A global service occurs when the physician both bears the expense of
equipment, supplies, etc., and provides supervision and/or prepares the
report. Global services generally take place in an office setting, where the
physician group owns the equipment and provides the dictated reports. When
reporting global services, modifiers TC and 26 are not required.
u For example, if the radiologist reads a two-view chest X-ray in the hospital,
you would report 71020 Radiologic examination, chest, 2 views, frontal and
lateral with modifier 26. If the radiologist supplies, in his own office, the
equipment on which the X-ray is performed, report 71020 without modifiers.
Report Only the Number of Views
Documented
u The number of views claimed must meet the basic requirements of the CPT®
code reported. If your department or office has a list of “standard views,” or
the number of views to be imaged on a patient, you cannot use it for coding
purposes. The medical report must state the number of views. It is the
coder’s responsibility to count the number of views and select the correct
corresponding CPT® code.
u For example, a knee exam may be reported using one of four CPT® codes. To
report 73564 Radiologic examination, knee; 4 or more views, documentation
has to substantiate four or more views. If the physician does not state “four
views,” but rather documents “AP, lateral, and both obliques,” that is also
acceptable documentation. If, however, the physician uses the phrase
multiple views of the knee, the rules state you must report the lowest-level
corresponding CPT® code for the particular study (73560 Radiologic
examination, knee; 1 or 2 views).
u This holds true for referring physician orders, too. If the views or the number
of views are not listed in the order, the radiology office cannot impose their
department standards of, for instance, four views. Instead, the radiology
department or office should contact the referring physician and ask for a new
order indicating the views he would like performed.
u Note, however, that some diagnostic studies require specific view names. For
example, if the physician dictates the number of abdomen views instead of
the precise names of the views, you must report the lowest-level code (74000
Radiologic examination, abdomen; single anteroposterior view) for that
servic
Distinguish Scout View and Contrast
Studies
u A scout view is a single supine view of the abdomen taken prior to
gastrointestinal (GI) examinations. It may be referred to as a KUB (Kidney,
Ureters, and Bladder). The physician must document that film was taken, and
he must dictate any findings from the film separately.
u During a single contrast study, the patient ingests a thin liquid barium sulfate
contrast. A double contrast upper GI study uses a thicker (heavy density)
barium sulfate and effervescent crystals taken with water. When mixed and
swallowed, the patient’s stomach fills with air or gas from the crystals. The
thicker barium coats the walls of the stomach so the physician can look for
ulcers, etc.
“Complete Exam” Documentation Must
Be Complete
u All diagnostic ultrasound examinations require permanent image
documentation. Abdomen and retroperitoneal studies have additional, strict
documentation requirements to code for a complete exam.
u A complete abdomen study (76700 Ultrasound, abdominal, real time with
image documentation; complete) requires documentation of the liver, gall
bladder, common bile ducts, pancreas, spleen, kidneys, and the upper
abdominal aorta and inferior vena cava. If any one of the required anatomy is
not documented, the study must be down-coded to a limited exam (76705
Ultrasound, abdominal, real time with image documentation; limited (eg,
single organ, quadrant, follow-up)).
Oral/Rectal Administration Doesn’t
Count as Contrast
u Whether intravenous contrast was injected determines coding for CT and MRI.
Only intravenous administration of contrast changes the code sets. Oral
and/or rectal contrast is not billable as a “with contrast” study. To report
contrast, the technique section of the dictated report must state, “with IV or
intravenous contrast.”
Don’t Forget Supplies

u Diagnostic nuclear medicine studies and PET do not include

radiopharmaceuticals. Hospitals and privately-owned nuclear medicine and
PET departments/offices should report the radiopharmaceutical kit separately
utilizing the correct supply code(s).
 u Screening : Preventive ; at zero cost to
patient ; Usually done once per 12
months depending on age
Breast u Diagnostic : Problem visit such as

Mammography follow up after a abnormal screening

mammogram

Basics u Bilateral : Both right and left breast

u Unilateral : One side only
u CAD : Computer Aided Detection
 u 77067
Screening mammography, bilateral (2-
view study of each breast), including
CAD when performed

Mammography u 77066
Diagnostic mammography, including
Coding (CAD) when performed; bilateral
u 77065
Diagnostic mammography, including
CAD when performed; unilateral.
MRI Coding
Lower Extremity
Types of Ultrasounds

u A-mode : one dimensional display reflecting the time it takes the sound eave
to reach a structure and reflect back . A is for amplitude of sound return
(echo)
u M-mode: One dimensional display of the movement structures . M stands for
motion
u B- Scan : Two-dimensional display of movement of tissue or organs and are
projected onto a black and white television screen . B stands for brightness
u Real-time scan : two-dimensional display of both the structure and the motion
of tissues and organs that indicate size ,shape and movement
 What is the CPT code for MRI of right shoulder
Code Review u
with contrast ?
Rational u 73222 Shoulder MRI with Contrast
Lesson 3.6
Pathology
 Qualitative : the drug is either
present or not
Drug
Screening Quantitative : measure the
presentence or absence AND the
amount of the drug
Drug Screening Codes

u 80305 Drug test(s), presumptive, any number of drug classes, any

number of devices or procedures; capable of being read by direct optical
observation only includes sample validation when performed, per date of
service
u 80306 read by instrument assisted direct optical observation, includes
sample validation when performed, per date of service
u 80307 Drug test(s), presumptive, any number of drug classes, any
number of devices or procedures, by instrument chemistry analyzers,
chromatography, and mass spectrometry either with or without
chromatography, includes sample validation when performed, per date of
service
Clinical Pathology

u Specimen : Sample of tissue from a suspect area

u Block : frozen piece of a specimen
u Section : Slice of the frozen block
Surgical Pathology Codes

u Level 1 : 88300 identifies specimens that normally don’t need to be viewed

under microscope . Minimal probability of disease
u Level 2 : 88302 tissues that are usually considered normal but removed for
other reasons such as fallopian tubes for sterilization
u Level 3 88304 Low probability of disease such as gallbladder removal
u Level 4 88305 higher probability of malignancy or disease such as uterus
being removed for prolapse
u Level 5 88307 More complex pathology
u Level 6 88309 neoplastic tissue or very involved specimens , such as resection
of colon
 u The specimen is a portion of the left lung . The
Code Review procedure was a left lower lobe segmental
resection . What is the CPT code ?
Rational u 88309 Pathology , surgical Level VI
Lesson 3.7 Female Genital / OB Care
 57452-Endoscopic cervical
examination (colposcopy)

57454-with biopsy(s) of the cervix and

endocervical curettage
Biopsy-
Cervical 57455-with biopsy(s) of the cervix

57456-with endocervical curettage

u 57460-with loop electrode biopsy(s) of the cervix • Is not a loop excision •
Does not include removal of a portion of the endocervix or removal of the
transformation zone (area at risk for cervical cancer); therefore is not a
conization
u 57461-with loop electrode conization of the cervix • Is a loop excision •
Excision of a specimen of a large discrete lesion identified in the exocervix
tissue from patients with abnormal Pap smears results • Endocervical
curettage (57456) is included and not separately reported
• 56605/56606-Biopsy of vulva or perineum (separate
procedure); 1 lesion •

56821-Colposcopy (examination of the cervix and

vagina) and Biopsy of vulva – Colposcopy is used to
evaluate patients with symptoms or physical findings
that suggest the presence of vulvar HPV, vulvar
intraepithelial neoplasia or vulvar malignancy

• 57100 Biopsy of vaginal mucosa; simple

• 57105 extensive, requiring suture (including cysts

Endoscopic Colposcopy

u 57420 Colposcopy of the entire vagina, with cervix if present;

u 57421 Colposcopy of the entire vagina, with cervix if present; with biopsies –
Reported for primary emphasis on vaginal examination – Includes evaluation
of all vaginal surfaces with various degrees of magnification – Includes
examination of the cervix
u 57461 loop excision procedure (conization) used to obtain a large tissue
specimen from patients with abnormal Pap smears where a discrete
colposcopic lesion is identified in the exocervixand can include: –
Endocervical curettage (Do not report code with 57456) – Removal of portion
of endocervix – Removal of transformation zon
Paravaginal Defect Repairs

u For treatment of:

u Anterior Repairs Cystocele/vesicocele--hernial protrusion of the urinary
bladder, usually through the vaginal wall.
u Posterior Repairs Rectocele/proctocele--hernial protrusion of part of the
rectum into the vagina
u Enterocele--a hernia containing intestine
 57423 -Paravaginal defect repair (including repair of
cystocele, if performed), laparoscopic approach

Colporraphy- 57240-Anterior colporrhaphy, repair of cystocele with

or without repair of urethrocele
Cystocele 57284 -Paravaginal defect repair (including repair of
cystocele, if performed); open abdominal approach
Repai
57285 -Paravaginal defect repair (including repair of
cystocele, if performed); vaginal approach
Colporraphy-Enterocele Repair

u 57265 -Combined anteroposterior colporrhaphy; with enterocele repair (57240

+ 57250 + 57268)
u 57268-Repair of enterocele, vaginal approach (separate procedure) -includes
suspension of the vaginal posterior fornix
u 57270 -Repair of enterocele, abdominal approach (separate procedure) –
includes approximation and reinforcement of weakened rectovaginal fascia
 u 58100 Endometrial sampling (biopsy) with or without
endocervical sampling (biopsy), without cervical
dilation, any method (separate procedure)

Endometrial u +58110 Endometrial sampling (biopsy) performed in

conjunction with colposcopy (List separately in addition
Biopsy to code for primary procedure) • Use with colposcopy
codes –sampling done via curette –
u 57420, 57421 endoscopic colposcopy –
u 57452-57461 endoscopic cervical colposcop
Dilation and Curettage

u 58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)

u 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or
polypectomy, with or without D & C (via scope) Hysteroscopy includes Exam
of: – entire endometrial cavity (anterior, posterior, fundal, lateral walls) –
endocervical canal
Vulvectomy
56620-5660
IUD
 u 58559 Hysteroscopy, surgical; with lysis of intrauterine
adhesions (any method) Includes: Use of resectoscope
for lysis via wire loop electrode, scissors, or laser
u 58561with removal of leiomyomata Includes: Use of
Endometrial resectoscope for myomectomy (single or multiple) via
scissors, wire loop electrode, or laser
Biopsy u 58563 with endometrial ablation (eg, endometrial
resection, electrosurgical ablation, thermoablation)
Includes: Initial curettage of entire endometrial cavity
Coagulation of the entire cavity via rollerball,
resectoscope, or laser
Myomectomy

u Open (Abdominal)
u 58140 (1-4 and less than 250 gm)
u 58146 (5 or more and/or greater than 250 gm)
u Vaginal
u 58145 (1-4 and less than 250 gm or less)
u Laparoscopic •
u 58545 (1-4 and less than 250 gm or less)

u 58546 (5 or more and/or greater than 250 gm)

Hysterectomy
Salpingectomy

u Open approach
u 58700 Salpingectomy, complete or partial, unilateral or bilateral
u 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral
u Laparoscopic
u 58661 Removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
(separation of the adnexal structures from the round ligament and other adhesions or attachments
are divided)

u 58670 Fulguration of oviducts (with or without transection) (coagulation of the midpoint of each
tube)
Maternity Care and Delivery

u Global services –Normally provided Uncomplicated care

u Antepartum care
u Delivery
u Postpartum care
 u • All initial and subsequent history,
u • Physical examinations
u • Recording of weight and blood pressures,
Antepartum u • Fetal heart tones,

Care u • Routine chemical urinalysis, and

u • Monthly visits up to 28 weeks gestation,
u • Biweekly visits to 36 weeks gestation, and
Weekly visits until delivery
Delivery Service

u Admission to the hospital,

u • Admission history and physical
u • Management of uncomplicated labor,
u • Vaginal delivery (with or without episiotomy, with or without forceps), or
u • Cesarean delivery.
 u Vaginal
u 59400 –routine (including episiotomy, forceps) (global)

Delivery u 59409 –delivery only

u 59410 –postpartum care
u 59412-External cephalic version (report in addition)
Cesarean u 59510-routine (global)

Delivery u 59514-delivery only

u 59515-postpartum car
VBAC

u Successful vaginal delivery after previous cesarean

u 59610-59614
u Unsuccessful vaginal delivery attempt with subsequent cesarean after
previous cesarean
u 59618-59622
 u Includes all inpatient and outpatient
services including:
u hospital and office visits following
delivery.
u Immediate post partum care
Postpartum u Post partum orders specific to the
patient, as well as a patient specific
Care dictation of the delivery events,
u • Completion of hospital and state
specific birth records
u • Examination of patient to secure
stability of mother and child with
necessary communication with patient
A la Carte Delivery Services

u All or part of the antepartum and/or postpartum patient care is provided

except delivery due to termination of pregnancy by abortion or referral to
another physician
u 59409 Vaginal delivery only
u 59425 Antepartum care only; 4-6 visits
u 59426 Antepartum care only; 7 or more visits
u 59430 Postpartum care only 59514 Cesarean delivery only;
u 59612 Vaginal delivery only, following previous csection
 Excessive antepartum visits if
more than 13-report additional
Services Not visits with Evaluation and
Management codes
Included in
Global Treatment of conditions unrelated
to pregnancy (eg, respiratory tract
Services or urinary tract infections) Report
additional E/M services
 u Both vaginal

Multiple Birth u Baby A 59400

u Baby B 59409-51
Reporting u One vaginal /one cesarean
u Baby B 59510
u Baby A 59409-51
 What is the CPT code for laparoscopic
Code Review u
salpingectomy for tubal ectopic pregnancy ?
 59151 Laparoscopy ,ectopic pregnancy with
Rational u
salpingectomy and or oophorectomy
Lesson 3.8 Physical Medicine
Vaccine Coding

u CPT Codes reported are:

99393 - Preventive service
90649 - HPV vaccine
90460 - Administration first component (1 unit)
90715 - Tdap vaccine
90460 - Administration first component (1 unit)
90461 - 2 additional components (2 units)
90660 - Influenza vaccine, live, for intranasal use
90460 - Administration first component (1 unit)
Psychiatric

u The psychiatry CPT codes addressed are:

u New Patient, Outpatient In-Office Services:
u 99201, 99202, 99203, 99204, 99205;
u Established Patient, Outpatient In-Office Services:
u 99211, 99212, 99213, 99214, 99215;
u New or Established Patient, Outpatient Consultation:
u 99241, 99242, 99243, 99244, 99245;
u Inpatient Consultations:
u 99251, 99252, 99253, 99254, 99255
Psychotherapy
Dialysis

u 90935 – Hemodialysis procedure with single provider evaluation – This code is

used to report a single treatment that includes physician evaluation
u 90937 – Hemodialysis procedure requiring repeated evaluations, with or
without substantial revision of dialysis prescription – This code is used to
report services provided by the physician during the patient’s hemodialysis
treatment
u 90940 Hemodialysis access flow study to determine blood flow in grafts and
arteriovenous fistulae by an indicator method
 u • 97010 hot or cold packs
u • 97012 traction, mechanical
u • 97014 elec stim (unattended) [G0283]

PT/ OT Codes u • 97018 paraffin bath

u • 97022 whirlpool
u • 97024 diathermy
u • 97026 infrared
u • 97110 Therapeutic exercises
u • 97112 Neuromuscular re-education
u • 97113 Aquatic therapy
u • 97116 Gait training
u • 97124 Massage
u • 97139 Unlisted therapeutic procedures
u • 97140 Manual therapy
u • 97150 Therapeutic procedures, group
u • 97530 Therapeutic activities
 u Time dependent code rules (CMS):
u • First unit is 15 (8-22) minutes
u • Second unit is 30 (23-37) minutes
PT/ OT Time u • Have patient use egg timers and
initial in chart
u • Two services must exceed 22 minutes
to bill 2 units, even if different codes
Time Documentation

u • Total timed code treatment minutes and total treatment time in minutes.
u • Total treatment time includes the minutes for timed code treatment and
untimed code treatment.
u • Total treatment time does not include time for services that are not
billable (e.g., rest periods).
u • For Medicare purposes, it is not required that unbilled services that are not
part of the total treatment minutes be recorded, although they may be
included voluntarily to provide an accurate description of the treatment,
show consistency with the plan, or comply with state or local policies.
Chiropractic Manipulation

u CPT Code 98940 Chiropractic manipulative treatment (CMT); Spinal, 1-2

regions
u CPT Code 98941 Chiropractic manipulative treatment (CMT); Spinal, 3-4
regions
u CPT Code 98942 Chiropractic manipulative treatment (CMT); Spinal, 5 regions
u CPT Code 98943 Chiropractic manipulative treatment (CMT); Extraspinal, 1 or
more regions
Infusion Documentation

u The diagnosis for the service

u • Medical Necessity
u • The drug(s) or substance(s) provided
u • The route (e.g., injection, push, infusion) into the patient • Flush or
clearing of line(s)between sequential administrations
u • Clarify drugs mixed in single bag or administered simultaneously
u • The length of time for infusions, according to start and stop times
u • Patient reactions, Nursing Action, Restart /stop times • Instructions given
to patient
Basic Infusion Guidelines

u • Only one initial service may be coded per encounter.

u • A bolus of prepackaged fluids or other specific medications should be
coded as therapeutic
u • Start and stop times determine how to calculate the hour(s).
u • The additional hour can be included only when the infusion has lasted
more than 30 minutes into the second hour. •
u The fluid used to administer drug(s) is incidental hydration and is not
separately payable.
Start and Stop Times

1st hour initial hour 2nd hour

16-90 minutes (exception for hydration 31- 91-150 minutes = 1 unit of additional
90 min) subsequent service code
3rd hour
• 151-210 minutes = 2 units of additional
subsequent service code
Infusion Codes - Hydration

u 96360© IV infusion therapy, 1 hour

u 96361© IV infusion, additional hour
u

u J7030 Infusion, normal saline solution 1,000 cc

u J7040 Infusion, normal saline solution, sterile, 50 ml
u J7042 5% dextrose/normal saline 500 ml
u J7050 Infusion, normal saline solution 250 cc
u J7060 5% dextrose/water 500 ml
u J7070 Infusion, D5W, 1,000 cc
u J7120 Ringer’s lactate, infusion, up to 1,000 cc
Injection

• last 15 minutes or less

• Can be therapeutic, chemo, or immunizations

• Includes IV Push, IM, SQ, IA

• Document type, site, duration, substance, purpose, tolerance

• Code per injection, not per medication

• Example CPT codes: 96411, 96372, 96374,96375, 96376

EKG
EKG Tracing
Holter Monitors
Preventive Medicine
Preventive Care
Preventive Exam
Preventive Care and Counceling
Preventive Counceling
Preventive care Coverage
Diagnosis Considerations
Medicare Benefits
AWV (Annual Wellness Visit)
Requirements of AWV
Initial AWV Documentation G0438
G0439 Subsequent AWV
Medicare Screening Services

u Requires ABN
u GYN covers every 2 years for low risk patients
u Annually for high risk patients
u G0101
u Q0091
Medicare Screening Pelvic Exam
 Obtaining the
Medicare pap
Screening
Q0091 Deductible and
copay waived
Medicare High Risk Criteria
MISC Preventive Codes
Eye Vision Field Testing
92250 Fundus Photography
 u John does to the chiropractor due to low back
pain and neck pain. The chiropractor provides a
Code Review chiropractic alignment to two spinal regions .
What code would be billed ?
 98940 Chiropractic treatment spinal,
Rational u
extraspinal 1-2 regions
Lesson 3.9 HCPCS
What is it ?

u HCPCS, often pronounced "hick picks", is an acronym for Healthcare Common

Procedure Coding System (HCPCS) - one of the standardized code systems
necessary for Medicare and other health insurance providers to submit
healthcare claims in a consistent and orderly manner. This system comprises
two medical code sets, HCPCS Level I and HCPCS Level II.
u HCPCS Level I consists of the Current Procedural Terminology (CPT®) code set
and is used to submit medical claims to payers for procedures and services
performed by physicians, nonphysician practitioners, hospitals, laboratories,
and outpatient facilities.
u HCPCS Level II is the national procedure code set for healthcare practitioners,
providers, and medical equipment suppliers when filing health plan claims for
medical devices, supplies, medications, transportation services, and other
items and services.
 J9355-Injection, trastuzumab, excludes biosimilar,
10 mg

G9631-Patient sustained ureter injury at the time of

surgery or discovered subsequently up to 30 days
HCPCS Level post-surgery

II codes C1823-Generator, neurostimulator (implantable),

non-rechargeable, with transvenous sensing and
stimulation leads

V2599-Contact lens, other type

TYPES OF TEMPORARY HCPCS LEVEL II
CODES
u 1. C codes are required under the Medicare Outpatient Prospective Payment System (OPPS) for use by
hospitals to report drugs, biologicals, magnetic resonance angiography (MRA), and devices. Other facilities
may report C codes at their discretion.
u 2. G codes are national codes assigned by CMS to identify professional healthcare procedures and services
that may not have assigned CPT® codes.
u 3. H codes establish unique HCPCS temporary codes to identify mental health services for state Medicaid
agencies mandated by state law to establish separate codes for those services.
u 4. K codes are used by Durable Medical Equipment Medicare Administrative Contractors (DME MACs). DME
MACs develop new K codes when existing national codes for supplies and certain product categories do not
include the codes needed to implement a DME MAC medical review policy.
u 5. Q codes identify services that would not be given a CPT® code or are not identified by national Level II
HCPCS codes but are needed by CMS to facilitate claims processing. Such services include drugs, biologicals,
and other types of medical equipment or services.
u 6. S codes meet various business needs of commercial and Medicaid agency health plans. HCPCS S codes
report drugs, services, and supplies for which national codes do not exist but are needed to implement
policies, programs, or support claims processing. They are not payable by Medicare.
u 7. T codes are designated for use by Medicaid agencies to establish codes for items for which there are no
permanent national codes, and for which codes are necessary to meet Medicaid program operating needs. T
codes are not used by Medicare but may be used by commercial health plans.
J0278 Injection, amikacin sulfate, 100 mg

J0280 Injection, aminophyllin, up to 250 mg

J0282 Injection, amiodarone hydrochloride, 30 mg

J0285 Injection, amphotericin b, 50 mg

J0287 Injection, amphotericin b lipid complex, 10 mg

J0288 Injection, amphotericin b cholesteryl sulfate

complex, 10 mg

Injection, amphotericin b liposome, 10 mg

J Codes
J0289

J0290 Injection, ampicillin sodium, 500 mg

J0291 Injection, plazomicin, 5 mg

J0295 Injection, ampicillin sodium/sulbactam sodium, per

1.5 gm

J0300 Injection, amobarbital, up to 125 mg

M1000 Pain screened as moderate to severe
M1001 Plan of care to address moderate to severe pain documented on
or before the date of the second visit with a clinician
M1002 Plan of care for moderate to severe pain not documented on or
before the date of the second visit with a clinician, reason not
given
M1003 Tb screening performed and results interpreted within twelve
months prior to initiation of first-time biologic disease modifying
anti-rheumatic drug therapy for ra
M1004 Documentation of medical reason for not screening for tb or
interpreting results (i.e., patient positive for tb and
documentation of past treatment; patient who has recently

M1005
completed a course of anti-tb therapy)

Tb screening not performed or results not interpreted, reason

not given
M Codes
M1006 Disease activity not assessed, reason not given
M1007 >=50% of total number of a patient's outpatient ra encounters
assessed
M1008 <50% of total number of a patient's outpatient ra encounters
assessed
A Codes

A0998 Ambulance response and treatment, no

transport
A0999 Unlisted ambulance service
A4206 Syringe with needle, sterile, 1 cc or less,
each
A4207 Syringe with needle, sterile 2 cc, each
A4208 Syringe with needle, sterile 3 cc, each
A4209 Syringe with needle, sterile 5 cc or
greater, each
A4210 Needle-free injection device, each
A4211 Supplies for self-administered injections
DME
 u In general terms—with some exceptions—medical coders
use the three code sets when submitting medical claims
to report the following:
Bringing it all u CPT® codes: what the provider did.

together u HCPCS codes: what the provider used.

u ICD : why the provider 'did' and 'used'.
 u True or False :
Open Book G codes are assigned by the WHO for healthcare
services that may not have CPT codes.
Discovery
Rational u Answer : False G codes are assigned by CMS
Lesson 3.10
Diving into Coding
 u Code the following in ICD 10:
ICD Practice #1 u Acute renal failure and acute
respiratory failure due to sepsis
 A41.9 Sepsis ,generalized

R65.20 Sepsis severe

Rational
N17.9 Failure, renal, acute

J96.00 Failure, respiration

,respiratory, acute
What ICD 11 would look like
 u Code the following in ICD 10:
u Patient with known Hepatitis B seen in the clinic
ICD Practice #2 complaining of joint pain, loss of appetite, nausea and
vomiting, and weakness and fatigue. He is admitted to
the hospital for severe dehydration
 E86.0 Dehydration
Rational
B19.10 Hepatitis B
 Lung abscess due to MRSA (methicillin
ICD Practice #3 u
resistant staphylococcus aureus)
 J85.2 Abscess,
lungs
Rational
B95.62 Infection, bacterial
, as cause of disease
classified elsewhere MRSA
 u Patient presents for follow up exam
ICD Practice #4 following reconstructive surgery to
repair hypospadias
 Z09 Examination, follow up (routine) following surgery

Rational Q54.9 Hypospadias

We code Hypospadias because this follow up exam is part of

the episode of care in which surgery corrected the
hypospadias, the hypospadias is still coded as if it is an active
disease . Once all treatment for the surgery is complete , a
history of hypospadias would be reported instead
ICD Practice #5

u Patient seen for cellulitis of left lower leg. He is a type 2 diabetic controlled
with oral medications. The cellulitis has evaluated his blood glucose and the
physician elects to treat with sliding scale insulin regime.
 L03.116Cellulitis, lower limb

Rational
E11.65 Diabetes, type 2, with
hyperglycemia
ICD Practice #6

u Patient with anemia due to prostate cancer.

Rational

u ICD 10
u C61 Neoplasm ,prostate ,malignant primary
u D63.0 Anemia , in neoplastic disease
u ICD 11
u 2C82.Z Malignant neoplasms of prostate, unspecified
u 3A71.0 Anemia in neoplastic disease
ICD Practice #7

u Meningitis caused by measles.

Rational

u ICD 10 :
u B05.1 Meningitis , in [due to ], measles
u ICD 11 :
u 1F03.2 Measles complicated by meningitis
ICD Practice #8

u Inability to swallow.
Rational

u ICD 10
u R37.0 Aphagia
u ICD 11
u MD93 Dysphagia or
u DD90.1 Functional swallowing disorder
ICD Practice #9

u COPD with emphysema

Rational

u ICD 10 :
u J44.9 Disease, lung, obstructive , with emphysema
u ICD 11 :
u CA22 Chronic obstructive pulmonary disease
u CA21 Emphysema
CPT Practice #1

u Initial observation of a patient was for upper abdominal pain, dizziness and
anemia. A comprehensive history and examination was performed . Moderate
complexity decision making was conducted to admit the patient to
observation to treat and rule out causes of patient's anemia . What is the CPT
code?
 99219 evaluation and management, hospital services
Rational
u
observation care
CPT Practice #2

u A 3-year boy with bacterial pneumonia is hospitalized and has had 5 days of
antibiotic therapy. Today the child developed a fever of 101 degrees with a
mild rash on his torso . In a subsequent hospital visit , the attending physician
performed a problem focused history and examination . The MDM complexity
was low. What CPT code would you bill ?
 99231 Hospital Services , Inpatient
Rational u
Services, Subsequent care
CPT Practice #3

u A male patient presents to the emergency department with a wrist sprain

sustained in a softball game when the patient slid into home, striking his hand
on home plate. The patient is in apparent pain with a swollen wrist, which he
is unable to flex. An expanded problem focused history and physical
examination are done. Radiographs show a Colles’ fracture of the distal radius
. The MDM complexity was low . What is the CPT ?
 99282 Established patient
Rational u
,emergency department services
CPT Practice #4

u A 34-year-old female was sent by her family practice physician for an office
consultation with a gynecologist . The patient has been suffering with
moderate pelvic pain and heavy sensation in her lower pelvis. In a detailed
history, the gynecologist noted the location, severity and duration of her
pelvic pain and related symptoms. In the review of systems , the paid had
positive findings related to her gastrointestinal, genitourinary and endocrine
body system . The physician noted that her medical history was
noncontributory to the present problem . The detailed physical examination
centered on her gastrointestinal and genitourinary systems with a complete
pelvic exam . The physician ordered laboratory tests and a pelvic ultrasound
to determine uterine fibroids, endo metritis or other internal gynecological
pathology . The MDM complexity was moderate . What is the CPT ?
 99243 Consultation , office and or
Rational u
other outpatient
CPT Practice #5

u History : This 16-year-old female is seen today after falling off the curb and
twisting her right ankle. She is normally a patient of Dr Smith, who is out of
town this week. (both physicians are the same specialty and clinic) She states
that she has pain surrounding the entire foot and ankle. Seems unable or
unwilling to bear weight (problem focused history)
u Examination\: Ankle and foot examined. Foot is warm to touch. Some swelling
and bruising noted around the lateral aspect of the ankle . X-ray is negative
for fracture (problem focused exam)
u Impression : Sprained right ankle (MDM complexity straightforward)
u Plan : Elevation , ice to affected area. Weight bearing as tolerated. Return to
clinic prn
Rational u 99212 Evaluation and Management
A deeper look into documentation

u Exam
u VS: T 99.8°F, otherwise normal.
u Mild jaundice noted.
u Abdomen distended and tender across upper abdomen3. Guarding is present. Bowel sounds
diminished in all four quadrants.
u Oral mucosa dry, chapped lips, decreased skin turgor
u Assessment and Plan
u Dehydration and suspected acute pancreatitis.
u Admit to the hospital. Orders written and sent to on-call hospitalist.
u 1L IV NS started in office. Blood drawn for labs.
u Recommend behavioral health counseling for substance abuse assessment and possible
treatment.
u Patient’s wife notified of plan; she will transport to hospital by private vehicle.
Clinical Documentation

u Describe the pain as specifically as possible based on location.

u When addressing alcohol related disorders you should distinguish alcohol use,
alcohol abuse, and alcohol dependence. ICD-10-CM has changed the
terminology and the parameters for coding substance abuse disorders. In this
encounter note, as the acute pancreatitis is suspected, and the patient’s
alcohol intake status is stated, the associated alcoholism code is listed.
u Abdominal tenderness may be coded. Ideally the documentation should
include right or left upper quadrant and indicate if there is rebound in order
to identify a more specific code. Currently the ICD-10 code would be R10.819,
Abdominal tenderness, unspecified site as the documentation is insufficient in
laterality and specificity.
Scenario 1: Abdominal Pain

u Chief Complaint
u “My stomach hurts and I feel full of gas.”
u History
u 47-year-old male with mid-abdominal epigastric pain1, associated with severe
nausea & vomiting; unable to keep down any food or liquid. Pain has become
“severe” and constant.
u Has had an estimated 13-pound weight loss over the past month.
u Patient reports eating 12 sausages at the Sunday church breakfast five days
ago which he believes initiated his symptoms.
u Patient admits to a history of alcohol dependence2. Consuming 5 – 6 beers per
day now, down from 10 – 12 per day 6 months ago. States that he has nausea
and sweating with “the shakes” when he does not drink.
Scenario 1 ICD 10 Coding

u R10.13 Epigastric pain

R10.819 Abdominal tenderness, unspecified site
R17 Unspecified jaundice
E86.0 Dehydration
F10.20 Alcohol dependence, uncomplicated
Scenario 1 ICD 11 Coding

u MD81.10 epigastric pain

u MD81.0 Abdominal tenderness, unspecified site
u ME10.1 Unspecified jaundice
u 5C70.0 Dehydration
u 6C40.20 Alcohol dependence, continuous on daily basis
Scenario 2 Cervical Disc Disease

u Chief Complaint
u “My neck hurts and I have a tingling pain sensation going down my right arm.”
u History
u Patient is a 68-year-old male with history of neck pain that has been
worsening over the last two years. Recently, he has experienced some
numbness and a painful tingling sensation in his right arm going down to his
thumb. No other symptoms or pertinent medical history.
u Review of Systems, Physical Exam, Laboratory Tests
u Review of systems is negative except for the neck pain and sensations in his
right arm described above. No history of acute injury to neck or arm.
u Physical exam is normal except for neurological exam of the right upper
extremity, which reveals slight decrease to sensation in the thumb and
forefinger region of the hand in the C6 nerve root distribution. No evidence of
weakness in the muscles of the arm or hand.
u MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral
protrusion of disc material. No other abnormalities noted.
u Assessment and Plan
u Cervical transforaminal injection at C5-6
Clinical Documentation

u Subcategory M50.1 describes cervical disc disorders. M50.12 Cervical disc

disease that includes degeneration of the disc as a combination code. The 5th
character differentiates various regions of the cervical spine (high cervical
C2-3 and C3-4; mid-cervical C4-5, C5-6, and C6-7; cervicothoracic C7-T1 and
the associated radiculopathies at each level). This is a combination code that
includes the disc degeneration and radiculopathy
ICD-10-CM Diagnosis Codes

u M50.12 Cervical disc disorder with radiculopathy, mid-cervical region

ICD 11 Code

u 8B93.Y Cervical disc disorder with radiculopathy

Scenario 3

u 19-year-old female presents with concerns about STI and wants to be tested
u ¤ General exam with focus on clinical manifestations of STI
u ¤ HIV counseling and testing ~15 minutes
u ¤ Contraceptive counseling
u ¤ Laboratory tests for chlamydia and gonorrhea, HIV Rapid Test ¤
Established patient – does not need an annual
u ¨ What are the CPT codes for this visit?
Scenario 3 Rational

u Procedures ¤ 9921x Established patient evaluation and management (last

digit assigned based on clinical notes and level of service provided)
u ¤ 99401 HIV counseling
u 86703 HIV-1/2 (or CPT for test administered if different)
u ¤ 87491 Chlamydia trachomatis, amplified probe technique
u ¤ 87591 Neisseria gonorrhoeae, amplified probe technique
Scenario 4

u 19-year-old female presents for IUD insertion

u ¤ Decision was made at her previous exam 2 weeks ago
u ¤ Pregnancy test given – results negative
u ¤ IUD inserted without difficulty
u

u ¨ What are the diagnoses and CPT codes for this visit?
Scenario 4

u Diagnoses ICD 10 ¤ (Primary) Z30.430 Insertion of intrauterine

contraceptive device Z32.02 Pregnancy exam or test, negative result
u ICD 11 QA21.2 Insertion of IUD and QA40
u ¨ Procedure Codes ¤ 58300 Insertion of IUD
u ¤ 81025 UPT
u ¤ J7300 Intrauterine copper contraceptive or J7302 Levonorgestrel-
releasing intrauterine contraceptive system, with Z30.430 Insertion of
intrauterine contraceptive device
u ¨ Reminder: Only Bill an E/M with Modifier 25 if it is separate and distinct
from the insertion procedure
Scenario 5

u A mother brings her 4-year-old son to the doctor because she found a lump at
the front of his neck. After an ultrasound and a blood test, the doctor
diagnoses a thyroglossal duct cyst and recommends surgery. On the day of
surgery, the surgeon tells the mother that he will perform a Sistrunk
operation.
u Code the diagnosis and procedure codes on the day of surgery.
Scenario 5 Rational

u ICD 10 Q89.2 Congenital malformations of other endocrine glands

u ICD 11 DA05.Y Other specified cysts of oral or facial-neck region

u CPT 60200 Excision Procedures on the Thyroid Gland

Scenario 6

u A 36-year-old patient is admitted through the Emergency Department with

epigastric abdominal pain and diarrhea. An ultrasound shows calculus in her
gallbladder but no obstruction. The doctor diagnoses the pain as cholelithiasis
with acute cholecystitis. The doctor performs a laparoscopic cholecystectomy
the next day.
u Code the diagnoses and procedure for this scenario.
Scenario 6 Rational

u ICD 10 K80.00 Calculus of gallbladder with acute cholecystitis without

obstruction
u ICD 11 DC11.0
u CPT 47562 Laparoscopic Procedures on the Biliary Tract
Scenario 7

u A 64-year-old male patient arrives at the hospital with acute renal failure
(unspecified). The IV team is unable to gain access, so the surgical resident is
called to obtain vascular access. The resident places a non-tunneled centrally
inserted central venous catheter in the patient's right subclavian vein.
u Code the diagnosis and procedure for this scenario
 u ICD 10 N17.9
u ICD 11 GB60.7
Scenario 7 u CPT 36556
Scenario 8

u A 47-year-old patient who has long-standing myasthenia gravis has become a

candidate for thymectomy because of an exacerbation of her illness. On the
day of surgery, the surgeon uses a transthoracic approach to perform a total
thymectomy, but he does not perform a mediastinal dissection.
u Code the diagnosis and procedure codes for this scenario.
 ICD 10 G70.01
Scenario 8 u

u ICD 11 8C60.Z
Rational u CPT 60521
Scenario 9 What is the CPT Code(s)
Scenario 9 u CPT G0101-GA , Q0091 -GA
Rational
Scenario 10
What is the
CPT Code?
27792-LT
Scenario 11
What is the CPT
Code(s)?
11403, 11402-51
Scenario 12
What is the CPT
code(s) ?
Scenario 13
What codes did
you come up
with ?
u ICD 10 : K40.9
u ICD.11: DD51&XK9K(Right)
u CPT 49505-RT
CPC Practice
Questions
 u This condition occurs when the lining
Exam Practice of the esophagus becomes inflamed.
It is generally caused by an infection
Question or irritation of the esophagus. What is
the name of this condition?
CPC Exam Answers

u 12004, 12011-51, 12034-51

u 99215-57 , 81025,76801
u Esophagitis
u 11400,11401(x2), 11402, 11602(x2)
u Multiple leads
u Ear drum
u 36415
u 01990-P6
u 52010, 74440
u Enlargement of
u When they begin prepping patient and no longer in post operative care
CPC Practice Question 1

u -Which gland not only produces thymosin, but also stimulates T-cells to
produce the hormones needed to regulate immune system function? This
gland is composed of two lobes that are identical. This gland usually
shrinks after puberty when it is replaced by fat, but still continues to
produce T-cells.
Mark one answer:
A. Thymus
B. Thyroid
C. Parathyroid
D. Adrenal
CPC Practice Exam Question 2

u The physician performed a partial Nissen Fundoplasty via a lower thoracic

incision. What is the correct code for this procedure?
Mark one answer:
A. 43327
B. 43328
C. 43325
D. 43331
CPC Practice Exam Question 3

u Q:3-Spongy bone tissue:

Mark one answer:
A. Is found along the shafts of hard bones
B. Is found along the outer layer of bones
C. Makes up the top edges of long bones
D. Makes up the insides of bones
CPC Practice Exam Question 4

u A 17-year-old patient presented to the orthopedist office after having

fallen off his skateboard. He suffered a closed fracture to the left tibia and
fibula as well as a severe sprain to the right wrist. The patient was in
severe pain, so an anesthesiologist administered anesthesia to him, while
the physician manipulated the fractures back into place and applied the
cast to the lower left leg. What are the appropriate anesthesia code(s)?
Mark one answer:
A. 01820, 01490
B. 01462
C. 01480, 01820
D. 01490
CPC Practice Exam Question 5

u -When a CPT code has the words “separate procedure” in parenthesis

after the code description, you:
Mark one answer:
A. Do not use this code if it is listed as a separate procedure
B. Code for all other elements of the procedure except this one
C. Only code for this procedure if it was the only thing performed
D. Code for this procedure, even if it was not performed
CPC Practice Exam Question 6

u The patient presents to the gynecologist's office complaining of stress

incontinence. The GYN decides to perform a sling operation using
synthetic materials to reinforce the patient's muscles and allow for
additional urinary control. This procedure is performed laparoscopically in
order to be less invasive. What is the correct code for this procedure?
Mark one answer:
A. 57288
B. 57287
C. 51990
D. 51992
CPC Practice Exam Question 7

u -When you see the symbol # in front of a CPT code, what does it mean?
Mark one answer:
A. That the code is listed out of numerical order
B. That the code is listed in numerical order
C. That the code used to be listed with a different number
D. That the code description has changed
CPC Practice Exam Question 8

u What is the correct code for the endocrinology service located in the
medicine section that allows for the ambulatory continuous glucose
monitoring of interstitial tissue fluid (includes the physician’s reading and
interpretation of the report's findings over a 72-hour period)?
Mark one answer:
A. 95250
B. 95251, 99091
C. 95251
D. 95250, 99091
CPC Practice Exam Question #9

u The patient is actively being treated for bladder cancer. The patient
presented to the office today for bladder instillation treatment. The
patient was catheterized, and his bladder was emptied of all contents. An
anticarcinogenic agent was introduced into the bladder at 0100 hours. The
patient was instructed to lie in supine position for 45 minutes. The
physician returned at 0145 hours and emptied the bladder of the
anticarcinogenic agent. The patient tolerated the procedure well. The
patient was instructed to return to office in one week for the next
treatment and a follow-up examination. What is the correct code for the
instillation treatment only?
Mark one answer:
A. 51715
B. 51701
C. 51702
D. 51720
CPC Practice Exam Question 10

u What is the purpose of temporary national codes in the HCPCS Level II

manual?
Mark one answer:
A. They are for procedures that are considered temporary
B. There are no temporary codes, only permanent codes
C. They allow the establishment of codes prior to the January 1st annual
update
D. They allow the deletion of codes prior to the January 1st annual update
Final Answers

u 1. A
u 2. B
u 3. D
u 4. D
u 5. C
u 6. D
u 7. A
u 8. C
u 9. D
u 10. C
Lesson 3.11
NCCI Edits, MUE, GME
What is NCCI?
Two Types
Where to find NCCI Edits
NCCI Coding
NCCI Indicators
Appropriate Modifiers
Denials
Medically Unlikely Edits
MUE Table
MUE Adjudication Indicator “1”
Example
Denials
Things to remember
Graduate Medical Education
Old GME guidelines
Problems with old model
New Changes
Exceptions to the New Rule
Problems with new Model
Modifiers
Time based Codes
Surgury
Radiology
Primary Care
Assist to surgery
Open Book u True or False NCCI edits can be found on CMS
website .
Discovery
Rational u Answer : True
Lesson 3.12
CAT Codes
CAT II Codes

u Set of supplemental tracking codes that can be used for performance

measurement.
u Intended for data collection
u HEDIS
Quality Healthcare
The Need for Quality Care
 u Healthcare
u Effectiveness

What is HEDIS u Data

u Informational
u Set
7 domains of care
HEDIS Score
Physician Role
CAT II Codes
 1000F Tobacco Use assessed

1134F Episode of back pain lasting 6 weeks or less

2000F Blood pressure measured

Examples 3016F Patient screened for unhealthy alcohol use using

systematic screening

3342F Mammogram assessment category if “benign”

documented

4561F Patient has a coronary artery stent

 u CMS is required by law to implement a
quality payment incentive program,
referred to as the Quality Payment
Program, which rewards value and
MIPS outcomes in one of two ways: Merit-
based Incentive Payment System (MIPS)
and Advanced Alternative Payment
Models (APMs).
 u Quality
4 Components u Promoting Interoperability

of MIPS u Improvement Activities

u Cost
 u This performance category replaces PQRS. This category
covers the quality of the care you deliver, based on
performance measures created by CMS, as well as
Quality medical professional and stakeholder groups. You pick
the six measures of performance that best fit your
practice.
 CMS is re-naming the Advancing Care Information performance
category to Promoting Interoperability (PI) to focus on patient
engagement and the electronic exchange of health information
Promoting using (CEHRT). This performance category replaced the Medicare
EHR Incentive Program for EPs, commonly known as Meaningful
Interoperability Use. This is done by proactively sharing information with other

(PI) clinicians or the patient in a comprehensive manner.

This may include sharing test results, visit summaries, and
therapeutic plans with the patient and other facilities to coordinate
care.
 u This is a new performance category
that includes an inventory of activities
that assess how you improve your care
processes, enhance patient
engagement in care, and increase
Improvement access to care.

Activities u The inventory allows you choose the

activities appropriate to your practice
from categories such as, enhancing
care coordination, patient and clinician
shared decision-making, and expansion
of practice access
Cost

u This performance category replaces the VBM. The cost of the care you provide
will be calculated by CMS based on your Medicare claims. MIPS uses cost
measures to gauge the total cost of care during the year or during a hospital
stay.
u Beginning in 2018, this performance category will count towards your MIPS
final score.
 u MIPS was designed to tie payments to
quality and cost-efficient care, drive
improvement in care processes and
Why? health outcomes, increase the use of
healthcare information, and reduce the
cost of care.
 Set of temporary codes for emerging
technologies , services, and procedures.

Use of unlisted code does not offer opportunity

to collect data

If CAT III code available, you are to use this

CAT III instead of unlisted code

Medical necessity rules and policy still apply

Highly used CAT III codes are converted to CPT

CAT III Codes
Conversion or deletion
 u What is the current name of a CAT I code ?
u A. HCPCS
Open Book u B. ICD

Discovery u

u
C. CPT
D. NCCI
Rational u Answer C CPT